细菌性肝脓肿并发脓毒血症1例药物治疗与监护实践

肝脓肿发病率目前在临床上呈逐渐上升的趋势,近年来,随着诊疗技术的发展,其临床表现及诊疗均发生了很大的变化。本文以作者参与的1例肝脓肿并发脓毒血症患者的药物治疗实践及药学监护进行分析讨论。1临床资料患者,男,75岁,因＂反复腹痛3个月,再发3 d＂于2014年8年4日入院。

Effects of ketamine on proinflammatory cytokines and nuclear factor kappaB in polymicrobial sepsis rats

AIM： To explore the effects of ketamine on hemodynamics, plasma proinflammatory cytokine （TNF-α and IL-6） levels and nuclear factor kappa B （NF-κB） activation during polymicrobial sepsis. METHODS： Male Sprague-Dawlay rats were subjected to cecal ligation and puncture （CLP） or sham operation. The rats were randomly assigned into four equal groups： sham CLP group, CLP group, ketamine （KT）Ⅰ group and KTⅡgroup. Thirty minutes before CLP, ketamine （5 mg/kg per hour and 10 mglkg per hour, respectively） was infused continuously through the left femoral vein cannula in KT Ⅰ group or KTⅡgroup. Sham CLP group and CLP group received 0.9% saline only （5 mL/kg per hour）. The right femoral artery was cannulated to monitor mean arterial pressure （MAP） and heart rates （HR）,and draw blood samples. The proinflammatory cytokine （TNF-α and IL-6） levels of plasma were measured using enzyme-linked immunosorbent assays （ELISA）. The hepatic NF-κB activation was determined by Western blot and HPIAS 2000 image analysis system. Twenty hours after CLP, the rats were killed by right femoral artery phlebotomization. RESULTS： CLP produced progressive hypotension, and a first increase followed by a decrease in HR. The hypotension was prevented, and the HR was slightly steady in ketamine treated rats. TNF-α levels of plasma reached a peak value at 2 h after CLP. Ketamine （KT Ⅰ group or KTⅡgroup） caused a significant decrease compared with CLP group at 2, 5 and 9 h time points after CLP （14.3 ± 1.9 vs 4.3 ± 0.9, 9.7 ± 1.4 vs 4.3 ± 0.9; 9.3 ± 1.5 vs 4.3 ± 0.9, 8.7 ± 1.4 vs 4.3 ±0.9; 6.0 ± 1.5 vs 5.0 ± 1.7, 5.3 ± 0.8 vs 5.0 ± 1.7; P 〈 0.01, respectively）. The IL-6 levels of plasma firstly ascended and then descended in CLP group, and reached a peak value at 9 h after CLP. Ketamine （KT I group or KTH group） caused a significant decrease compared with CLP group at 5, 9 or 20 h after CLP （135.0 ± 52.6 vs 60.0 ± 16.3, 112.5 ± 52.6 vs 60.0 ± 16.3; 410.0 ± 68.7 vs 62.5 ± 12.5, 250.0 ± 28.0 vs 62.5 ± 12.5; 320.0 ± 25.9 vs 52.5 ± 10.1, 215.0 ± 44.6 vs 52.5 ± 10.1; P 〈 0.05, respectively）. The IL-6 levels of plasma in KTⅡgroup were lower than those of KT Ⅰ group at 9 h after CLP （250.0 ± 28.0 vs 410.0 ± 68.7; P 〈 0.05）. In addition, CLP increased hepatic NF-κB expression compared with sham CLP. Ketamine suppressed NF-κB activation in a dose-dependent manner at 4 h after CLP （237.7 ± 3.5 vs 246.9 ± 3.1; P 〈 0.05）. CONCLUSION： Ketamine stabilizes the hemodynamics, attenuates the proinflammatory cytokine responses, and inhibits hepatic NF-κB activation. These findings suggest that ketamine has protective effects against polymicrobial sepsis in rats.

Pancreatic abscess following scrub typhus associated with multiorgan failure

Clinical severity of scrub typhus ranges from mild to fatal. Acute pancreatitis with abscess formation is a rare complication among patients with scrub typhus. This paper reports a case of scrub typhus in a 75 years old man with acute pancreatitis with abscess formation and multiorgan failure. Abdominal computed tomography showed multiple infected pancreatic pseudocysts with periopancreatic infiltration. Multiorgan failure was successfully treated with doxycycline, ceftriaxone, and supportive management. The pancreatic abscess was successfully drained percutaneously and the sizes of pseudocysts decreased remarkably.

Predictive factors for early aspiration in liver abscess

AIM: To determine the predictive factors for early aspiration in liver abscess. METHODS: A retrospective analysis of all patients with liver abscess from 1995 to 2004 was performed. Abscess was diagnosed as amebic in 661 (68%) patients, pyogenic in 200 (21%), indeterminate in 73 (8%) and mixed in 32 (3%). Multiple logistic regression analysis was performed to determine predictive factors for aspiration of liver abscess. RESULTS: A total of 966 patients, 738 (76%) male, mean age 43 ± 17 years, were evaluated: 540 patients responded to medical therapy while adjunctive percutaneous aspiration was performed in 426 patients. Predictive factors for aspiration of liver abscess were: age ≥ 55 years, size of abscess ≥ 5 cm, involvement of both lobes of the liver and duration of symptoms ≥ 7 d. Hospital stay in the aspiration group was relatively longer than in the non aspiration group. Twelve patients died in the aspiration group and this mortality was not statistically significant when compared to the non aspiration group. CONCLUSION: Patients with advanced age, abscess size > 5 cm, both lobes of the liver involvement and duration of symptoms > 7 d were likely to undergo aspiration of the liver abscess, regardless of etiology.

A phantom gallbladder on endoscopic retrograde cholangiopancreatography

Various complications have been related to laparoscopic cholecystectomy but most occur shortly after the procedure. In this report, we present a case with very late complications in which an abscess developed within the gallbladder fossa 6 years after laparoscopic cholecystectomy. The abscess resolved after treatment with CT-guided extrahepatic aspiration. However, 4 years later, an endoscopic retrograde cholangiopancreatography （ERCP） performed for choledocholithiasis demonstrated a “gallbladder” which communicated with the common bile duct via a patent cystic duct. This unique case indicates that a cystic duct stump may communicate with the gallbladder fossa many years following cholecystectomy.

Meckel's diverticulum manifested by a subcutaneous abscess

This case report describes an extremely rare complication of a Meckel's diverticulum:enterocutaneous fistula of the diverticulum.The presence of Meckel's diverticulum is a well known entity,but subcutaneous perforation of the diverticulum is very rare.Here we report the case of a patient with the complaint of a right lower quadrant abscess,preoperatively diagnosed as enterocutaneous fistula,which was determined intraoperatively to be a fistula resulting from Meckel's diverticulum.

ROLE OF TUMOR NECROSIS FACTOR IN NEONATAL SEPSIS

In order to assess the role of tumor necrosis factor (TNF) in neonatal sepsis, plasma TNF levels were determined by a method using L929 cells at the time of septic work-up in 67 neonates. Thirty-three patients, with sepsis were found to have significantly higher TNF levels (533. 33 ±468. 74 U/ml ; 1 U corresponding to 1. 67 pg recombinant TNF) as compared with 34 non-sepsis patients (100. 0±188, 97 U/ml) and 30 healthy newborns (27. 33±1 6. 1 7 U/ml, P<0. 05. respectively) . The upper limit of normal plasma TNF levels was 60 U/ml and the best cutoff value for predicting neonatal sepsis was 160 U/ml. This had remarkable sensitivity (88%), specificity (82%). positive predictive value (83%). and negative predictive value (88%). Plasma TNF levels were significantly associated with the occurrence of shock,organ failure. sclerema and outcome. Thus, anti-TNF antibodies might be used in protecting newborns from septic death.

Congenital H-type anovestibuler fistula

The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn′t performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.

Acute appendicitis presenting with abdominal wall and right groin abscess:A case report

We report a case of right lower abdominal wall and groin abscess resulting from acute appendicitis. The patient was an 27-year-old man who had no apparent abdominal signs and was brought to the hospital due to progressive painful swelling of right lower abdomen and the groin for 10 d. Significant inflammatory changes of soft tissue involving the right lower trunk were noted without any apparent signs of peritonitis. Laboratory results revealed leukocytosis. Abdominal ultrasonography described the presence of abscess at right inguinal site also communicating with the intraabdominal region. Right inguinal exploration and laparotomy were performed and about 250 mL of pus was drained from the subcutaneous tissue and preperitoneal space. No collection of pus was found intraabdominally and subserous acute appendicitis was the cause of the abscess. The patient fully recovered at the end of the second post-operation week. This case reminds us that acute appendicitis may have an atypical clinical presentation and should be treated carefully on an emergency basis to avoid serious complications.

Churg-Strauss syndrome complicated by colon erosion, acalculous cholecystitis and liver abscesses

We report on a case of Churg-Strauss syndrome (CSS)with colon erosion, cholecystitis and liver abscesses. A 21-year-old woman with a history of bronchial asthma for 3 years was admitted with a complaint of abdominal pain. Laboratory findings included remarkable leukocytosis and eosinophilia, and a colonoscopy revealed erosion from the rectum to the ileocecal region. In addition, a colonic biopsy specimen showed necrotizing vasculitis and marked eosinophilic infiltration. On the basis of the clinical features and histopathological findings, she was diagnosed with CSS and subsequently treated with oral prednisolone,after which the eosinophilia and abdominal pain disappeared. However, on the 15th d in hospital she developed cholecystitis and liver abscesses. She was therefore treated with antibiotics and as a result went into clinical remission.

Duplicated appendix complicated by appendiceal cancer

A 37-year old male presented with an acute abdomen suggestive of an appendiceal perforation.Urgent laparotomy showed a duplicated appendix with one of the lumens involved with appendicitis and a focal periappendicular abscess while the other lumen had a localized appendiceal cancer.Recognition of congenital intestinal duplications in adults is important to avoid serious clinical consequences.

A CASE OF TRICUSPID ENDOCARDITIS WITH SUBSEQUENT LUNG ABSCESS

THE incidence of isolated right heart infective endocarditis （IE） is far less common than that of left heart. Clinical presentation is often associated with pulmonary manifestations. The main symptoms include high fever, chest pain, and dyspnea due to septic pulmonary emboli. Degenerative valvular disease, congenital heart diseases, prosthetic valves, long-term hemodialysis, diabetes mellitus predispose patients at increased risk of IE.1 In young persons, IE may be associated with intravenous drug abuse.2 This report dealt with a young patient who had none of the risk factors mentioned above. He was diagnosed and treated for lung abscess and septemia for one and a half months. Further investigation unveiled infective vegetation on tricuspid valve. Following surgical resection of the vegetation, fever and respiratory symptoms completely remitted. The mechanism of the IE occurred on the normal native tricuspid valve is proposed.

Liver abscess and sepsis with Bacillus pantothenticus in an immunocompetent patient:A first case report

Bacillus species are aerobic,gram-positive,spore forming rods that are usually found in the soil,dust,streams,and other environmental sources.Except for Bacillus.anthracis(B.anthracis) ,most species display low virulence,and only rarely cause infections in hosts with weak or damaged immune systems.There are two case reports of B.cereus as a potentially serious bacterial pathogen causing a liver abscess in an immunologically competent patient.We herein report a case of liver abscess and sepsis caused by B.pantothenticus in an immunocompetent patient.Until now,no case of liver abscess due to B.pantothenticus has been reported.

Effect of purulent moxibustion on Zúsānlǐ(足三里ST 36) point on the clinical symptoms of patients with malignant tumor

Objective To discuss the effect of purulent moxibustion on Zusanli （足三里 ST 36） point on the clinical symptoms and life quality of patients with malignant tumor. Methods Sixty patients with malignant tumor were divided into an observation group and a control group with 30 cases in each group. The observation group was treated with purulent moxibustion on Zusanli （足三里 ST 36） in combination with herbal medicine; the control group was only treated with herbal medicine. After 80 days, the changes of the clinical symptoms and KPS of the two groups before and after the treatment were observed. Results The effective rates for the improvement of lassitude, poor appetite and insomnia in the observation group were 72.4% （21/29） ,25.0% （15/20） ,71.4% （15/21）, and those in the control group were 42.9%（12/28） ,55.6% （10/18） ,42.9% （6/14）, and there was no statistical significance of difference between the two groups（P〉0.05）. KPS has statistical significance in the two groups after the treatment （P〈0.01）,and the observation group was higher than the control group. Conclusion Purulent moxibustion on the point of Zusanli （足三里 ST 36） has certain effect to improve the clinical symptoms of patients with malignant tumor, and raise KPS and upgrade the life quality of patients.

Brodie＇s abscess of medial distal femoral condyle after thorn prick： rare clinical presentation

Thorn prick injuries are generally conceded frivolous and rarely demand medical attention. Howbeit deep seated injuries are well described in the literature. We presented a case of thorn prick injury to the knee that manifested as Brodie＇s abscess of the medial distal femoral condyle and synovitis. Magnetic resonance imaging （MILl） and ultrasonography could only construe the affliction but not spot the thorn. Arthrotomy was undertaken for explora- tion and debridement. Empirical therapy with initial systemicCefotaxime and subsequent Ofloxacin worked well after the surgery. Deep seated injuries by a thorn prick may take a protracted and torpid course. Thorough curettage of the bony lesion and debridement are vital for proper management.