这项研究得到了希腊雅典的“胸部”基金会的支持。
病历
A 33-yr-old, Caucasian male, smoker (40 pack-yr) presented to the current authors' hospital complaining of a painful and swollen right breast, which had already lasted a few weeks. He had poor oral hygiene, had been subject to several teeth extractions over the previous 2 yrs and had sporadically used oral antibiotics. He denied fever, cough and shortness of breath or weight loss. The chest physical examination disclosed a painful large soft tissue mass (10×8 cm) on the anterior right side of the chest wall, right in the upper part of the breast.
生命体征是正常的,常规实验室测试的结果也是正常的,除了红细胞沉积速率和C反应蛋白,两者均升高。动脉血液分析在正常范围内。结核病皮肤测试为阴性。患者的胸部X光片和计算机断层扫描(CT)扫描如图1所示×和2×,,,,respectively. A surgical biopsy was performed under local anesthesia and the tissue histology is also shown in figure 3×。
在翻页之前,请解释患者病史,胸部X光片,CT扫描和组织学,并提出诊断。
解释
Treatment and clinical course
The initial differential diagnosis included malignancy (breast carcinoma, rabdomiosarcoma or other) or an inflammatory process, probably a subcutaneous abscess. The surgical biopsy provedA.以色列软组织感染。组织学确认后,立即用青霉素G治疗患者(2400万U,I.V.,每日),由于白细胞增长而在3周后停产。随后,青霉素GWAs被强力霉素(每天两次)取代了6个月的时间。此外,病人在医院的病发后立即提交了一项强烈的修复牙科计划。1个月后获得的新CT扫描显示,质量尺寸显着降低,而6个月时的CT扫描显示出炎症过程的完全分辨率。
讨论
Actinomycosis is a subacute or chronic disease caused by anaerobic or microaerophilic bacterial species of the genus Actinomyces. These causative agents are Gram-positive, pleomorphic and filamentous organisms, found in the normal flora of the oral cavity, gastrointestinal tract and bronchial secretions. It classically involves cervicofacial, abdominopelvic, thoracic and mixed organs, including skin, pericardium, brain and limbs1,,,,2。Thoracic actinomycosis (15–20% of all cases) usually involves the lungs, pleura, mediastinum and the chest wall, and is considered a rare infection, particularly in the developed world. Mabesa and Macfarlane3reported that, in a teaching hospital in the UK (1,100 beds), serving a large metropolitan area and acting as a regional centre for thoracic surgery, pulmonary actinomycosis was diagnosed histologically in only four cases over a 15-yr period. Predisposing factors are poor oral hygiene, alcoholism and epilepsy, which predispose to colonisation and subsequent aspiration of contaminated oropharyngeal secretions. Other routes of infection include direct extension from cervicofacial infection through the mediastinum to the pleura and the lungs, transdiaphragmatic spread from abdominal infection, and, rarely, haematogenous dissemination4。
The present patient presented poor oral hygiene, had undergone several teeth extractions and had sporadically and for short periods used oral antibiotics over the previous 2 yrs. The anterior chest wall mass was the presenting manifestation of his disease and this suggests that the infecting organism entered the lung通过支气管树,通过微污染的口腔污染物质。在这个患者中,还可以假定他没有出现广泛而破坏性的肺部参与的事实可能与零星使用抗生素用于牙齿问题有关。确实,放线菌病可能会从早期的肺炎焦点传播到胸膜,而不必引起严重明显的胸膜感染,然后延伸到胸壁,忽略解剖障碍,并导致骨质破坏5,,,,6。No cutaneous draining sinus was evident at admission in the patient.
Pulmonary actinomycotic infection may affect immunocompetent hosts, as in this case. Complications of the disease are related to its ability to invade across anatomical barriers, such as interlobar fissures, pleura, mediastinum, pericardium, diaphragm, chest wall, adjacent bones and soft tissue7。
放线菌病及时诊断并得到充分治疗,是一种罕见的疾病,死亡率非常低。但是,否则它可以提出相当大的发病率和死亡率。确定放线菌病的诊断的最佳方法是通过证明在临床标本培养物中存在放线菌种类的存在,并且最准确地证明了在组织学检查中含有丝状生物的硫颗粒的证明4。此外,总是指出组织学标本排除恶性肿瘤,因为胸放线菌病可能会在恶性肿瘤中发生ASA继发感染8。获得准确诊断的最合适的程序是手术活检,通常仅限于诊断目的;然而,据报道,一种综合医学手术方法是用于复杂的肺,腹神经或中枢神经系统疾病的治疗方法。
长时间的抗生素治疗是治愈放线菌病的关键。适当且几乎总是“终极”的药物是青霉素G,或者是四环素和/或克林霉素,用于青霉素过敏患者9,至少6个月。在本案中,最初用青霉素G治疗该患者,该患者因白细胞增长的发展而停产并取代了池塘环素。
- 已收到June 21, 2004.
- 公认2004年7月12日。
- ©ERS Journals Ltd