医学专题新英格兰双语病例讨论2

1、Bilingual case discussion2015-09-1112021/7/20 星期二 A 35-year-old man with dyspnea, anemia, and renal failure22021/7/20 星期二several weeks ago,the patient felt fatigue . Two days before admission, dyspnea developed , decreased urination,without fever, cough, or chest pain,no hemoptysis咯血,chills, night s

2、weats, headaches, visual loss, dry eyes,dry mouth, or joint pain.He was transferred by ambulance to the emergency department at this hospital 32021/7/20 星期二Four years before admission, he had been evaluated because of back pain, fatigue, and a temperature of 38.6C.Urinalysis showed hematuria血尿 and p

3、roteinuria；testing for rapid plasma reagin(RPR快速血浆反应素) was positive for antibodies to Treponema pallidum（梅毒螺旋体）.During the previous 6 months, the patient had had episodes of bilateral finger, ankle, and facial swelling, without pain or change in color.He had no history of recent travel, exposure to

4、sick persons, blood transfusions, or previous surgery.He did not smoke, drink alcohol, or use illicit drugs.42021/7/20 星期二 On examination, T 36.9C, BP 173/89 mm Hg, P 95b/m, R36 b/m, and S02 88% ( ambient air).The skin and conjunctivae 结膜were pale, and there were hypopigmented macules 色素减退斑on the ri

5、ght temple and both lower cheeks and hyperpigmented macules 色素沉着斑on the bridge of the nose.There were bibasilar rales双肺底湿罗音 in the lungs, and the remainder of the examination was normal.52021/7/20 星期二62021/7/20 星期二72021/7/20 星期二82021/7/20 星期二 total and direct bilirubin胆红素, liver-function tests and l

6、actate were normal .testing for rheumatoid factor ,screening of the blood and urine for toxins were negative; Testing for hepatitis B and C viruses and autoantibodies against histones组蛋白 was negative.Serum protein electrophoresis 电泳revealed a diffuse increase in the IgG level.92021/7/20 星期二 Transtho

7、racic cardiac ultrasonography revealed normal global cardiac function and right-ventricular size, no evidence of a pericardial effusion心包积液, and findings that were consistent with pulmonary Edema. Ultrasonography of the abdomen revealed normal renal size, position, and echotexture回声特性 and normal art

8、erial blood flow. An electrocardiogram (ECG) showed sinus tachycardia,counterclockwise rotation逆钟向, and nonspecific ST-segment and T-wave abnormalities.102021/7/20 星期二on admission 112021/7/20 星期二122021/7/20 星期二ground-glass opacities GGO132021/7/20 星期二142021/7/20 星期二Bronchoscopic examination revealed

9、 thick, red mucus in the main-stem and right-lower-lobe bronchi; airways of the left lung were normal. Bronchoalveolar lavage on the right, with 300 and 24,500 red cells per cubic millimeter (in the first tube ), 975 and 1475 white cells per cubic millimeter (in fourth tubes) In the fourth tube, the

10、 white-cell differential count revealed 84% leukocytes白细胞. On the second day, the sputum culture grew very few klebsiella克雷伯 152021/7/20 星期二 what do you think 162021/7/20 星期二Pulmonary hemorrhage？172021/7/20 星期二PCP 卡氏肺孢子？（梅毒阳性、HIV）pulmonary embolism 肺栓塞？182021/7/20 星期二 Rapidly progressive glomerulone

11、phritis Pulmonary hemorrhage192021/7/20 星期二 Ernest W. Goodpasture reported in 1919 on the autopsy findings in the case of an 18-year-old man who had died of massive lung hemorrhage and crescentic glomerulonephritis during the height of the influenza pandemic The term Goodpastures syndrome is applied

12、 to the combination of lung purpura and nephritis, regardless of the underlying pathogenesis.202021/7/20 星期二(一)anti-GBM diseaseantiglomerular basement membrane (GBM) antibodies (anti-GBM disease)anti-GBM antibody 212021/7/20 星期二（二）vasculitisvasculitis大血管炎 大动脉炎 巨细胞动脉炎中等血管炎 结节性多动脉炎 川崎病小血管炎 ANCA相关性血管炎

13、显微镜下型多血管炎（MPA） 肉芽肿性多血管炎（GPA，Wegeners） 嗜酸细胞性肉芽肿性多血管炎（EGPA，CSS） 免疫复合物相关性小血管炎 冷球蛋白血管炎 IgA血管炎 低补体荨麻疹性血管炎（抗C1q血管炎）222021/7/20 星期二（三）infectionA variety of both systemic and pulmonary microbial infections can be accompanied by pulmonary hemorrhage and renal disease, including nephritis .In one exceptional

14、case, legionnaires disease军团菌病.No infections could be implicated in this patient.232021/7/20 星期二242021/7/20 星期二The antinuclear antibody titer was positive at 1:1280and had a homogeneous pattern. The titer forantibodies to double-stranded DNA was positiveat 1:80.252021/7/20 星期二 clinical + imaging +pa

15、thology262021/7/20 星期二272021/7/20 星期二 肾小体结构模式图 282021/7/20 星期二292021/7/20 星期二* 足细胞（ podocyte） 有初、次级突起，其次级突起间相互嵌合为栅栏状，之间有裂孔，上有裂孔膜。302021/7/20 星期二滤过膜 filtration membrane 又称滤过屏障 filtration barrier，由有孔毛细血管内皮、基膜和足细胞裂孔膜构成。 312021/7/20 星期二 滤过屏障模式图 返回322021/7/20 星期二diffusely thickened capillarywalls and mil

16、d endocapillary proliferationCellular crescents 332021/7/20 星期二(arrows)tubular atrophy and interstitial inflammationfragmented red cellsThe GBM was markedly thickened, imparting a “wire loop” appearance白金耳342021/7/20 星期二abundant granular immune-complex deposition in the mesangium and along the glome

17、rular basement membrane in a classic “full house” pattern 满堂亮(anti-IgG immunofluorescence)Immunecomplex deposition is also seen along the tubular basement membrane352021/7/20 星期二abundant electron-dense depositsare seen in a mesangial, intramembranous, subepithelial, and subendothelial distribution36

18、2021/7/20 星期二showed strong staining with IgG, IgM, IgA, C3, C1q, and kappa and lambda light chains in a granular pattern in the mesangium and along the GBM372021/7/20 星期二所涉及的病理学术语的定义弥漫性病变(diffuse)：病变累及50肾小球。局灶性病变(focal)：病变仅累及50肾小球。球性病变(global)：病变累及一个肾小球的大部分毛细血管袢(50)。节段性病变(segmental)：病变仅累及一个肾小球的少部分毛细

19、血管袢(50)。系膜细胞增生(mesangial hypercellularity)：3m切片中，一个系膜区超过3个细胞。毛细血管内增生(endocapillary proliferation)：肾小球毛细血管内皮细胞和系膜细胞增生，单个核细胞浸润，导致毛细血管腔狭窄。382021/7/20 星期二I型 轻微病变性狼疮性肾炎II型 系膜增殖性狼疮性肾炎III型 局灶性狼疮性肾炎III（A）：活动性病变局灶增殖性LNIII（A/C）：活动和慢性化病变局灶增殖和硬化性LNIII（C）：慢性非活动性病变局灶硬化性LNIV型 弥漫性狼疮性肾炎IV-S（A）IV-G（A）IV-S（A/C）型 膜性狼疮性肾炎型 终末硬化性狼疮性肾炎狼疮性肾炎的病理组织学分类（ISN/RPS 2003）IV-G（A/C）IV-S（C）IV-G（C）392021/7/20 星期二根据活动性和硬化性病变又分为多个亚型IV-S（A）：活动性病变弥漫节段增殖性LNIV-G（A）：活动性病变弥漫球性增殖性LNIV-S（A/C）：活动和慢性化病变并存弥漫节段增殖和硬化性LNIV-G（A/C）：活动和慢性化病变并存弥漫球性增殖和硬化性LNIV-S（C）：慢性非活动性病变伴疤痕形成弥漫节段硬