Last Sunday I was on a day shift, and in the afternoon the rescue room asked me to consult a patient with a fever. The patient is from the countryside of Tonglu and usually has a history of raising chickens and ducks. Because of the fever five days ago, the fever appeared for unknown reasons five days ago, the body temperature reached 40 degrees, there was no chills, sore throat, cough, accompanied by dizziness and discomfort, no headache, and it was not taken seriously at that time. I developed unsteady walking 2 days ago and went to the local hospital. Chest CT examination shows a large solid change in the upper left lung, and head CT shows "multiple nodule foci in the left cerebral hemisphere with the formation of peripheral edema bands, demyelinating of the white matter of the brain".
Laboratory tests are as follows:
Blood count shows white blood cells 3.92 * 10 ^ 9 / L, neutrophil ratio of 93.9%;
Procalcitonin 3.585 ug/ml, C-reactive protein 308.9 mg/L, ESR 73 mm/h;
Biochemistry: propionate aminotransferase 56U/L, aspartate aminotransferase 77U/L, albumin 23.6g/L, lactate dehydrogenase 320U/L.
Tumor indicators: CEA5.04ug/L (reference 0-5ug/L), cytokeratin 8.43ug/L (reference 0-3.5ug/L), NSE17.45ug/L (reference 0-16.6ug/L);
The local hospital diagnosed severe pneumonia and gave anti-infective treatment of "cefoperazone sulbactam" and glycerol fructose to reduce cerebral edema and reduce cranial pressure. Since the improvement of symptoms was not obvious, the patient's family requested to be transferred to our hospital for further treatment.
After I learned about these conditions, one of the first diseases that jumped into my mind was Chlamydia psittaci pneumonia, which I have said many times (see Chlamydia psittaci pneumonia, a "severe pneumonia" that should not be unfamiliar" and "How do I diagnose and treat pneumonia?"). (1) - Clinical thinking on the diagnosis and treatment of pneumonia"), this case is also basically in line with these characteristics, we list them one by one:
Epidemiological perspective: history of chicken and duck exposure;
High fever, body temperature exceeding 39 degrees, often reaching 40 degrees;
Often accompanied by neurological symptoms, including dizziness, gibberish, and walking unsteadily;
Signs have relative bradycardia;
WBC is normal or decreased, but the neutral ratio is significantly increased, C-reactive protein is significantly increased, and PCT will increase;
Significant decrease in albumin in biochemistry, increased LDH and/or creatine kinase;
Broad-spectrum antimicrobial therapy is ineffective.
Above: The patient's temperature list, we can see that when the patient's body temperature is 39.2 degrees, the pulse is only 90 times / min, while under normal circumstances, it should be 110-120 times / min, and the body temperature is separated from the pulse curve.
Although ct of the outer hospital head was reported abnormally, the patient did not have any neurological diseases and manifestations before the onset of the disease, and did not resemble tumor metastasis. However, since the outer hospital reported this, coupled with a number of abnormal tumor indicators, for the sake of caution, we still gave the patient a cranial MRI, and the result report was: "Multiple lacunar cerebral infarction on both sides of the ventricle and basal ganglia area". Further NGS tests of cerebrospinal fluid and blood also found the sequence of Chlamydia psittaci.
We asked the doctor of the imaging department to help us see the patient's CT from the outer hospital and the MR examination of the hospital, and he was also surprised that the patient's image results were very different, but after careful analysis, it was believed that the previous head CT may be due to the fact that the patient's head movement was not fixed due to delirium during the examination, and there was a phantom. The reason is that there is no continuity of lesions shown by ct of the skull and that the image quality is poor.
This case is relatively complex, a variety of clinical manifestations and laboratory abnormalities, including imaging results lead to deviations in the initial judgment, which requires our clinicians to have good clinical thinking, while dialectical analysis of various test results. If the relevant results are found to not explain the clinical manifestations, we must be good at grasping the main contradictions, for example, this patient, when the laboratory tests of the patient's multiple clinical manifestations have pointed to parrot fever, dare to diagnose the drug, and can no longer be afraid of the feet or still give carbapenems or anti-positive bacteria drugs, thus missing the opportunity for treatment.
Fortunately, under our timely and effective treatment, the patient's situation has improved significantly, the body temperature has returned to normal, and the inflammatory indicators have also decreased.
Finally, it needs to be emphasized that winter has arrived, and parrot fever has reached the peak of the disease, we must correct the misconception that the disease is a rare disease or a rare disease in the past, and seize the characteristics of the disease, in fact, it is not difficult to diagnose, and the treatment of drugs is also very cheap.