This article is authorized to be reproduced from the infection team of Zhongshan Hospital affiliated to Fudan University
Author: Miao Qing Huang Yingnan
Review: Hu Bijie Pan Jue
Photo and text arrangement: Chen Xiaoxiao
Monday afternoon outpatients were always the most attended, and after seeing forty patients, the assistant who helped copy the square couldn't help but yawn.
Yes, half of the people who come to our general outpatient clinic of the infectious disease department are difficult and complicated diseases; and those who come to our infectious disease department need to be treated in the outpatient clinic, basically all of them are difficult and complicated diseases that are screened by other hospitals and the ordinary outpatient clinics of our hospitals and are still unresolved.
In one afternoon, after seeing more than 100 copies of their hospitalization materials and hundreds of pounds of video film, the August sunset finally couldn't stay up, and I didn't know when it quietly fell. Only the call screen tirelessly spoke: "Infection Disease Special Needs Clinic, Hu Bijie, No. 41 Zhang Meiling, please go to Clinic No. 1 for treatment." ”
"Professor Hu, I was bitten by a large stray dog more than a month ago and was vaccinated against rabies. Later there was fever, the wound was red and swollen and oozing out very obviously, and the inguinal lymph nodes were enlarged, and two debridements and one inguinal lymph node biopsy were done, and the lymph nodes detected non-tuberculous mycobacteria, and the treatment retreated from the fever, but the wound did not heal well. This is my profile. “
I can't help but be a little surprised that the person who narrated the medical history so concisely and focusedly was probably a peer. As soon as she looked up, the patient's well-organized conversation could not hide her anxiety.
"I'm an anesthesiologist," the patient seemed to guess what I was thinking, adding. "Show you the wound."
After she lifted the loose cuffs of her pants, my assistant and I were startled: the gauze covering the right knee was soaked with reddish blood, and when the gauze was turned over, there were two wounds on the outside of the joint, the edge of the wound was still swollen in a circle, and it was stained with oozing liquid, which looked fragile and abrupt in contrast to the large area of dark bruises around it; the wound was like a narrow opening, but the inside was large and deep, and the bottom of the "cave" was bright red and crisp fleshy tissue, and the surface was oozing with liquid shiny crystals.
Swipe up to see the picture
Apparently, these two wounds are the two tooth marks left by the dog's bite, and the missing part of the "cave" is the inactive tissue removed by the two local debridement surgeries. The thought of the fangs and bites of large dogs is chilling.
The treatment of bites is very troublesome, whether it is a human bite or an animal bite, in addition to the need for surgical treatment, it also requires difficult internal medicine anti-infection treatment: there are many kinds of microorganisms in the mouth, and they can change with food changes; while stray animals have complex food sources, and it is more difficult to handle.
Looking through the patient's information, she had been hospitalized in the local area and had undergone two debridement surgeries, and had used many kinds of antibiotics before and after, but the wound infection was not well controlled.
Inflammation collects through the lymphatic system to the inguinal lymph nodes, causing inguinal lymphadenopathy.
The local hospital did its best to confirm the etiological diagnosis, gave her a biopsy of enlarged lymph nodes, and sent her for advanced pathogen genetic testing.
This is an emerging microbial detection technology, unlike traditional culture techniques that require waiting for microorganisms to grow to a certain number before they can be identified, sometimes taking dozens of days.
This technology can directly detect the genes of pathogenic microorganisms, so as to give a test report within 48 hours, and can also detect microorganisms that cannot be cultivated by traditional culture technology; of course, this test is not cheap, generally ranging from three or four thousand yuan.
The patient's surgery was not done in vain, the money was not spent in vain, and the lymph nodes identified Mycobacterium abscess, which is a non-tuberculous mycobacteria and also the infamous tuberculosis bacteria - that is, the "brother" of Mycobacterium tuberculosis, which can infect the lungs, skin soft tissues, and even the spine, but usually people with normal immunity are less susceptible to infection.
In general, this bacterium is also not a common bacteria that is abundant in the mouth, but the mouth of stray dogs may be the most complex continent on the planet.
Identification of the bacterium is time-consuming and laborious — the kind that takes dozens of days to be cultured to identify , and treatment is extremely cumbersome — and the common antibiotics are powerless against it, require a combination of multiple antimicrobials, and require long courses of treatment, sometimes even years.
This infection is rare in a fair number of hospitals, but we have treated hundreds of cases here, and this patient has the convenience of a companion, and I found out that we have come here to the right place.
This patient was unfortunately bitten by a stray dog, and in addition to the bacteria that can be handled by conventional anti-infection treatment, he was unfortunately infected with the "non-mainstream" non-tuberculosis mycobacteria.
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Fortunately, he met a dedicated doctor who helped him with many debridements and biopsies, and clearly diagnosed this rare infection.
Looking at the patient's four-drug combination anti-infection program is also considered complete, the patient's fever symptoms have been resolved after taking the drug, but the wound infection is still not controlled after a month of use.
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The local doctor was obviously also very confused, and gave her a perfect blood test, as well as a chest, abdomen and pelvic examination, for fear of missing other parts of the problem caused by the infection will not heal, but fortunately and unfortunately, this colleague really has no other problems except this bite.
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Was the wound infected with other pathogens that escaped state-of-the-art detection techniques without being detected?
What other pathogens may stray dogs carry?
It's trickier.
The patient may perceive my mental activity: "Professor Hu, I know that my disease is difficult to diagnose rather than treat, and I also know that the difficult disease is the most difficult disease in your internal medicine system; the previous doctors have tried their best, and I know that most of the doctors in the hospital should only be able to do this; I have inquired about many colleagues, and they all say that you are famous for seeing difficult and complex diseases here, so I want you to try it here." ”
As a doctor, she is sensitive: sensitive to changes in the condition, sensitive to the state of her peers;
As a patient, she was helpless, helpless to progress in the disease, helpless to the inability of previous doctors to do their best.
We were originally comrades in the same trench, helping the sick to cope with the enemy of disease;
And now, my comrades-in-arms are trapped by the enemy, and they have thrown all their trust and final help to me, and I can only do my best.
- "Hospitalize." ”
" Okay, thank you. ”
？
"The director rounds the room, and the resident doctor reports the medical history"
answer
"3 bed Zhang Meiling, female, 49 years old, was admitted to the hospital for more than a month after the redness and swelling oozed out of the right lower limb dog bite..."
Every 1 to 2 days, I would go to the ward for rounds. Generally, professors can round once a week, but the patients in the infectious disease department are too complex, and most of them come to seek the last hope, and we have no way back.
Even if you miss a meeting, an interview, or a prize, you can't miss the patient's condition. Happily, the young doctors in the infectious disease department are growing up very fast, and even in the face of difficult diseases, many of them can stand alone.
"What infections may be found in dog bites, let's analyze it"
"Streptococcus is a common oral bacterium, if it is hemolytic streptococcus, it is more virulent, causing acute symptoms such as high fever and obvious suppuration of wounds, and is sensitive to common antibacterial drugs." However, this patient only has low-grade fever, wound suppuration is not obvious, and the effect of a variety of anti-infective drugs is not good;"
"Pasteurella is a common pathogen of bite infections in cats and dogs, and can also cause symptoms such as redness, swelling and suppuration of wounds, but general antibiotics can cure it. So unlikely. ”
"Carbon dioxide fibrous bacteria..."
"Anaerobic bacteria..."
Microbial populations are large and complex, and there are different places, symptoms and treatments, which cannot be solved by the common public "eating nodding spore".
To become a qualified infectious disease doctor, you need a huge knowledge reserve, continuous learning and persistent exploration spirit. I am often happy about the progress of the young doctors in our department, and it is my unshirkable responsibility to lead them to explore and let them go faster and farther.
"Everybody's done a good job. The oral flora of stray dogs is complex, and the detection of non-tuberculous mycobacteria can already be proved. The infections analyzed by everyone are all possible, but combined with the patient's medication, there should be other pathogens that are not covered.
We expand our thinking, the result of tuberculosis infection T cells (T-spot.TB) in this patient is: A well /B hole: 27/32 (the normal range of AB wells are <6), this result is said to be high, low is not low. At present, chest CT is normal, that is, the most common form of tuberculosis is ruled out - tuberculosis, is there a possibility of wound tuberculosis bacteria infection?
Think about it, a century ago, the poor people were poorly nourished, and they were prone to infection. Tuberculosis, also known as tuberculosis, was a very important infectious disease in society at that time! Tuberculosis has also been reported in animals living in the wild. Stray dogs are precarious and have poor nutritional status, are they also susceptible to tuberculosis, which is then transmitted to patients through bites?
We proceed to treat the infection with clear evidence and improve the tests, particularly the microbiology of blood and wound exudate. ”
The patient's wound was still oozing in large quantities, and there was a suspicious abscess locally, and with our advice and encouragement, the patient agreed and completed the ultrasound-guided downward abscess puncture, draining bloody fluid.
In line with the principle of "not wasting any specimens in difficult cases", we maximize the use of the patient's exudate and drainage fluid, fully send various examinations, and do not let go of any possible hope.
But mycobacteria culture takes dozens of days, which is another long wait.
In the absence of other evidence, it takes courage to rely on T-spot.TB alone to add anti-TB treatment, after all, anti-TB treatment has its side effects, and even if it is really TB, anti-TB treatment will take a long time to appear effective.
But the patient's wound, which has no tendency to heal, is like a pair of eyes that stare at us every day.
We understand the patient's suffering, and her ordeal that grows exponentially over time.
We decided:
Instead of using first-line anti-TB drugs, a potent second-line anti-TB drug linezolid is added, which has the advantage of being able to fight both TB and non-TUBERCULOC mycobacteria.
Patients, although struggling with the lack of a definitive diagnosis, can also accept this regimen.
Since mycobacterial culture takes dozens of days, and the hospital environment is not conducive to the rest and recovery of patients, we recommend that patients take medicine out of the hospital and go home for good maintenance.
I can feel the patient's unwillingness, after two months of illness and suffering, she and her family's patience has been exhausted, this hopeful request for help, with just a few days of hospitalization and the addition of a drug, she has anxiety and questions written on her face: Is this medicine so godly?
To be honest, I'm not 100% sure. But I'm 80% sure.
And her waiting for the results in the hospital will only increase her anxiety, which is 100% detrimental to her recovery.
I insisted on her decision to discharge her and wait for the outcome while treating her. Fortunately, as a peer, although she was unwilling, she still agreed.
A month later, we looked forward to the stars and the moon and finally looked forward to the results of the exudate culture:
tuberculosis! It's tuberculosis!
This cunning enemy, which escaped the most advanced detection technology, was finally caught by our unremitting repeated inspection of the traditional method - microbial culture!
So the patient is a mixed infection!
In addition to the common bacteria, the patient was infected with two "non-mainstream" pathogens after being bitten by the dog: two mycobacteria, Mycobacterium tuberculosis and non-Mycobacterium tuberculosis, but genetic sequencing only detected the latter, so treatment for the latter alone did not make the patient completely better.
If the former infection is not treated, over time it will consume all her spirit and even be life-threatening.
Is there anything more unfortunate than walking down the road and getting bitten by a dog? This is a dog with tuberculosis!
We quickly called the patient to tell her the good news, and the patient gave us good news: after the dosing, her inguinal lymph nodes were significantly reduced.
We further adjusted the treatment regimen for the patient and standardized anti-mycobacterium therapy.
Every time they are rechecked, patients bring good news: exudation is reduced, wounds are reduced, markers of inflammation are reduced to the normal range...
In mid-October, her wound was completely healed, and coincidentally, it was exactly a hundred days after she was bitten by a dog.
Later, I met her again at a meeting, shed her sad face, and she said that she had started work again, back to the rhythm of routine anesthesia interspersed with sudden rescue.
She said that after this accident, she had more understanding and empathy for the suffering beings.
Except for the dogs, "The dogs are so scary, really. ”
Related cases
Cat scratches
Old Meng had a tanuki cat. One day Old Meng was accidentally scratched by a flower cat, and then there was a swollen lymph node in the neck, he thought he had cancer, he quietly went to the hospital to do an examination but did not find the tumor basis, was introduced to the infection department of Zhongshan Hospital, and the doctors found that he was infected with Bartonella through examination. After standardized treatment, Lao Meng's lymphadenopathy improved significantly.
Fish stings
Aunt Xue was stabbed by a sea fish while cooking, and used iodine wine, alcohol, and red potion to disinfect the wound, and the wound was always red and swollen. Doctors prescribed him penicillin and cephalosporins, which did not help. Later, she came to the Infectious Disease Department of Zhongshan Hospital, and the doctors diagnosed her with mycobacterium sea infection through examination, and after 5 months of treatment, she was finally cured.
Doctor reminds
Pets are common these days, and many people have come to treat animals as close family members.
But in order to live in harmony, it is necessary to understand the pathogens that animals may carry and to prevent them. One diagram to understand animal-related infections.
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