学龄期男孩发热、全身疼痛并肺部多发结节

Fever, generalized pain, and multiple pulmonary nodules in a school-aged boy

摘要:

9岁男孩，左下肢外伤后疼痛5 d，发热、全身疼痛2 d入院。当地医院行左下肢X片未见异常，肺部CT示双肺多发结节，肾上腺CT示左肾上腺明显增粗，并出现全身小疱疹及间断胡言乱语，血压升高达155/93 mm Hg，疑诊嗜络细胞瘤转入我院。入院时血压86/44 mm Hg，全身皮肤散在斑丘疹及疱疹，全身触痛并浅表静脉显露，舌右侧白色脓苔覆盖，腹肌紧张，左下肢未见皮肤破损，强迫伸直位，膝关节以下肿胀明显，实验室检查发现血小板降低，低蛋白血症并肌酶大幅升高。CRP 348 mg/L，PCT>100 ng/mL，胸腹盆腔CT：两肺多发斑片及结节，脾大。左膝关节、左胫骨骨膜下穿刺液、血培养及骨髓培养均为耐甲氧西林金黄色葡萄球菌。给予抗休克，万古霉素抗感染，左胫骨骨髓炎病灶清除及持续冲洗引流等治疗，仍反复寒颤高热，皮下及肺部结节增多，于入院后第8天加用利奈唑胺治疗后体温于入院后第24天恢复正常，皮下结节和肺部结节逐日减少并消失，疗程共两个月、痊愈停药。

Abstract:

A 9-year-old boy was admitted to Xiangya Hospital due to pain after trauma in the left lower limb for 5 days and fever with generalized pain for 2 days. The results of X-ray of the left lower limb were normal. Pulmonary computed tomography (CT) showed multiple pulmonary nodules in both lungs. Adrenal CT showed marked enlargement of the left adrenal gland. The patient also experienced generalized herpes and intermittent delirium and had a blood pressure up to 155/93 mm Hg. He was transferred to our hospital with a suspected diagnosis of pheochromocytoma. On admission, the patient had a blood pressure of 86/44 mm Hg, sporadic maculopapule and herpes, touch-evoked pain, exposure of superficial veins, white pus coating on the right side of the tongue, and tension in the abdominal muscle. No skin damage was observed in the left lower limb, and the patient was forced to be in the extending position and experienced significant swelling below the knees. Laboratory examination showed a reduction in platelet count, hypoproteinemia, a significant increase in creatase, a C-reactive protein level of 348 mg/L, and a procalcitonin level of >100 ng/mL. Thoracoabdominal and pelvic CT showed multiple patchy and nodular lesions in both lungs, which had an undetermined nature, as well as an enlarged spleen. The tests of puncture fluid from the left knee joint and the periosteum of the left tibia, blood culture, and bone marrow culture all showed methicillin-resistant Staphylococcus aureus. The patient was given anti-shock treatment, anti-infective therapy with vancomycin, debridement and continuous irrigation/drainage of osteomyelitis lesions in the left tibia, but the patient still experienced recurrent shivering and severe fever and increased subcutaneous and pulmonary nodules. Linezolid was added on day 8 after admission, and the patient's body temperature returned to normal on day 24 after admission. Subcutaneous and pulmonary nodules were gradually reduced and disappeared. The patient was treated for 2 months and then evaluated as cured.