虫咬伤致横纹肌溶解症并发急性肾衰竭一例

2018-03-20 佚名 中国药师

患者,男,62岁,急性起病,因间断腰腹疼痛伴少尿2d入院。

【一般资料】

患者,男,62岁

【主诉】

急性起病,因间断腰腹疼痛伴少尿2d入院。

【现病史】

缘于2016年7月在野外做户外运动时被不知名昆虫叮咬,伤口无红肿、瘙痒,中央有咬痕。受伤后出现腰腹部疼痛,为持续酸胀样疼痛,伴胸闷、憋气、呼吸困难、纳差明显、恶心、呕吐,自觉尿量明显减少,尿液呈红色,2016年7月4日来医院就诊治疗。

【既往史】

既往健康,近3个月内未服用任何药物,无药物及食物过敏史。

【体格检查】

2016年7月4日入院,入院体检:T36.1℃,P41次/min,R16次/min,BP126/82mmHg;意识清,痛苦面容,精神差。下腹及剑突下轻压痛,四肢肌力正常,无反跳痛;双肾区叩击痛阳性,双下肢不浮肿。双肺呼吸音粗,未闻及明显干湿性啰音。

【辅助检查】

急诊查肝胆胰脾双肾彩超提示:胆囊附壁隆起性病变,双肾、输尿管无异常。胸片正常。肾功能:尿素氮21.95mmol?L-1,肌酐500μmol?L-1,尿酸560μmol?L-1,肝功能、淀粉酶正常。心肌酶谱:磷酸肌酸激酶1199U?L-1、肌酸激酶同工酶47U?L-1、乳酸脱氢酶179U?L-1、α-羟丁酸脱氢酶142IU?L-1。心肌标志物:肌酸激酶同工酶17.45ng?ml-1、肌钙蛋白T0.019ng?ml-1、肌红蛋白1217.00ng?ml-1。心电图无明显异常。

【初步诊断

横纹肌溶解症并急性肾功能衰竭。

【治疗】

予以碱化尿液(碳酸氢钠注射液120ml,qd,ivd),抗炎(地塞米松磷酸钠注射液3mg,qd,ivd),护胃(注射用泮托拉唑钠40mg,qd,ivd),护肝(注射用复方甘草酸单铵S160mg,qd,ivd),维持电解质酸碱平衡(葡萄糖注射液2g,qdivd)等对症支持治疗4d后,患者精神好转,腹痛、腰痛、腹胀症状较前明显缓解,病情稳定。入院第11天复查心肌标志物:肌酸激酶同工酶1.08ng?ml-1、肌钙蛋白T0.012ng?ml-1、肌红蛋白31.56ng?ml-1;肾功能:尿素5.31mmol?L-1、肌酐104.0μmol?L-1、尿酸352μmol?L-1;心肌酶谱:磷酸肌酸激酶105U?L-1、肌酸激酶同工酶18U?L-1、乳酸脱氢酶140U?L-1、α-羟丁酸脱氢酶113IU?L-1。结果提示肝肾功能、心肌酶谱等指标基本恢复正常,患者好转出院。

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    2018-10-24 丁鹏鹏
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    2018-03-22 habb
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    2018-03-21 雅文博武

    学习了很多先进的技术水平

    0