糖尿病合并带状疱疹,是周围神经病变吗?

2019-08-29 晨晨 徐乃佳 医学界内分泌频道

患者,男,62岁,以“发现血糖升高30年,低热后出疹1周”。患者于30年前于体检时发现血糖升高,空腹血糖约8-9mmol/l,无口渴多饮多尿体重下降等症状,30年来未予以重视,未行相关诊治,血糖控制情况不详,近2月自觉乏力,体重下降约7kg,门诊以“2型糖尿病”收治入院,病程中偶有头晕,无头痛,偶有视物模糊,无视物旋转,无咳嗽咳痰,无胸闷气短,无恶心呕吐,无腹痛腹泻,无尿频尿急尿痛,偶有指尖麻木,

病史回顾

患者,男,62岁,以“发现血糖升高30年,低热后出疹1周”。患者于30年前于体检时发现血糖升高,空腹血糖约8-9mmol/l,无口渴多饮多尿体重下降等症状,30年来未予以重视,未行相关诊治,血糖控制情况不详,近2月自觉乏力,体重下降约7kg,门诊以“2型糖尿病”收治入院,病程中偶有头晕,无头痛,偶有视物模糊,无视物旋转,无咳嗽咳痰,无胸闷气短,无恶心呕吐,无腹痛腹泻,无尿频尿急尿痛,偶有指尖麻木,饮食睡眠可,二便正常。

特殊病情

1月前无明显诱因出现低热,最高温度可达38度,无明显规律且可自行退热,未予以重视,也未行相关诊治,1周前无意间发现左侧后腰部、左侧下腹部及会阴部出现红疹,无疼痛,但伴有腰痛,持续存在,休息后缓解不明显,夜间疼痛加重,未行相关诊治。

既往病史及个人史

既往高血压病史30年,最高血压185/120mmHg,未治疗;冠心病史15年。吸烟史300支/年;饮酒史160g/天

体格检查

T 37.7℃ P 80次/分 R80次/分 R18次/分 Bp160/100mmHg,神志清楚,精神尚可,左侧后腰部、左侧下腹部及会阴部红疹(未超过中线),无触痛,全身浅表淋巴结未触及肿大,甲状腺不大,双肺呼吸清,未闻及干湿性啰音,心率80次/分,律齐,各瓣膜区未闻及杂音及额外心音,腹软,无压痛反跳痛及肌紧张,肝脾肋下未及,神经系统查体未见明显异常,双下肢未见明显浮肿,双下肢足背动脉减弱。

入院随机血糖16mmol/L。


患者皮肤改变

实验室检查

尿常规:葡萄糖4+ 酮体1+

生化+电解质:空腹血糖9.3mmol/l 总胆固醇 4.6mmol/l(血糖为治疗后第二日空腹血糖),余项目未见明显异常。

糖化血红蛋白:9.3%

血常规、甲状腺功能、肿瘤标志物、电解质未见明显异常。

物理检查

双下肢血管彩超提示:双侧股动脉内膜增厚伴斑块形成。

眼底检查示:双眼糖尿病视网膜病变I期。

上腹部CT示:脾大、脾脏钙化灶,心包少量积液,腹膜后多发淋巴结肿大。

腰椎MR示:腰4-5,腰5-骶1椎间盘膨出,腰椎退行性改变。

分   析

患者糖尿病史30余年,一直未行规范治疗,血糖控制不佳,入院随机血糖高达16mmol/l,尿常规提示酮体阳性,糖尿病酮症诊断明确;实验室检查提示患者伴有周围血管病变及糖尿病视网膜病变,与此同时,患者出现了双侧指尖麻木,鉴于医院条件限制,无法获得肌电图检查结果,但是从患者病程、血糖控制情况以及外周血管病变的情况,可疑诊断为糖尿病周围神经病变。

关于患者的皮肤改变,请皮肤科会诊,诊断为带状疱疹,建议予患者更昔洛韦及干扰素治疗。带状疱疹(HZ)是由水痘带状疱疹病毒(VZV)引起的一种自限性疾病,这种病毒可引起水痘和带状疱疹,水痘主要可引起病毒血症和爆发,之后病毒可继续存在于神经背根和颅神经的感觉神经节;带状疱疹是由于潜伏病毒重新激活所引起,多表现为单侧阶段性皮疹,最初的症状多为皮肤疼痛,极少情况下不出现疼痛,且疼痛可在未出疹前48-72小时就出现,严重者可伴有发热、局部神经根的疼痛甚至可致侵犯区域淋巴结肿大,这种病毒往往侵犯抵抗力减低的人群[1]。

这位病人的复杂之处在于患者皮肤出现的皮疹是患者无意间发现,并无疼痛,这是由于糖尿病病神经病变所致吗?

此外,患者出现的腰痛,事实上患者对于腰痛无法形容疼痛的性质,这是由于带状疱疹侵犯到神经所致还是由于腰椎间盘突出症所致?

 处理1:

征询骨科医生的意见,我们对患者做了一些腰椎间盘突出的专科检查,以及我科糖尿病周围神经病变的检查。

补充查体:直腿抬高阴性,4字试验阴性,10g尼龙丝试验阳性。从上述的检查可以看出,患者的腰痛似乎与腰椎间盘突出的关系并不大,追问病史获知,患者既往并无腰痛病史,且本次出现的腰痛与发热出现的时间一致,考虑本次腰痛的出现可能和带状疱疹侵犯神经所致,此外,通过查体可以看出患者并无皮肤感觉障碍,更加应证了带状疱疹所致腰痛的可能。

患者腹部CT平扫可见到腹膜后淋巴结的肿大,请肿瘤科会诊,建议其完善骨髓穿刺、外周血涂片、结核抗体、以及肿瘤标志物检查,患者拒绝骨髓穿刺,予患者完善了外周血涂片、结核抗体及血沉检查。

 处理2:

针对肿瘤科的会诊意见,我们予患者完善了相关实验室检查:外周血涂片大致正常。血沉为28mm/h,结核抗体为阴性。那么患者腹膜后淋巴结肿大的原因是什么呢?患者拒绝活检,这种淋巴结的肿大是否是带状疱疹所带来的呢?


患者补充的实验室检查结果

治   疗

在上述分析的基础之上,患者诊断为2型糖尿病,糖尿病周围血管病变,糖尿病视网膜病变I期,糖尿病周围神经病变,高血压3级(很高危),冠心病,带状疱疹,治疗上我们除了积极纠正患者糖尿病酮症,对患者糖尿病及相关并发症和伴发的冠心病高血压进行了治疗以外,同时遵循皮肤科会诊意见,予患者抗病毒治疗,在治疗1周以后,患者腰痛明显缓解,皮肤疱疹开始结痂,病情好转后出院。

本例患者虽然缺乏带状疱疹血清学检查结果(实验室无法做血清学检查),但后续抗病毒治疗对于患者皮肤结痂好转和腰痛的改善证实了腰痛和带状疱疹的相关性,这体现了查体和病史追问对本例患者的诊断的重要性。

此外,本例患者仍然存留的问题仍然是腹膜后淋巴结肿大,到底与带状疱疹是否相关,仍然是谜,我们建议患者出院1月后复查,我们期待后续的随访结果!

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    2019-09-01 724765917_36481625

    学习了

    0

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    2019-08-31 axin012
  4. [GetPortalCommentsPageByObjectIdResponse(id=1748281, encodeId=60ea1e482819a, content=<a href='/topic/show?id=15b33952464' target=_blank style='color:#2F92EE;'>#周围神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39524, encryptionId=15b33952464, topicName=周围神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f00136108751, createdName=Smile2692, createdTime=Fri Jan 10 07:37:00 CST 2020, time=2020-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=372133, encodeId=bcbb3e21338f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/13/e51eda1902bf3197b7b2a48e1ba1e39c.jpg, createdBy=6a672335244, createdName=724765917_36481625, createdTime=Sun Sep 01 22:55:48 CST 2019, time=2019-09-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1491349, encodeId=de08149134952, content=<a href='/topic/show?id=5316e4387aa' target=_blank style='color:#2F92EE;'>#神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74387, encryptionId=5316e4387aa, topicName=神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1ab48885684, createdName=axin012, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1500399, encodeId=1bab1500399f3, content=<a href='/topic/show?id=ecdfe438970' target=_blank style='color:#2F92EE;'>#神经病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74389, encryptionId=ecdfe438970, topicName=神经病变)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ea69427176, createdName=lingaifan, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1580437, encodeId=91e7158043ed9, content=<a href='/topic/show?id=c026e05485f' target=_blank style='color:#2F92EE;'>#疱疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70548, encryptionId=c026e05485f, topicName=疱疹)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2dcf16628144, createdName=ms2694732865965676, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1042659, encodeId=c3e610426598a, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Thu Aug 29 22:37:00 CST 2019, time=2019-08-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=371980, encodeId=75943e198016, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Thu Aug 29 21:31:19 CST 2019, time=2019-08-29, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1748281, encodeId=60ea1e482819a, content=<a href='/topic/show?id=15b33952464' target=_blank style='color:#2F92EE;'>#周围神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39524, encryptionId=15b33952464, topicName=周围神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f00136108751, createdName=Smile2692, createdTime=Fri Jan 10 07:37:00 CST 2020, time=2020-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=372133, encodeId=bcbb3e21338f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/13/e51eda1902bf3197b7b2a48e1ba1e39c.jpg, createdBy=6a672335244, createdName=724765917_36481625, createdTime=Sun Sep 01 22:55:48 CST 2019, time=2019-09-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1491349, encodeId=de08149134952, content=<a href='/topic/show?id=5316e4387aa' target=_blank style='color:#2F92EE;'>#神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74387, encryptionId=5316e4387aa, topicName=神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1ab48885684, createdName=axin012, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1500399, encodeId=1bab1500399f3, content=<a href='/topic/show?id=ecdfe438970' target=_blank style='color:#2F92EE;'>#神经病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74389, encryptionId=ecdfe438970, topicName=神经病变)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ea69427176, createdName=lingaifan, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1580437, encodeId=91e7158043ed9, content=<a href='/topic/show?id=c026e05485f' target=_blank style='color:#2F92EE;'>#疱疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70548, encryptionId=c026e05485f, topicName=疱疹)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2dcf16628144, createdName=ms2694732865965676, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1042659, encodeId=c3e610426598a, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Thu Aug 29 22:37:00 CST 2019, time=2019-08-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=371980, encodeId=75943e198016, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Thu Aug 29 21:31:19 CST 2019, time=2019-08-29, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1748281, encodeId=60ea1e482819a, content=<a href='/topic/show?id=15b33952464' target=_blank style='color:#2F92EE;'>#周围神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39524, encryptionId=15b33952464, topicName=周围神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f00136108751, createdName=Smile2692, createdTime=Fri Jan 10 07:37:00 CST 2020, time=2020-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=372133, encodeId=bcbb3e21338f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/13/e51eda1902bf3197b7b2a48e1ba1e39c.jpg, createdBy=6a672335244, createdName=724765917_36481625, createdTime=Sun Sep 01 22:55:48 CST 2019, time=2019-09-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1491349, encodeId=de08149134952, content=<a href='/topic/show?id=5316e4387aa' target=_blank style='color:#2F92EE;'>#神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74387, encryptionId=5316e4387aa, topicName=神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1ab48885684, createdName=axin012, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1500399, encodeId=1bab1500399f3, content=<a href='/topic/show?id=ecdfe438970' target=_blank style='color:#2F92EE;'>#神经病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74389, encryptionId=ecdfe438970, topicName=神经病变)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ea69427176, createdName=lingaifan, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1580437, encodeId=91e7158043ed9, content=<a href='/topic/show?id=c026e05485f' target=_blank style='color:#2F92EE;'>#疱疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70548, encryptionId=c026e05485f, topicName=疱疹)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2dcf16628144, createdName=ms2694732865965676, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1042659, encodeId=c3e610426598a, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Thu Aug 29 22:37:00 CST 2019, time=2019-08-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=371980, encodeId=75943e198016, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Thu Aug 29 21:31:19 CST 2019, time=2019-08-29, status=1, ipAttribution=)]
    2019-08-29 misszhang

    谢谢MedSci提供最新的资讯

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1748281, encodeId=60ea1e482819a, content=<a href='/topic/show?id=15b33952464' target=_blank style='color:#2F92EE;'>#周围神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39524, encryptionId=15b33952464, topicName=周围神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f00136108751, createdName=Smile2692, createdTime=Fri Jan 10 07:37:00 CST 2020, time=2020-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=372133, encodeId=bcbb3e21338f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/13/e51eda1902bf3197b7b2a48e1ba1e39c.jpg, createdBy=6a672335244, createdName=724765917_36481625, createdTime=Sun Sep 01 22:55:48 CST 2019, time=2019-09-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1491349, encodeId=de08149134952, content=<a href='/topic/show?id=5316e4387aa' target=_blank style='color:#2F92EE;'>#神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74387, encryptionId=5316e4387aa, topicName=神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1ab48885684, createdName=axin012, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1500399, encodeId=1bab1500399f3, content=<a href='/topic/show?id=ecdfe438970' target=_blank style='color:#2F92EE;'>#神经病变#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74389, encryptionId=ecdfe438970, topicName=神经病变)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ea69427176, createdName=lingaifan, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1580437, encodeId=91e7158043ed9, content=<a href='/topic/show?id=c026e05485f' target=_blank style='color:#2F92EE;'>#疱疹#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70548, encryptionId=c026e05485f, topicName=疱疹)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2dcf16628144, createdName=ms2694732865965676, createdTime=Sat Aug 31 10:37:00 CST 2019, time=2019-08-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1042659, encodeId=c3e610426598a, content=谢谢MedSci提供最新的资讯, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=misszhang, createdTime=Thu Aug 29 22:37:00 CST 2019, time=2019-08-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=371980, encodeId=75943e198016, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Thu Aug 29 21:31:19 CST 2019, time=2019-08-29, status=1, ipAttribution=)]
    2019-08-29 一个字-牛

    学习了谢谢分享

    0

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