病例:一位反复发热、干咳伴胸痛的少女

2018-07-10 佚名 中国循环杂志

外院就诊查血沉63~93 mm/h,CRP 16.75~76.87 mg/L;肺部CT可见左肺中上叶斑片状密度增高影(治疗后吸收)、双侧胸膜增厚、左肺沿胸膜下分布斑片实变影;风湿科相关抗体阴性;给予抗感染治疗效果欠佳。

阜外医院肺血管诊治中心熊长明、曾绮娴等遇到这样一例年轻蹊跷患者。

患者女性,19岁,因“反复发热、干咳、胸痛、气短 11 个月”入院。

外院就诊查血沉63~93 mm/h,CRP 16.75~76.87 mg/L;肺部CT可见左肺中上叶斑片状密度增高影(治疗后吸收)、双侧胸膜增厚、左肺沿胸膜下分布斑片实变影;风湿科相关抗体阴性;给予抗感染治疗效果欠佳。

入院查体:体温:36.5℃;双肺野、肩胛间区及胸骨左缘第二肋间闻及血管杂音。

实验室检查:ESR 76 mm/h; CRP 65.5 mg/L。心电图提示右心肥厚,电轴右偏。超声心动图示肺动脉扩张,估测肺动脉收缩压 84 mmHg。初步诊断为“肺动脉高压待查”。

患者为年轻女性,炎性指标升高,查体可闻及肺血管杂音,筛查主动脉及肺动脉CTA显示:主动脉及其分支未见明显异常;主肺动脉及左右肺动脉管壁偏厚,双侧肺动脉各叶、段分支管腔偏细,走行僵硬,可见多发狭窄,未见血栓征像(图 1)。



行右心导管检查:肺动脉收缩压、舒张压和平均压分别为 63、5 和 22 mmHg,肺小动脉楔压 8 mmHg,全肺阻力 310.19 dyn·s/cm5。

该例患者的肺动脉压力有其特殊之处,由于肺动脉广泛狭窄,管壁僵硬,肺动脉舒张压明显低,造成肺动脉平均压不高,但其收缩压还是明显升高,因此诊断为肺动脉高压。最后诊断:大动脉炎累及肺动脉,多发肺动脉狭窄,肺动脉高压。

为进一步评估病情活动性,查肺动脉磁共振成像(MRI):双侧肺动脉分支管壁偏细,走行僵硬,多发狭窄,主肺动脉管壁增厚及纤维化;肺动脉高压(图 2)。18F-FDG-PET:主肺动脉、左右肺动脉及双肺下叶动脉代谢不均匀增高(图 3)。


患者目前处于血管炎活动期,治疗给以足量激素(0.8~1 mg/kg)强的松60 mg qd 口服;联合环磷酰胺 0.4 g,每周静点一次;并应用华法林预防血栓。

熊长明等指出,大动脉炎累及肺动脉者并不少见,但单纯累及肺动脉者不多。当患者出现咳嗽、咯血、胸痛、呼吸困难等症状,抗感染治疗效果欠佳,并反复出现沿胸膜下分布的肺部阴影,或者肺动脉段以下多发肺栓塞时应考虑到大动脉炎累及肺动脉的可能。

需要警惕的是,很多单纯累及肺动脉的患者临床进展隐匿,就诊时就已出现肺动脉高压及右心衰竭,需要临床医生提高诊断意识,早发现,早治疗。

如何准确判断 TA 活动性是临床中的一大难题,现多采用美国国立卫生研究所推荐的标准:

⑴系统症状再发和加重;

⑵ ESR 升高;

⑶新近出现器官缺血和炎性活动的症状、体征;

⑷血管造影显示血管病变加重。

然而该标准对于单纯累及肺动脉者并不实用。近来研究发现,影像学检查通过对血管壁的分析,可以判断受累血管的范围、监测血管炎症的活动及是否出现血管并发症,对于大动脉炎早期诊断、病情及预后评估有重要价值。

原始出处:曾绮娴, 熊长明. 大动脉炎单纯累及肺动脉一例. 中国循环杂志,2018, 33: 287.

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  1. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2022-09-24 gqylhd

    肺动脉受累

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2019-03-12 bioon15
  3. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2018-07-14 Charm0707

    又开阔了思路!

    0

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    2018-07-12 感谢上帝

    非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2018-07-11 白袍甘道夫

    学习了

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2018-07-11 lyh994

    学习.谢谢分享

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=2090065, encodeId=afbd2090065fd, content=肺动脉受累, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Sep 24 07:23:05 CST 2022, time=2022-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1743719, encodeId=8ec01e43719d3, content=<a href='/topic/show?id=234a48e040a' target=_blank style='color:#2F92EE;'>#干咳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48704, encryptionId=234a48e040a, topicName=干咳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=561635200442, createdName=bioon15, createdTime=Tue Mar 12 22:41:00 CST 2019, time=2019-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331494, encodeId=05ac331494b1, content=又开阔了思路!, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/lpHJrtHiaxD12exW6icPqClj8O6xY2tlsEWan5wGcdf8dMDibWwR2icMGXFoUFSPTM8NgnV9BVruu23J0v2KKXicnlw/132, createdBy=2e682361427, createdName=Charm0707, createdTime=Sat Jul 14 09:52:17 CST 2018, time=2018-07-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=331124, encodeId=15fd3311246f, content=非常好.感谢!这种情况还可以考虑其他的疾病吗?鉴别诊断, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82f32400712, createdName=感谢上帝, createdTime=Thu Jul 12 18:15:25 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330981, encodeId=708d33098136, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Thu Jul 12 05:24:30 CST 2018, time=2018-07-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330849, encodeId=1ba333084975, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/10/17/33f971601e45370716a5daf5304c5753.jpg, createdBy=caf52395744, createdName=白袍甘道夫, createdTime=Wed Jul 11 14:33:31 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330817, encodeId=724b33081ed1, content=学习.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/04/24/1c2dbd6706e64df33befd6663f1d6b37.jpg, createdBy=94f61661779, createdName=lyh994, createdTime=Wed Jul 11 10:11:30 CST 2018, time=2018-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330771, encodeId=c97f330e7141, content=好文献学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Jul 11 07:10:56 CST 2018, time=2018-07-11, status=1, ipAttribution=)]
    2018-07-11 张新亮1853311252142e2fm

    好文献学习了

    0

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