探案:发热4月抗生素治疗无效,骨穿PET肺活检,查因成功!

2018-04-17 黄英男、金文婷等 SIFIC感染官微

主诉:反复干咳、发热4月,伴活动后气促3月

一、病史简介

男性,69岁,江苏人,2018-03-01入中山医院感染病科

主诉:反复干咳、发热4月,伴活动后气促3月

现病史:

4月前患者带状疱疹痊愈后出现发热伴干咳、盗汗,T 38℃左右,无畏寒寒战、咳痰气促、胸闷胸痛,未予重视。3月前出现活动后心悸、气促,体温波动于37.5-38℃,当地胸部CT示胸腔积液(未见报告及片子),建议置管引流患者拒绝。

1月余前仍有发热,活动后气促加重,当地医院予静脉抗感染(具体不详)3日无好转。01-28突发气急加重,血检:WBC 2.02*10^9/L,N 70.3%,Hb 76g/L,CRP 93mg/L。胸部CT:左下肺门旁团块影,左肺及右上肺炎症,左侧胸腔积液伴左肺膨胀不全,纵膈淋巴结肿大。

02-02收入当地医院,予亚胺培南1g q8h+莫西沙星0.4g qd抗感染。02-04血检:WBC 2.60 *10^9/L,N 71.9%,Hb 79g/L,CRP 69.5 mg/L。左侧胸腔穿刺引流出淡黄色透明液体,胸水常规:RBC 790/mm3,WBC 1300/mm3,L 80%,李凡他试验(+),ADA 8U/L,胸水涂片找抗酸杆菌(-),胸水细菌+真菌培养(-)。

02-06复查胸部CT:左下肺门旁团块影,右肺炎症较前进展,左肺少许吸收,纵膈淋巴结肿大。02-09调整为亚胺培南1.0 q8h+利奈唑胺0.6 q12h抗感染。02-15 血检:WBC 2.3 *10^9/L ,N 66.1%,Hb 72g/L,CRP 72.8 mg/L。再次调整抗感染方案为哌拉西林/他唑巴坦5.0g iv gtt q12h ,02-20 血常规:WBC 2.4 *10^9/L,N 65.4%,Hb69g/L,CRP 44.8 mg/L。胸部CT:左下肺门旁团块影,左肺炎症,左侧胸腔积液,右肺炎症较前吸收,纵膈淋巴结肿大。患者仍发热,考虑抗感染效果不佳,02-22改为异烟肼+利福平+乙胺丁醇诊断性抗结核,热峰无下降;加用米乐松20mg qd*5天抗炎仍有发热。为明确发热、肺部病灶原因,03-01收入我科。

既往史及个人史:有房颤病史2年,口服华法林2.5mg qd抗凝;高血压病史20余年,血压最高160/100mmHg,口服珍菊片降压;否认糖尿病;否认近6月旅游史、否认生食史、宠物饲养史、禽畜类接触史、拔牙史、昆虫叮咬史、外伤史及发霉物接触史。



二、入院检查(2018-03-01)

体格检查:

T:38.7℃ P:114次/分 R:22次/分 BP:121/82mmHg

浅表淋巴结未及肿大。左下肺呼吸音低。腹平软无压痛,双下肢不肿。

实验室检查:

血气(不吸氧)pH 7.51,氧分压99mmHg,二氧化碳分压32mmHg

血常规 Hb 69g/L,WBC 1.87X109/L,N 57%,L28%

炎症标志物 ESR 93mm/H,CRP 84.1mg/L,PCT 0.13ng/mL

肝肾功能电解质 Alb 27g/L,见可疑M蛋白;sCr 45μmol/L,钙 2.02mmol/L

呼吸道病原体九联检,G试验,血隐球菌荚膜抗原均(-)

T-SPOT A/B 0/4

细胞免疫,甲状腺功能,自身抗体,肿瘤标志物均(-)

血培养 阴性(双侧五瓶)

辅助检查:

03-02 心超:1、双房增大伴轻中度三尖瓣反流 2、主动脉窦部及升主动脉动脉增宽 3、轻度肺动脉高压 4、极少量心包积液

三、临床分析

病史特点:患者老年男性,反复发热、咳嗽气促,伴盗汗,进行性加重,血两系下降,CT示肺部阴影、胸水及纵膈、肺门淋巴结肿大,炎症标记物升高,血培养阴性,多种抗感染治疗无明显好转。诊断和鉴别诊断考虑如下:

1.感染性疾病:

结核感染:患者有低热盗汗咳嗽等症状,胸部CT示单侧为主的胸水,多种抗感染效果不佳,需考虑结核感染可能;但患者T-SPOT阴性,肺部影像学与典型结核感染不甚相符,抗结核治疗后体温好转不明显。当然临床上亦遇到过多次T-SPOT阴性的肺结核,抗结核10天时间较短不一定能正确评价疗效,而且如果无效也有可能是耐药结核因素。可进一步完善胸水ADA及微生物检查,以及痰液、肺活检等的微生物或组织病理检查,以明确或排除诊断。

特殊病原体感染,如奴卡氏菌,放线菌,非结核分枝杆菌(NTM)感染:患者老年男性,发病前有带状疱疹,表明患者存在免疫力低下。肺部多形性病变不排除以上特殊病原体感染可能。诊断需依赖痰、胸水、肺或淋巴结组织的病原学或病理学证据,也可采用非培养的检测方式如基因测序等,后者的敏感性高且检验时间可望明显缩短。

2.非感染性疾病:

肿瘤:患者有低热盗汗,白细胞及血红蛋白减低,肺部占位,纵膈淋巴结肿大,单侧胸腔积液,使用多种抗生素广覆盖、甚至诊断性抗痨后仍无明显好转,需考虑肿瘤,包括实体瘤和血液系统肿瘤。但患者多项肿瘤标记物均无明显升高。进一步检查包括腹盆部CT,胸水找肿瘤细胞、肺部肿块或纵膈淋巴结穿刺等,必要时可完善骨穿+活检及PET/CT等检查。

四、进一步检查、诊治过程和治疗反应

03-02 行左侧胸腔积液穿刺引流,引流出黄色液体。

常规:RBC 1000/mm3,WBC 3200*10^6/L,L 88%,N 12%;

生化:LDH 95.0U/L;总蛋白 42.64g/L;Alb 18.99g/L;Glu 8.40mmol/L;

ADA: 21.0U/L;CEA 2.7ng/mL;

微生物:细菌、真菌涂片和培养,涂片找抗酸杆菌均阴性。

03-03 开始予米诺环素100mg q12h+亚胺培南0.5g q8h抗感染治疗。

03-03 寄生虫抗体:阴性

03-03 免疫固定电泳: 阳性(IgG-λM带);M蛋白浓度:14.3g/L;M蛋白比例:22.4%;

03-04 仍高热,Tmax39.3℃,再次抽血培养

03-05 胸水引流后,复查胸部CT:左下肺病灶较外院02-22进展,仍有少量胸腔积液。腹部增强CT见盆腔少量积液。建议行左下肺病灶穿刺以明确诊断,家属拒绝。



03-06 骨髓穿刺+活检。仍高热,考虑非感染可能大,开始试用甲基强的松龙20mg qd。

03-07 骨髓活检初步报告:骨髓造血组织与脂肪组织比约占70%,造血组织三系细胞均可见到,造血组织中可见到较多增生浆样细胞。

03-08 建议PET/CT检查,家属拒绝。当日回报03-04送检血培养:阴性。

03-09 拔除胸腔引流管。血液科会诊:血液系统疾病目前证据不足,建议:查血清游离轻链、尿轻链;PET/CT了解有无骨质损害及肿瘤性病灶;必要时肺门旁及纵隔淋巴结穿刺或活检;可重复骨髓穿刺。

03-11 骨髓活检正式报告提示对血液系统疾病诊断证据不足,仍发热,再次建议做PET/CT和肺活检以明确诊断。



03-12 PET/CT:考虑为浆细胞瘤累及全身多处骨骼可能性大。



03-12 行CT引导下左下肺病灶穿刺活检。初步病理:肺泡腔内充满纤维性渗出物,肺泡上皮轻度增生,肺泡间隔少量淋巴细胞浸润,近胸膜处可见较多淋巴细胞、浆细胞聚集。

03-14 肺活检免疫组化结果:考虑浆细胞瘤。停用抗感染治疗。

03-15 转至我院血液科进一步治疗。骨髓FISH检测,诊断为多发性骨髓瘤(IgG λ型,DS III期A组 ISS III期)。自03-06至03-20应用甲强龙20mg qd治疗,体温峰值逐渐下降,炎症标志物有所下降。

03-21 行第一周期VCD方案(万珂2.2mg+CTX500mg+DEX40mg,d1,8,15,22)化疗。第一天用药后出现发热,考虑化疗后反应,对症治疗后好转,后体温降至基本正常。

04-02复查胸部CT示肺部病灶较前明显吸收。

04.11第一周期化疗结束,体温平,无咳嗽胸闷等,予以出院。



胸部影像学



炎症标志物



体温情况



五、最后诊断与诊断依据

最后诊断:

浆细胞瘤(多发性骨髓瘤)

诊断依据:

患者老年男性,反复发热伴气急,伴血两系下降,多种抗感染治疗无效;入院查免疫固定电泳阳性,骨髓涂片及病理浆细胞增多;肺穿刺病理见较多淋巴细胞、浆细胞聚集,免疫组化结果示浆细胞明显增生,考虑浆细胞瘤;PET/CT考虑为浆细胞瘤累及全身多处骨骼可能性大,左肺上叶尖后段及下叶、多处淋巴结(纵隔、左肺门、左侧内乳及左侧心膈角)累及可能;两周期化疗后体温转平,肺内病灶明显缩小,故本病诊断明确。

六、经验与体会

发热待查(FUO)病因众多,虽然感染依然是发热待查最重要的原因,但是近年来统计资料显示非感染性疾病所占比例明显增加。上海中山医院感染病科2017年共收治FUO患者199例,164例(82.4%)最终得到明确诊断。最常见的原因是感染性疾病(94例,47.2%),其他病因包括为结缔组织病(23例,11.6%),血液系统疾病(18例,9%),实体恶性肿瘤(15例,7.5%),其他疾病如甲状腺炎等(14例,7%),此外尚有未明确诊断者35例 (17.6%)。

多发性骨髓瘤是一种浆细胞克隆性增生性疾病,是来源于终末分化的B淋巴细胞的恶性肿瘤,特征是骨髓被恶性浆细胞取代,常见的临床表现为骨痛,贫血,肾功能不全,感染等。多数患者起病隐匿,急性细菌感染可为首发表现。本患者以发热起病,但抗感染效果不佳,需要考虑其他原因包括血液系统疾病。

抗菌药物合理应用需要知识和技能训练。对于发热患者,广谱抗生素覆盖的经验性治疗是不少临床医生初始治疗的策略。常规抗感染治疗无效,便可能会一路升级,甚至被戏称为 “大(大扶康)万(万古霉素)能(泰能)”、“美(美平)斯(斯沃)斯(科赛斯)”方案,效果不佳还可能进一步诊断性抗痨治疗。其实,对于抗感染治疗效果不佳,尤其感染不明确的患者,以及有占位性病变、淋巴结肿大的患者,应积极开展病原学检查而不是一味的升级抗菌药物。包括有创检查如各种穿刺,送微生物及病理检查,当然需要病人和家属的理解和支持。本例来我院后,考虑特殊感染或非感染性疾病可能,积极动员病人做骨穿、肺活检和PET/CT,10天后患者家属最终同意接受有创检查,才使疾病得以明确诊断。

PET/CT在发热待查中的作用。PET/CT通过对影像和代谢的有机结合,在发热待查的诊治中发挥重要作用。在其他检查提示有限的情况下, PET/CT可提供思路和鉴别诊断依据。FDG-PET/CT的诊断价值已在一项前瞻性研究和1523例FUO患者的回顾性研究中进行了研究(2)。Keidar等(3)的前瞻性研究纳入48名FUO患者,PET/CT确定了22例(46%)FUO的潜在病因,为90%病例的诊断或排除诊断提供了重要信息。

原始出处:

(1)XC SHI,XQ LIU,BT ZHOU,et al. Major causes of fever of unknown origin at Peking Union Medical College Hospital in the past 26 years, Chin Med J 2013;126(5):808-812

(2) Kouijzer IJE, Mulders-Manders CM, Bleeker-Rovers CP,et al.  Fever of Unknown Origin: the Value of FDG-PET/CT. Semin Nucl Med. 2018;48(2):100-107

(3) Keidar, Z., Gurman-Balbir, A., Gaitini, D. et al. Fever of unknown origin: The role of 18F-FDG PET/CT. J Nucl Med. 2008; 49: 1980–1985

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    2018-08-08 feather89
  2. [GetPortalCommentsPageByObjectIdResponse(id=1727251, encodeId=45e81e272510a, content=<a href='/topic/show?id=986913980dd' target=_blank style='color:#2F92EE;'>#PE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13980, encryptionId=986913980dd, topicName=PE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f06c33759375, createdName=feather89, createdTime=Wed Aug 08 12:57:00 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1278085, encodeId=a2a012e808531, content=<a href='/topic/show?id=d34e6523544' target=_blank style='color:#2F92EE;'>#活检#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65235, encryptionId=d34e6523544, topicName=活检)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c39f145, 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topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-19 smlt2008
  3. 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channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=109a2326858, createdName=122604e1m48暂无昵称, createdTime=Wed Apr 18 11:51:36 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306904, encodeId=30d4306904ca, content=少见的病例.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/22/1442d9106653d5d3fe5964c51c353c1d.jpg, createdBy=62dd2153454, createdName=2066xq, createdTime=Wed Apr 18 08:29:01 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306902, encodeId=15f93069028b, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-19 hb2008ye
  4. 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channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=109a2326858, createdName=122604e1m48暂无昵称, createdTime=Wed Apr 18 11:51:36 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306904, encodeId=30d4306904ca, content=少见的病例.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/22/1442d9106653d5d3fe5964c51c353c1d.jpg, createdBy=62dd2153454, createdName=2066xq, createdTime=Wed Apr 18 08:29:01 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306902, encodeId=15f93069028b, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
  5. 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channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=109a2326858, createdName=122604e1m48暂无昵称, createdTime=Wed Apr 18 11:51:36 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306904, encodeId=30d4306904ca, content=少见的病例.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/22/1442d9106653d5d3fe5964c51c353c1d.jpg, createdBy=62dd2153454, createdName=2066xq, createdTime=Wed Apr 18 08:29:01 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306902, encodeId=15f93069028b, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-19 mfx801
  6. 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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-18 122604e1m48暂无昵称

    学习

    0

  7. 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channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=109a2326858, createdName=122604e1m48暂无昵称, createdTime=Wed Apr 18 11:51:36 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306904, encodeId=30d4306904ca, content=少见的病例.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/22/1442d9106653d5d3fe5964c51c353c1d.jpg, createdBy=62dd2153454, createdName=2066xq, createdTime=Wed Apr 18 08:29:01 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306902, encodeId=15f93069028b, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-18 2066xq

    少见的病例.学习了

    0

  8. 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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-18 龙胆草

    学习谢谢分享

    0

  9. 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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-18 1209e435m98(暂无昵称)

    知道了.谢谢分享

    0

  10. 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createdName=smlt2008, createdTime=Thu Apr 19 14:57:00 CST 2018, time=2018-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1331093, encodeId=90e7133109379, content=<a href='/topic/show?id=15e2140e438' target=_blank style='color:#2F92EE;'>#PET#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14074, encryptionId=15e2140e438, topicName=PET)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=hb2008ye, createdTime=Thu Apr 19 14:57:00 CST 2018, time=2018-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1345226, encodeId=5ee513452266d, content=<a href='/topic/show?id=cd305543152' target=_blank style='color:#2F92EE;'>#抗生素治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=55431, encryptionId=cd305543152, topicName=抗生素治疗)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/D2FD7704B41C9E22364B1E54ABB223BB/100, createdBy=1df22500220, createdName=ms1260584454294838, createdTime=Thu Apr 19 14:57:00 CST 2018, time=2018-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1457308, encodeId=1824145e308dd, content=<a href='/topic/show?id=61ec8215094' target=_blank style='color:#2F92EE;'>#肺活检#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82150, encryptionId=61ec8215094, topicName=肺活检)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=66e95876910, createdName=mfx801, createdTime=Thu Apr 19 14:57:00 CST 2018, time=2018-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306948, encodeId=03ac30694863, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=47, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=109a2326858, createdName=122604e1m48暂无昵称, createdTime=Wed Apr 18 11:51:36 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306904, encodeId=30d4306904ca, content=少见的病例.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/22/1442d9106653d5d3fe5964c51c353c1d.jpg, createdBy=62dd2153454, createdName=2066xq, createdTime=Wed Apr 18 08:29:01 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306902, encodeId=15f93069028b, content=学习谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Nd44v3xHnnictn9UpctwtH62EPQ59TMdI9lnqHMgQ16nH7GmGCfpzicsHgjibYVk6vwSpXrC86gMibRkoaIzf5HwSz7/0, createdBy=78cc1691107, createdName=龙胆草, createdTime=Wed Apr 18 08:17:55 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306868, encodeId=7e913068681e, content=知道了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Apr 18 07:17:03 CST 2018, time=2018-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=306856, encodeId=d9e43068564f, content=学习学习.继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93f31631454, createdName=1dd8c52fm63(暂无匿称), createdTime=Wed Apr 18 07:06:04 CST 2018, time=2018-04-18, status=1, ipAttribution=)]
    2018-04-18 1dd8c52fm63(暂无匿称)

    学习学习.继续关注

    0