胸闷气短本以为心脏病 没承想竟是

2018-05-18 熊长明 肺血管病

40岁男性患者,因间断低热2年,活动后气短、胸闷入院。患者自发病以来,体重明显下降,食欲缺乏。入院诊断:1.先心病,肺动脉狭窄?2.感染性心内膜炎。行超高速CT显示,前纵隔占位性病变,侵及主肺动脉及左右肺动脉,致肺动脉管腔狭窄,右心室增大。本例患者曾被误诊为先心病、肺动脉瓣上狭窄以及肺栓塞等疾病。患者到底所患何病?请阅读以下病例。

40岁男性患者,因间断低热2年,活动后气短、胸闷入院。患者自发病以来,体重明显下降,食欲缺乏。入院诊断:1.先心病,肺动脉狭窄?2.感染性心内膜炎。行超高速CT显示,前纵隔占位性病变,侵及主肺动脉及左右肺动脉,致肺动脉管腔狭窄,右心室增大。本例患者曾被误诊为先心病、肺动脉瓣上狭窄以及肺栓塞等疾病。患者到底所患何病?请阅读以下病例。

临床资料】

患者,男,40岁。因间断低热2年,活动后胸闷﹑气短2个月于1998年6月17日入院。患者于1996年4月始无明显诱因出现间断低热,T 37~38℃,伴双肩酸痛,当地医院以“感冒”治疗。1997年9月因发热住院检查发现心脏杂音,超声心动图发现肺动脉瓣上狭窄。此后自觉体力下降,快步上三楼感胸闷﹑气短,乏力。1998年4月活动耐力明显下降,轻微活动感气短,并伴反复低热。患者发病以来,体重明显减轻,食欲缺乏,乏力。

入院查体:BP 90/70mmHg,R 18次/分,双肺闻及散在干鸣音,HR 84次/分,律齐,P2亢进分裂,胸骨左缘2~3肋间闻及3级收缩期喷射性杂音,向颈部传导。肝脾无肿大,双下肢无水肿。入院诊断:1.先心病,肺动脉瓣上狭窄?2.感染性心内膜炎

实验室检查:动脉血气:pH 7.43,PCO2 28.2mmHg,PO2 60.5mmHg,HCO3 -18.8mmol/L,BE-0.3mmol/L。血沉 44mm/h。

心电图:右心室肥厚。

经食管超声心动图:主肺动脉及左右肺动脉内栓塞,卵圆孔开放,右心室舒张末内径:34mm,右心房内径增大,左心室舒张末内径35mm,左心房内径19mm,估测肺动脉收缩压95mmHg,左心室EF:77%。

放射性核素肺灌注检查:心影增大,双肺影像清晰,形态完整,未见明显呈肺段分布的放射性稀疏﹑缺损区。

超高速CT:前纵隔占位性病变,侵及主肺动脉及左右肺动脉,致肺动脉管腔狭窄,右心室增大,考虑前纵隔恶性肿瘤(如恶性畸胎瘤等)。

核磁共振成像:前纵隔巨大占位性肿块,并局部浸润生长,右心室增大,前纵隔恶性肿瘤可能性大。

最后诊断:1.纵隔肿瘤,畸胎瘤可能性大。2.继发肺动脉狭窄。

【讨论】

原发性纵隔肿瘤并不少见,据上海市胸科医院报道的1228例纵隔肿瘤中,以胸腺瘤最为常见,其次是神经源性肿瘤和畸胎瘤,这些肿瘤多数为良性,但有恶变可能。生长在前纵隔的肿瘤以畸胎瘤较为常见,可发生于任何年龄,但半数病例症状出现在20~40岁之间,畸胎瘤常可恶变为表皮样癌或腺癌。文献报道386例畸胎瘤,其中14.2%呈恶变。畸胎瘤体积小者常无症状,多在X线检查中发现,若瘤体增大压迫邻近器官,则可产生相应器官的压迫症状,本例前纵隔肿瘤压迫并浸润主肺动脉及左右肺动脉致肺动脉狭窄,导致右心室增大,肺动脉高压,最后引起右心衰竭。当患者以某一器官受压的症状为主要临床表现时,容易造成误诊。本例患者曾被诊断为先心病,肺动脉瓣上狭窄以及肺栓塞等疾病。因此,临床上对任何一例患者都应仔细分析病史和辅助检查,才能减少(特别是某些少见疾病)误诊和漏诊。

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    2018-05-31 cxg966504

    感谢分享.

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    2018-05-18 wxl882001

    了解一下

    0

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