肾内、泌尿、感染、急诊病例分享

肾内、泌尿、感染、急诊病例分享 History 病史 A 61-year-old woman presents with septic shock. 患者女性，61岁，脓毒性休克 一、 Which of the following is shown in this ultrasound image of the right kidney? 下图为右肾超声图像，以下说法正确的是: 1、 Mirror-image artifact obscuring the normal kidney 2、 Dirty shadowing from gas 3、 Clean shadowing from a staghorn calculus 4、 Aliasing related to a medullary sponge kidney 1、 镜面伪像使正常的肾脏结构模糊不清 2、 气体产生的边缘模糊的声影 3、 鹿角状结石产生的边缘清晰的声影 4、 与髓质海绵肾相关的叠影 二、 CT of the abdomen and pelvis is obtained. Given the imaging findings, the patient most likely has a history of which of the following? 下图为腹部和盆腔CT，根据图像显示，该患者最有可能有以下哪种病史: 1、 Von Hippel-Lindau syndrome 2、 Lithium use 3、 Diabetes mellitus 4、 Sickle cell trait 1、 希佩尔-林道综合征(VHL)综合征 2、 使用含锂制剂 3、 糖尿病 4、 镰状细胞性贫血 三、 Emphysematous pyelonephritis is usually managed by which of the following? 气肿性肾盂肾炎通常采用以下哪种方法治疗, 1、 Better glucose control 2、 Conservative management 3、 Immunosuppression 4、 Drainage or surgery 1、 进一步控制血糖 2、 保守治疗 3、 免疫制剂 、 利尿或手术治疗 4 四、 Which is the most common cause of emphysematous pyelonephritis? 气肿性肾盂肾炎最常见的病因是, 1、 Escherichia coli 2、 Proteus 3、 Adenovirus 4、 Schistosomiasis 5、 大肠杆菌感染 6、 变形杆菌感染 7、 腺病毒感染 8、 血吸虫感染 Ultrasound demonstrates "dirty shadowing" related to the large amount of gas in the renal parenchyma and perirenal space (arrows). 超声显示在肾实质和肾周间隙(箭头所示)因气体产生了边界不清的声影。 This axial CT image with soft-tissue windows shows gas replacing the renal parenchyma (arrow) as well as a large amount of perinephric gas. 软组织轴向CT显示气体替代了肾实质(箭头所示)和肾周围有大量的气体。 This axial CT image with lung windows better depicts the amount of gas replacing the renal parenchyma (arrow) as well as the perinephric gas. 肺窗轴向CT更清晰的显示了大量的气体替代了肾实质(箭头所示)和肾周围有大量 的气体。 his axial CT image of the patient in the decubitus position was obtained following the placement of a 14F catheter into the perirenal space (arrow). 该图为在患者肾周间隙放置14F导管(箭头所示)后的卧位轴向CT。 This plain film image shows a right-sided drainage catheter. Foci of gas can still be seen (arrow). 该平片显示的是右侧导尿管，仍然可以看到气体影像(箭头所示)。 Diagnosis 诊断 Emphysematous pyelonephritis 气肿性肾盂肾炎 Case Points 病例要点 1、 Imaging findings include cortical destruction and the presence of gas, which may produce a gas-fluid level on CT or dirty shadowing on ultrasound. 2、 Emphysematous pyelonephritis is typically seen in immunocompromised patients, including poorly controlled diabetics. 3、 Causative agents include E. coli and Klebsiella. 4、 Prompt treatment with drainage and/or nephrectomy is required. 5、 图像可见肾脏皮质破坏，气体充盈，在CT上可见气-液线，超声图像上可见边界不清的 声影。 6、 气肿性肾盂肾炎一般见于免疫力低下的患者，包括控制不好的糖尿病患者。 7、 该病的致病因子包括大肠杆菌和克雷伯氏菌。 8、 该病应迅速采用导尿和/或肾切除术治疗。 Discussion Emphysematous pyelonephritis is a severe infection of the kidney, almost always seen in patients with poorly controlled diabetes mellitus. However, once emphysematous pyelonephritis has developed, the severity of the underlying diabetes has no correlation to mortality rates. Instead, the presence of thrombocytopenia, altered level of consciousness, and shock are predictors of poor prognosis. Causative agents are usually bacteria, most commonly E. coli, but Klebsiella and Proteus are also often culprits. On CT, emphysematous pyelonephritis can be divided into two categories. Type 1 is more aggressive and involves replacement of renal parenchyma by gas. Type 2 involves fluid collections with a smaller foci of gas. Type 1 tends to have a more aggressive course and worse clinical prognosis. Mortality rates of type 1 emphysematous pyelonephritis are nearly 70%, so prompt intervention is necessary. The gas of emphysematous pyelonephritis corresponds to areas of dirty shadowing due to reverberation artifact on sonographic imaging. Care must be taken to ensure that bowel loops are not mistaken for emphysematous pyelonephritis. Gas may also be seen on plain film radiography and should not be overlooked. However, CT is considered the mainstay in diagnosing and evaluating this disease.