19例初诊为肺炎的急性肺血栓栓塞症临床特点及鉴别诊断
摘要
目的探讨初诊为肺炎的急性肺血栓栓塞症(PTE)临床特点,并总结其鉴别诊断方法。方法对初诊为肺炎的PTE患者的临床资料作回顾性分析。结果本组患者中男14例、女5例,年龄28～86(68. 95±14. 96)岁。临床症状:呼吸困难15例(78. 9%)、胸痛11例(57. 9%)、咯血7例(36. 8%)。体征:下肢水肿8例(42. 1%)。实验室检查:D-二聚体升高19例(19/19)。血气分析:动脉血二氧化碳分压<35 mm Hg 7例(36. 8%),肺泡-动脉氧分压差增大11例(73. 3%)。超声心动图:三尖瓣反流8例(42. 1%),肺动脉压增高7例(36. 8%),右心房扩大4例(21. 1%)。下肢静脉超声:下肢深静脉血栓(DVT) 7例(7/10)。CT肺动脉造影(CTPA):多肺叶病灶10例(52. 6%)、肺动脉扩张8例(42. 1%); CT血管成像:DVT(15/18)。结论在初诊肺炎的PTE患者中,临床常表现为呼吸困难、胸痛或咯血,并伴有下肢水肿。若初诊肺炎的患者中出现肺泡-动脉氧分压差增大、低碳酸血症、DVT、三尖瓣反流或肺动脉高压等表现提示PTE的可能,应尽早行CTPA。
引文
[1] Giordano NJ,Jansson PS,Young MN,et al. Epidemiology,pathophysiology,stratification,and natural history of pulmonary embolism[J]. Tech Vasc Interv Radiol,2017,20(3):135-140.
[2]Jimenez D,de Miguel-Diez J,Guijarro R,et al. Trends in the management and outcomes of acute pulmonary embolism:analysis from the RIETE registry[J]. J Am Coll Cardiol,2016,67(2):162-170.
[3]Tan S,Haramati LB. Overdiagnosis versus misdiagnosis of pulmonary embolism[J]. Am J Roentgenol,2016,206(4):59.
[4]Hendriksen JM,Koster-van Ree M,Morgenstern MJ,et al. Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care:a retrospective observational study[J].BMJ Open,2017,7(3):e012789.
[5]于海建,王灿良,蒋兰茂,等.肺栓塞99例临床特点及误诊原因[J].中国老年学杂志,2015,35(22):6475-6477.
[6]贾卫滨,张春秀,顼志敏.中国肺动脉栓塞误诊近四年文献分析[J].中华心血管病杂志,2006,34(3):277-280.
[7]梁振宇,蔡绍曦,佟万成,等.肺栓塞首诊失误原因分析[J].南方医科大学学报,2009,29(3):509-511.
[8]贾志艳.肺栓塞老年患者的临床特点及误诊分析[J].中国现代药物应用,2014,8(21):47.
[9]刘艳君,欧阳松云,孙培宗,等.肺栓塞误诊为社区获得性肺炎1例并文献复习[J].河南医学研究,2016,25(2):268-269.
[10]中华医学会呼吸病学分会肺栓塞与肺血管病学组,中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会,全国肺栓塞与肺血管防治协作组.肺血栓栓塞症诊治与预防指南[J].中华医学杂志,2018,98(14):7-8.
[11]宋莉红,肖红丽,辛德莉,等.成人肺炎支原体急性感染致社区获得性肺炎的临床特征:一项多中心横断面研究[J].中华危重病急救医学,2016,28(6):492-497.
[12]Zhang Y,Zhou Q,Zou Y,et al. Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia:a prospective cohort study[J]. J Thromb Thrombolysis,2016,41(4):619-627.
[13]Miniati M,Prediletto R,Formichi B,et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism[J]. Am J Respir Crit Care Med,1999,159(3):864-871.
[14]Wells PS,Ginsberg JS,Anderson DR,et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism[J]. Ann Intern Med,1998,129(12):997-1005.
[15]赵军,周玉民,黎书梅,等. 50例误诊为肺炎的肺栓塞患者的临床特点分析[J].实用心脑肺血管病杂志,2016,24(11):93-95.
[16]俞斌,季英,禹宝庆.下肢深静脉血栓的诊断及治疗进展[J].中国骨与关节损伤杂志,2017,32(1):109-111.
[17]余浩,万圣云,孔令尚,等.下肢深静脉血栓形成并发肺动脉栓塞的策略探讨[J].医学信息,2017,30(1):36-37.
[18]Paparoupa M,Spineli L,Framke T,et al. Pulmonary embolism in pneumonia:still a diagnostic challenge results of a case-control study in 100 patients[J]. Dis Markers,2016:8682506.
[19]Geibel A,Zehender M,Kasper W,et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism[J]. Eur Respir J,2005,25(5):843-848.
[20]Moore AJE,Wachsmann J,Chamarthy MR,et al. Imaging of acute pulmonary embolism:an update[J]. Cardio vasc Diagn Ther,2018,8(3):225-243.
[21]中华医学会放射学会心胸学组.急性肺血栓栓塞放射学检查技术方案与诊断共识[J].中华放射学杂志,2012,46(12):1066-1070.
[22]Stein PD,Fowler SE,Goodman LR,et al. Multidetector computed tomography for acute pulmonary embolism[J]. N Engl J Med,2006,354(22):2317-2327.
[23]中华医学会,中华医学会杂志社,中华医学会全科医学分会,等.成人社区获得性肺炎基层诊疗指南[J].中华全科医师杂志,2019,18(2):3.
[2]Jimenez D,de Miguel-Diez J,Guijarro R,et al. Trends in the management and outcomes of acute pulmonary embolism:analysis from the RIETE registry[J]. J Am Coll Cardiol,2016,67(2):162-170.
[3]Tan S,Haramati LB. Overdiagnosis versus misdiagnosis of pulmonary embolism[J]. Am J Roentgenol,2016,206(4):59.
[4]Hendriksen JM,Koster-van Ree M,Morgenstern MJ,et al. Clinical characteristics associated with diagnostic delay of pulmonary embolism in primary care:a retrospective observational study[J].BMJ Open,2017,7(3):e012789.
[5]于海建,王灿良,蒋兰茂,等.肺栓塞99例临床特点及误诊原因[J].中国老年学杂志,2015,35(22):6475-6477.
[6]贾卫滨,张春秀,顼志敏.中国肺动脉栓塞误诊近四年文献分析[J].中华心血管病杂志,2006,34(3):277-280.
[7]梁振宇,蔡绍曦,佟万成,等.肺栓塞首诊失误原因分析[J].南方医科大学学报,2009,29(3):509-511.
[8]贾志艳.肺栓塞老年患者的临床特点及误诊分析[J].中国现代药物应用,2014,8(21):47.
[9]刘艳君,欧阳松云,孙培宗,等.肺栓塞误诊为社区获得性肺炎1例并文献复习[J].河南医学研究,2016,25(2):268-269.
[10]中华医学会呼吸病学分会肺栓塞与肺血管病学组,中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会,全国肺栓塞与肺血管防治协作组.肺血栓栓塞症诊治与预防指南[J].中华医学杂志,2018,98(14):7-8.
[11]宋莉红,肖红丽,辛德莉,等.成人肺炎支原体急性感染致社区获得性肺炎的临床特征:一项多中心横断面研究[J].中华危重病急救医学,2016,28(6):492-497.
[12]Zhang Y,Zhou Q,Zou Y,et al. Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia:a prospective cohort study[J]. J Thromb Thrombolysis,2016,41(4):619-627.
[13]Miniati M,Prediletto R,Formichi B,et al. Accuracy of clinical assessment in the diagnosis of pulmonary embolism[J]. Am J Respir Crit Care Med,1999,159(3):864-871.
[14]Wells PS,Ginsberg JS,Anderson DR,et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism[J]. Ann Intern Med,1998,129(12):997-1005.
[15]赵军,周玉民,黎书梅,等. 50例误诊为肺炎的肺栓塞患者的临床特点分析[J].实用心脑肺血管病杂志,2016,24(11):93-95.
[16]俞斌,季英,禹宝庆.下肢深静脉血栓的诊断及治疗进展[J].中国骨与关节损伤杂志,2017,32(1):109-111.
[17]余浩,万圣云,孔令尚,等.下肢深静脉血栓形成并发肺动脉栓塞的策略探讨[J].医学信息,2017,30(1):36-37.
[18]Paparoupa M,Spineli L,Framke T,et al. Pulmonary embolism in pneumonia:still a diagnostic challenge results of a case-control study in 100 patients[J]. Dis Markers,2016:8682506.
[19]Geibel A,Zehender M,Kasper W,et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism[J]. Eur Respir J,2005,25(5):843-848.
[20]Moore AJE,Wachsmann J,Chamarthy MR,et al. Imaging of acute pulmonary embolism:an update[J]. Cardio vasc Diagn Ther,2018,8(3):225-243.
[21]中华医学会放射学会心胸学组.急性肺血栓栓塞放射学检查技术方案与诊断共识[J].中华放射学杂志,2012,46(12):1066-1070.
[22]Stein PD,Fowler SE,Goodman LR,et al. Multidetector computed tomography for acute pulmonary embolism[J]. N Engl J Med,2006,354(22):2317-2327.
[23]中华医学会,中华医学会杂志社,中华医学会全科医学分会,等.成人社区获得性肺炎基层诊疗指南[J].中华全科医师杂志,2019,18(2):3.