Case Discussion A 55 year-old man suffered from fever and consciousness disturbance for two days. Brief History The 55 year-old man was rather well before except abnormal blood glucose level was noted occasionally. Fever was noted on July 29,2000 without cough, sneeze, abdominal pain, diarrhea and dysuria. Headache and nausea developed one day later and these symptoms can be relieved transiently after taking medication. The condition deteriorated with vomiting and persistent fever. He was noticed to become disoriented on the morning of the first of August and could not respond adequately to her wife. He was sent to a community hospital where seizure attacked on arrival. General convulsion and consciousness loss ensured and endotracheal intubation was done. Lumbar puncture was performed and pus-like material was aspirated. Ceftriaxone 1gm was given immediately under the impression of bacterial meningitis. He was transferred to NTUH for further management. Physically, his consciousness was E1M1VT . Blood pressure was 121/74 mmHg and temperature was 37.8 °C. The pulse rate was 142 beats per minute and no spontaneous respiration was noted. Head was grossly normal. Conjunctiva was not pale and sclera was not icteric. Neck was stiff to the degree of two finger-width. Breath sound was clear and chest expansion was symmetric. Regular heart beat without murmur was disclosed. Abdomen was soft and flat and bowel sound was normoactive. Liver and spleen were not palpable. Extremities showed no petechiae and edema. Laboratory Data 1. CBC   WBC (K/μL) RBC (M/μL) HB (g/dL) MCV (fL) PLT (K/μL) Band (%) Seg (%) 8/1 9.42 4.74 14.3 87.1 74.0 23 68 8/5 18.22 3.49 10.4 90.3 34.0     2. ABG   pH PCO2(mmHg) PO2(mmHg) HCO3-(mEq/L) B.E(mEq/L) FiO2(PEEP) Ventilator Mode 8/1 7.41 18 82.9 11.3 -11.0 0.4 (5) CMV 8/4 7.02 41.3 62.7 10.2 -19.7 1.0 (10) CMV 3. BCS     Glu(mg/dL) T-Bil(mg/dL) D-Bil(mg/dL) AST(U/L) ALT(U/L) BUN mg/dL Cre mg/dL 8/2 434 2.1 1.4 44 58 34 2.0 8/7 257 9.8 7.3 350 472 70 7.8 4. Coagulation profile   PT PTT Fibrinogen (mg/dL) 3P FDP (μg/mL) D-Dimer 8/1 15.2/11.9 54.5/38.1 858 4+ 160-320 12.25 8/7 20.5/12.1 69.0/38.7   4+ 80-160 17.35 5. CSF study    WBC (/μL) L:N Gram's stain Acid fast stain Total protein LDH 8/1 20736 576:20160 G(-) bacilli negative 4.2 69900 Clinical Course & Treatment  After admission, ceftriaxone 2gm q12h and penicillin G 3MU q4h were given under the impression of bacterial meningitis. Cerebrospinal fluid examination showed marked pleocytosis with neutrophil in majority and cerebrospinal fluid smear revealed gram negative bacilli. Penicillin G was discontinued. Head computed tomography showed diffuse brain swelling and mannitol 150 mL q8h was given under the impression of increased intracranil pressure. Septic shock was impressed since August 1. Cerebrospinal fluid culture yielded Klebsiella pneumoniae which was sensitive to ceftriaxone. He was found to have red eyes with chemosis during hospitalization. Ophthalmologist was consulted under the impression of endophthalmolitis. Intravitreal injection with imipenem was given. Abdominal echo was performed on August 3 with negative findings. Repeat lumbar puncture showed elevated intrathecal pressure (open pressure 250 mmHg) and improvement of cerebrospinal fluid status. Refractory hypoxemia with increased oxygen demand to the level of FiO2 of 1.0 developed on August 5. CXR disclosed bilateral diffuse haziness. Acute renal failure and deteriorated liver function ensured later. His blood pressure deceased to 50/30 mmHg at the night of August 6 and refractory to norepinephrine infusion. The patient passed away at 4:37 pm August 7. 案例分析 當病人有發燒不退且伴隨有意識變化的情形，其鑑別診斷必須將中樞神經系統的感染排在第一位，至於是病毒性、細菌性或其他血行散佈而來，只有靠進一步的檢查來縮小範圍，因為儘早的治療對病人的預後是重要的決定因素。因此在時間許可下應先作頭部電腦斷層，確定無uncal hernation的危險再施行腰椎穿刺。取得腦脊髓液作抹片檢查，可提供我們作初步的診斷。如本案例執行腰椎穿刺後，腦脊髓液呈現膿狀且抹片有看到G(-)bacilli，即可斷定是細菌性腦膜炎，然而有些病毒性腦膜炎在發病時，腦脊髓液之血球計數可以是中性白血球為主，若當時無法確定是病毒性或細菌性，則必須同時治療兩種病因。對於治療細菌性腦膜炎，一般建議給予第三代Cephalosporin及Penicillin G，但因抗藥性之pneumococcus盛行，臨床上漸有以Vancomycin取代Penicillin G之趨勢；至於治療病毒性腦膜炎，目前可使用的藥物是Acyclovir。 本案例為55歲男性，為糖尿病病人，平時血糖控制不良，台灣地區糖尿病病人特別好發Klebsiella pneumoniae感染，肺部、肝臟、泌尿道及腦部為常見感染部位，特別當有Klebsiella pneumoniae 感染時，必須先檢查肝臟是否有肝膿瘍及眼睛是否有因血行性散佈而導致的endophthalmolitis。 繼續教育考題 1. (C) 案例中病人所表現的症狀如噁心、嘔吐、頭痛是因為： A 急性腸胃炎 B 急性膽囊炎 C 腦壓升高 D 心理因素 2. (D) 承上題，病人有上述症狀，經評估有可能為中樞神經系統問題，下列檢查哪一項是不必要的檢查？ A 頭部電腦斷層 B 眼底檢查 C 腰椎穿刺 D 肌電圖檢查 3. (A) 承上題，病人經過腰椎穿刺所得腦脊髓液，不需送檢的項目為何？ A 分光儀測定 B 血球分類計數 C 細菌培養 D 生化值測定 4. (D) 承上題，病人住院治療後，發生了哪些器官的衰竭？ 1.肝,2.腎,3.肺,4.中樞神經 A 1,3,4 B 1,2,4 C 2,3,4 D 1,2,3,4 5. (C) 治療細菌性腦膜炎，下列何種藥物較不常被使用？ A 第三代cephalosprin B Penicillin G C Erythromycin D Vancomycin 6. (A) 下列哪一項不是細菌性腦膜炎重要的預後決定因子？ A 病人是否有合併使用降腦壓藥物 B 適當的抗生素治療 C 病人最初的神經學表現 D 是否有敗血性休克 7. (B) Klebsiella pneumoniae 是哪一類細菌？ A G(+) cocci B G(-) bacilli C G(+) Bacilli D G(-) cocci 8. (D) 哪一類病人不是好發Klebsiella pneumoniae 感染的族群？ A 糖尿病 B 肝硬化 C 酒精成癮 D 吸煙者 9. (B) 病人若有Klebsiella pneumoniae 感染需檢查哪些部位以偵測血行性菌血症的散佈？ 1.肝,2.眼睛,3.皮膚 A 1,2,3 B 1,2 C 2,3 D 1,3 10. (C) 台灣地區成人社區性細菌性腦膜炎佔第一位的細菌為何？ A Klebsiella pneumoniae B Neisseria meningitidis C Streptococcus pneumoniae D Haemophilus influenzae

答案解說 答案解說: 1、 病人有噁心、嘔吐及劇烈頭痛情形，若是加上血壓升高心跳減緩(cushing effect)，需懷疑是腦壓升高(IICP)，其原因可以是因為腦梗塞、腦出血、腦炎、腦膜炎及腦部腫瘤等。 2、 案例中病人若懷疑有中樞神經系統問題，在時間許可情況下，應作緊急頭部電腦斷層，否則經眼底檢查後，即可行腰椎穿刺並儘快給予治療。 3、 實驗室檢查腦脊髓液的基本項目包括(1)抹片檢查(2)血球分類計數(3)生化值測定(4)細菌培養(5)細胞學鑑定等。 4、 案例中病人住院之後因嚴重敗血症引發多重器官衰竭(Multiple organ dysfunction syndrome)，包括有中樞神經、肺、肝、腎及血液系統等。 5、 傳統上建議對於成人社區性腦膜炎，在未確定診斷前，應給予第三代cephalosporin 及penicillin G。有鑑於對於penicillin G 抗藥性的pneumococcus 與日俱增，漸漸已用vancomycin取代penicillin G作為初始治療。 6、 決定細菌性腦膜炎預後的重要因子包括(1)適當及時的抗生素治療(2)發病當時的意識狀態(3)腦脊髓液的乳酸含量(4)病人是否有敗血性休克 7、 8、好發Klebsiella pneumoniae 感染的高危險族群通常是泛指免疫功能較差的病人，如糖尿病、肝硬化、酗酒、使用免疫抑制劑及惡性腫瘤等患者。 9、對於已證實為Klebsiella pneumoniae感染的病人，特別要小心注意因血行性菌血症而引起的endophthalmolitis，若延遲處理，常造成病人失明。在台灣地區，糖尿病患者罹患細菌性肝膿瘍，以Klebsiella pneumoniae 佔第一位。 10、 Top of Page