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病例簡述
Mr. Chang, a 65-year-old gentleman, was hospitalized on
Dec. 4, 2000 because of queer behavior, confusion and visual
hallucination for 4-5 days.
He had a past history of hypertension and diabetes
mellitus for more than 10 years. His blood pressure was poor
controlled (around 150-200/100 mmHg) despite of a therapy with
several antihypertensive agents (slow-release nifedipine 60 mg
bid, labetalol 100mg bid, fosinopril 10 mg bid and doxazosin 4
mg qd). He has been diagnosed to have diabetic retinopathy,
neuropathy and nephropathy. He began to depend on maintenance
hemodialysis thrice per week since 2 years ago due to
end-stage renal disease. Pulmonary tuberculosis was found 5
years ago; anti-tuberculosis drugs had been given for 4-5
months and discontinued because of adverse drug reaction. He
was a smoker for about 45 years and consumed more than 1 pack
of cigarette per day.
He had been admitted to our hospital several times in
2000. On Feb. 25, he was hospitalized due to poor appetite and
drowsy consciousness for 3 days. Blood pressure up to 240/130
mmHg and hypercalcemia (Ca 2.77 mM, albumin 2.9 g/dL) were
found. His symptoms subsided after medical treatment for
hypercalcemia and hypertension. He was readmitted again twice
on Apr. 13 and Oct. 7 because of a similar presentation.
Hypercalcemia, up to 3.11 and 3.42 mM, respectively, was
detected, which was attributed to the concomitant use of vit
D3 and calcium carbonate after a series of studies. Several
episodes of bloody stool developed on Oct. 19 with unstable
hemodynamics. He was treated with emergent angiography with
embolization in addition to massive transfusion. Panendoscope
revealed multiple gastric and duodenal ulcers. Because
Helicobacter pylori infection was diagnosed by pathology,
amoxicillin (1gm bid), clarithromycin (500 mg bid), and
famotidine (20 mg bid) were prescribed since Nov. 26.
He became hypertalkative, irritable and disoriented
since Nov. 30. Visual hallucination, insomnia and echolalia
were also noted. On the same day, he fell down to the ground
and the accident resulted in a laceration wound over his
forehead. There was no fever, hypersomnolence, headache or
limb weakness. Under the impression of acute confusional
state, he was admitted for further workup.
His blood pressure was 174/88 mmHg, body temperature
37℃, pulse rate 76 and respiration rate 18 per minute. He was
awake but disoriented and confused. There was a laceration
wound over his left forehead. The conjunctivae were not pale
and sclerae anicteric. The pupils looked isocoric with prompt
light reflex. There was no meningismus or neck vein
distension. No apparent murmur or crackle was audible. The
abdomen was soft without organomegaly. Mild pitting edema at
bilateral pedal areas was noted. Because he was not
cooperative, detailed neurological examinations were
impossible. However, no definite focal neurological deficit
was identified.
Laboratory tests showed normocytic anemia (Hb 10.7
g/dL), azotemia (BUN 31 mg/dL, creatinine 3.7 mg/dL) and
hypoalbuminemia (2.6 g/dL). The white count was 7890/μL. The
serum calcium level was 2.07 mM, plasma glucose 80 mg/dL,
ammonia 21μM. There was no elevation of troponin I or CK-MB.
Urinalysis revealed proteinuria (≧300 mg/dL), microscopic
hematuria (10-20/HPF) and leucocyturia (50-75/HPF). Chest film
showed pleural effusion, especially left side, without new
pneumonic patch, a finding similar to previous films.
Cytology, Gram’s stain, acid-fast stain and cultures of
pleural effusion were all negative. The VDRL test was negative
and the TSH within normal limit. Emergent head CT scan showed
no intracranial hemorrhage and the EEG was normal. MRI of the
brain showed multiple old infarcts and leukoaraiosis.
After admission, several tests were performed for
determining the cause of delirium. His blood pressure was
controlled by slow-release nifedipine (30mg bid), labetalol
(200 mg bid) and minoxidil (5 mg bid). Omeprazole (20 mg qd)
was given for peptic ulcers. Besides, a drug was discontinued.
His symptoms subsided gradually.
病案分析
此病人共有四次因急性意識障礙而住院。前三次以嗜睡為主要表現，檢查發現有高鈣血症，經控制血鈣後，意識恢復正常;最後一次則以躁動、視幻覺（看到松鼠跳來跳去一直伸手要去抓松鼠）、不停地說話來表現，經去除病因後意識也回復。老年人在短時間內突發意識及認知功能障礙，必須考慮譫妄症（delirium），而非失智症（dementia）。
譫妄症臨床表現可以用活動度偏低（嗜睡、疲倦、面無表情、反應遲緩）、活動度偏高（躁動、坐立不安、不停地說話、失眠）或活動度偏低與偏高交替出現等不同方式來呈現。譫妄症常見的原因包括：感染症（肺、泌尿道、血液、腦膜等）、藥物副作用、代謝異常（血糖過高或過低、血氧太低、二氧化碳太高、肝腎功能衰竭、電解質異常、內分泌疾病….等）、心臟疾病（急性心肌梗塞、心律不整、心衰竭等）、中樞神經疾病（外傷、中風、癲癇等）…..等。譫妄症病人的處置最重要是找出致病原因，病史與理學檢查可以提供思考的方向決定那一些實驗室檢查是必要的。一般而言，血球計數、血糖、電解質、肝、腎功能、尿液檢查、心電圖與胸部X光是第一線篩檢項目，至於血液培養、心肌酵素、梅毒血清試驗、甲狀腺功能、毒藥物測試、腰椎穿刺、腦波、腦部電腦斷層或核磁共振等則視是否有相關症狀或徵象才作，本案例即稍有過度使用實驗室檢查之嫌。
此病人雖有腎衰竭，但一直有規則透析且尿素氮與肌酸酐也不是太高，所以不能用腎衰竭來解釋其譫妄症。維生素D與鈣片合用時，偶而可發生高鈣血症的副作用。然而，此病人曾有肺結核病史，肋膜積水雖可用白蛋白偏低來解釋，但也不可不排除肺結核的可能性。幾次住院中曾反覆驗痰與胸水，並無明顯證據支持此病尚有活動性。其他也常引起高鈣血症的原因尚有：副甲狀腺機能亢進與惡性腫瘤，此病人也曾接受相關檢查，但都查無實證，所以只能歸諸於藥物副作用。某些高鈣血症的治療方式並不適用於尿毒病人。
病人最後一次住院時，血鈣並未上升，必須另找譫妄的原因。由於病人沒有發燒，白血球也未增加，感染症不是太像。代謝異常、心臟疾病與中樞神經疾病也大略可從病史、理學檢查與實驗室檢查排除，所以藥物的副作用仍是最可能的原因，最可疑的藥不外乎發病前四天剛開始使用的藥。為了治療幽門桿菌感染及胃潰瘍，醫師開立的處方包括：amoxicillin、clarithromycin與famotidine。在尿毒症病人用藥時必須考慮藥物的代謝或排泄是否受腎衰竭或透析的影響，以適當減少劑量或增長給藥間隔並決定透析後是否需補充藥量。此病患在停用某一藥物後，意識狀況逐漸恢復。
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Case Discussion
繼續教育考題