Case Discussion A 67-year-old woman was transferred to our hospital on May 2, 2001 because of abdominal pain and dyspnea and hypotension for several days. She initially complained of an intermittent cramping pain over the right upper quadrant (RUQ) abdomen 4 days prior to admission. Sudden onset of dyspnea and altered mental status were noticed 2 days later. She was sent to the emergency room of a local hospital where a body temperature of 37.5oC and blood pressure 80/30 mm Hg were found. The abdominal sonography showed multiple gallstones and swelling of the gallbladder wall with the “triple-layer” sign. Her hemodynamics were stabilized by fluid challenge and empirical antibiotic therapy. She was then transferred to our hospital for further management. The patient had had hypertension for several years with regular medical control. She also had received hormone replacement therapy with one tablet of unknown drug per day due to osteoporosis for 2 years. The past history was otherwise non-contributory. On examination, her consciousness was drowsy. The body temperature was 37.5oC, blood pressure 160/92 mm Hg, pulse rate 120 beats/min, and respiratory rate 24 breaths/min. The sclerae were not icteric. The pupils were isocoric with prompt light reflex. The neck was supple, without jugular vein distension or lymphadenopathy. The chest expanded symmetrically and the breathing sounds were clear. No heart murmurs were detected. There were tenderness and muscle guarding at the RUQ abdomen and the Murphy’s sign was positive. The liver and spleen were not palpable. The bowel sounds were hypoactive. No lower leg edema was noticed. Neither skin rash nor petechiae were found. The initial laboratory studies revealed white blood cell count of 16.61x 109 cells/L, with 86.2% neutrophil, 5.6% monocytes, and 8.1% lymphocytes; red blood cell count of 4.19 x 1012 cells/L; hemoglobin 12.7 g /dL; and 104 x 109 platelets/L. The prothrombin time and activated partial thromboplastin time (PTT) were within normal limits. The asparate aminotransferase was 57 U/L; total bilirubin 1.26 mg/dL; the amylase 253 U/L; the amylase 123 U/L；blood urea nitrogen 2.0 mmol/dL; and creatinine 67.2 μmol/dL. The arterial blood gas analysis when breathing through a mask at an inspired O2 fraction of 35% showed pH 7.448；PCO2 35.9 mm Hg; PO2 127.9 mm Hg and HCO3- 25.0 mmol/L . The electrocardiography revealed sinus tachycardia only.  She underwent a laparoscopic cholecystectomy on May 3, 2001. The operation findings and pathologic report were both compatible with the diagnosis of chronic cholecystitis. Unfortunately, she developed haemoptysis, persistent RUQ abdominal pain and fever immediately after cholecystectomy. Chest examination showed decreased breathing sounds over right lower lung field with some basal crackles.  Imaging studies, including the initial chest radiograph at the local hospital (Fig. 1), the chest radiographs while the patient was being prepared for cholecystectomy (Fig.2) and 14 days after the cholecystectomy (Fig. 3), and the computer tomography (CT) scans of the chest 7 days after the cholecystectomy (Fig. 4a and 4b), are shown. The initial chest radiograph (Fig. 1) is clear, but the image taken while preparing for the cholecystectomy (Fig. 2) shows alveolar consolidation over the right lower lung and blunting of the right cardiophrenic angle. The CT scans of the chest (Fig. 4a and Fig. 4b) reveal a large filling defect in the right main pulmonary artery and consolidation of the lower right lung with cavitation. The follow-up chest radiograph (Fig. 3) revealed prominent cavitation of the previous lung consolidation.  The pulmonary angiography showed a large filling defect in right pulmonary artery, without visualization of the branches of right pulmonary artery to the right lower lobe. The duplex study of deep veins of the lower limbs was negative, and the echocardiography did not show right ventricular (RV) thrombi either. The serum levels of protein C, protein S, and antiphospholipid antibody were within normal limits. The autoimmune profiles were also normal. The sputum culture grew Pseudomonas aeruginosa. A diagnosis of cavitary pulmonary infarct was made. High dose of intravenous ceftazidine and heparin were administered immediately after the findings of the CT scans were obtained on the 7th day after cholecystectomy, with the activated PTT maintained at 1.5-2.0 folds of the control. The follow-up chest radiograph 8 weeks later, however, showed only partial resolution of the consolidation of the right lower lung and the CT scans did not reveal shrinkage of the thrombi in the right pulmonary artery. The perfusion scan (Fig. 5) and the Doppler sonography failed to show reperfusion of the infracted lung either. The patient therefore underwent a lobectomy of the right lower lobe and embolectomy on July 5, 2001. Culture of the removed lung tissues still yielded Pseudomonas aeruginosa which was sensitive to the antibiotic used. The post-operation course was smooth and the patient was discharged on the 10th hospital day after the operation with continued maintenance therapy of anticoagulation. Laboratory data:  1. CBC/DC:   WBC RBC Hb Hct MCV PLT   K/uL M/uL G/dL % fL K/uL 900502 16.6 4.19 12.7 38.7 92.4 104 900504 24.57  3.93 12.0 36.4 92.6 158 900704 9.01 4.71 13.3 41.1 87.3 250 2. Biochemistry   BUN Cre Na K T-Bil D-Bil GOT ALP   mg/dl mg/dl mmole/l mmole/l mg/dl mg/dl U/l U/l 900502 5.5 0.76 137 3.8 1.26 890822 57 123 3. ABG   pH PCO2 PO2 HCO3- BE condition   * mmHg mmHg mEq/l mEq/l   900502 7.448 35.9 127.9 25 +1.2 mask, 8 L, FiO2 = 35% 900503 7.43 32.9 143.5 21.3 -1.9 Mask 8L FiO2=40% 4. Inhibitor protein study   ATIII: Ag ATIII:Fun PC: Ag PC: Fun   PS Ag:Total PS Ag:Free 900507(%) 73 72 83 53 122 80 5. Antiphospholipid antibody   APA<5:(-); 5~15:BL;>15:(+) ACA<16:(-);16~21:BL;21~60:Mod.(+) DRVVT>1.2 900507 2.262 4.273 1.24 900704 1.860 8.942 NEGATIVE 6. 900508 Sputum culture: (2+)* Pseudomonas aeruginosa 7. 900528 Culture of protected sheath brushing : Pseudomonas aeruginosa                                             Catheter:     Confluent 8. 900528 Culture of bronchioalveolar lavage: Pseudomonas aeruginosa 89000 /ml 9. 900705 Culture of lung abscess : (3+)Pseudomonas aeruginosa 病案分析 本病例為一位接受賀荷蒙補充療法的停經後女性。突然產生右上腹痛、低血壓、及呼吸喘之症狀，經過初步的檢查，診斷為膽囊結石併敗血症。但是開刀後呼吸喘及右上腹痛的症狀持續，併出現血痰，才將診斷的注意力集中至肺部。從臨床上的症狀，再加上病人在接受賀荷蒙療法，肺栓塞應列入診斷考慮。之後雖然迅速診斷並且給予適當劑量的抗凝血劑，但是經過影像學上的追蹤，發現血栓並無溶解的跡象，同時肺部引起壞死和繼發性感染，形成肺膿瘍。 本病例為少見的肺栓塞的併發症。在文獻上Pulmonary infarct佔所有肺栓塞病例之10%, Cavitary pulmonary infarct只佔所有pulmonary infarct 病例之4-5%。在輔以外科手術的方法，將肺膿瘍及右肺動脈內的血栓清除，此病患於術後順利出院，沒有留下明顯的後遺症，為一成功治療之典範。 繼續教育考題 1. (B) Which description below about acute pulmonary embolism is WRONG? A Dyspnea, pleuritic chest pain and hemoptysis are common B PaO2 and A-a O2 gradient are very sensitive and specific for the diagnosis C About half of patients with pulmonary embolism have no history of deep vein thrombosis D D-dimer is sensitive to pulmonary embolism and can be used for screening 2. (A) Which method is the diagnostic “gold standard” for pulmonary embolism? A Pulmonary angiography B Lung ventilation/perfusion scan C Spiral CT D HRCT 3. (D) The Virchow’s triad for the etiology of thromboembolism includes A Stasis B Hypercoagulopathy C Local vascular trauma D All are correct 4. (D) What clinical conditions are at risk of pulmonary embolism EXCEPT A Spinal operation B Immobilization C Oral contraceptives D Stock bandage 5. (A) Which condition justifies thrombolytic therapy in acute pulmonary embolism? (1) unstable hemodynamics (2) acute respiratory failure needing ventilator support (3) signs of RV failure (4) RV strain documented by echocardiography (5)all pulmonary embolism A (1),(2),(3),(4) B (1),(2),(3),(4),(5) C (1),(3),(4),(5) D (1),(2),(3) 6. (B) Which statement about anticoagulation and thrmobolytic therapy is WRONG? A Thrombolytic therapy can be considered within 14 days B In long term, thrombolytic therapy is better than anticoagulation therapy for recurrent pulmonary embolism and patent rate of occluded artery C Dissolution of thromoemboli may take weeks or months D Percutaneous mechanical fragmentation and surgical embolectomy are alternatives for thrmbolytic therapy 7. (A) Which of the following description about pulmonary infarct after embolism is wrong? A Occurs in 40% patients of pulmonary embolism B The main reason of relative rare incidence of pulmonary infarct is dual blood supply from pulmonary artery and bronchial artery C Secondary infection of pulmonary infarct may come from bronchial trees or systemic arteries D Morbidity is around 70% and mortality around 40% in pulmonary embolism 8. (A) Which belongs to the complications of cavitary pulmonary infarct? (1) massive hemoptysis (2) broncho-pleural fistula (3) empyema (4) septic shock A (1),(2),(3),(4) B (1),(2) C (3),(4) D (2),(4) 9. (D) Which condition is at risk of pulmonary infarct in pulmonary embolism? A congestive heart failure B hypotension C positive pressure ventilation D All of the above 10. (D) Which method can identify the reperfusion of pulmonary infarct? A MR angiography B color Doppler of chest sonography C perfusion lung scan D All of the above

答案解說 (B) PaO2 and A-a O2 gradient 正常並不能完全排除肺栓塞 (A) Lung ventilation/perfusion scan 依照通氣-灌流不配合的情形可分為低可能性,高可能性,及無法區分; Spiral CT只能看到肺動脈近端的血栓 (D) 所列皆正確 (D) Spinal operation and immobilzation都會增加血液滯流的機會, 至於口服避孕藥有可能提高血液凝滯力。 (A) (1)-(4)所列皆為血栓溶解治療的適應症 (B ) 根據研究,用血栓溶解治療的藥物如r-TPA對血栓溶解的效果上只有在前五天會優於抗凝血劑, 之後兩者無明顯之差異, 但出血的併發症血栓溶解治療高於抗凝血劑, 至於對未來肺栓塞復發的預防,兩者亦無明顯之差異。 (A ) 在文獻上Pulmonary infarct佔所有肺栓塞病例之10%, Cavitary pulmonary infarct只佔所有pulmonary infarct 病例之4-5%。 (A) (1)-(4)所列皆為肺梗塞之可能併發症。(A ) 空鞍和腦下垂腺無發育的鑑別診斷主要是靠腦下垂腺後葉在核磁共振上的顯影來區分。 (D)(1)-(3)所列皆為引發肺梗塞之可能危險因子,另外還包括免疫功能低下者,肺部疾病如擴張不全,胸水,肺炎及慢性阻塞性肺疾等 (D)(1)-(3)皆可作為追蹤的方法,但以Doppler sonography最方便､非侵襲性