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*For medical professionals only
Clinically monism is important, but don't squeeze out the space
where dualism exists.
Synopsis:An elderly woman was admitted to the hospital with generalized pain and wasting due to poor nutrition, and the diagnosis
of Sjogren's syndrome (SS) was confirmed after consultation and examination.
At the same time, the patient was also found to have fever, biliary abnormalities, and a positive
tuberculin test (PPD).
Although SS can affect multiple organ systems, the patient's complex condition does not seem to be explained
by SS monism.
So what's wrong? Please follow in the footsteps of Deputy Chief Physician Shi Lianjie of Peking University International Hospital (Interpreting Physician) and Chief Physician He Jing (Commenting Physician) of Peking University People's Hospital to explore the case together!
Case introduction
.
Complaints: Pain in the whole body with a difference of more than 20 days
.
Medical history: the patient had no obvious cause of pain more than 20 days ago, accompanied by joint swelling and pain (obvious knee joints), poor nutrition, reduced eating, intermittent dry mouth, dry eyes, no obvious eye gritty feeling, and can swallow dry food
.
Decreased defecation since the onset of the disease, about 5-6 days 1 defecation, dry; mild discomfort during urination in the past 1 week; Weight loss of about 3.
5kg
in the past 20 days.
▌ Past history
- He has a history of recurrent body pain for more than 40 years (feeling that the nature of pain is different from this visit, the previous duration is short, and the degree is mild), he has been treated in a local hospital, diagnosed as rheumatism, the details are unknown, and hormone therapy has been given for more than 1 year (about 4-6 tablets of prednisone), and then the patient requests to stop stopping hormones
due to hormonal side effects (full moon face, osteoporosis).
- History of type 2 diabetes mellitus for 3 years, osteoporosis, no history of
hepatitis, tuberculosis.
▌ Physical examination
- Bilateral shoulder, elbow, hip, knee tenderness without significant swelling
. - Fibromyalgia tender points 12 points positive
. - After admission, the patient was found to have a moderate to low fever, fever began every afternoon, the maximum body temperature was about 38 ° C, and the fever
was reduced in the early morning.
Figure 1 Thermal pattern
▌ Laboratory examination 1.
No obvious abnormalities of the three
major routines, renal function, coagulation function, hepatitis virus examination
, respiratory virus nine items, tumor markers, complement, There were no obvious abnormalities
in four vasculitis and four rheumatoid items.
2.
Examination with abnormal results
- ESR: 58 mm/h, C-reactive protein 11.
61 mg/L
. - Liver function: total protein: 66.
9 g/L, albumin: 30.
9 g/L, prealbumin: 126 mg/L, alanine aminotransferase: 55 units/L, aspartate aminotransferase: 44 units/L, alkaline phosphatase: 514 units/L, glutamyltransferase: 354 units/L, no abnormalities
. - PPD test: 12mm×15mm, positive
interferon release test for tuberculosis. - Glycated hemoglobin: 7.
5
%. - Four items of bone metabolism: 25-0H-VitD 12.
53 ng/ml, no obvious abnormalities
were seen. - Serological antibody test: antinuclear antibody (ANA) 1:640 (granular type), anti-SSA/RO60+ positive, anti-SSB/La, no abnormalities
.
▌ Abdominal CT on imaging can
show full pancreatic head, thickening of the bile duct wall and dilation
of the bile duct.
Fig.
2 Abdominal CT
▌ Salivary gland and ophthalmic examination
- Salivary gland scintigraphy: impaired
uptake and excretion function of both parotid and submandibular glands. - Ophthalmic consultation: dry eye; Meibomian gland dysfunction; Senile cataract
.
Monism or dualism?
Looking at a bunch of information, does it have a feeling of being confused but I don't know how to sort it out? The history and examination of dry mouth and eyes clearly point to the diagnosis of SS and may explain manifestations such as fibromyalgia and abnormal liver enzymes, but where do liver damage and fever come from?
We know that it is an important principle
to explain disease clinically in terms of monism.
However, in this case, Deputy Director Shi Lianjie found two major doubts about the monist interpretation of SS: first, fever is not a common clinical manifestation of SS, and patients with SS should be alert to fever combined with other diseases that often manifest as fever, such as infection; Second, SS may have elevated ESR but normal CRP, and coexistence of infection or other inflammatory diseases should be vigilant
when CRP is elevated.
Therefore, in order to discover the clues of dualism, Deputy Director Shi Lianjie made such a table:
Table 1 Case analysis
He dug deep again and again, and finally found a breakthrough in the following six key characteristics:
Fig.
3 Case characteristics analysis
According to the information in Figure 3, SS can only explain pain and elevated liver enzymes, but not fever, weight loss, elevated CRP, biliary abnormalities, PPD (+) and other manifestations
.
Shi Lianjie considered that this series of clinical manifestations that SS could not explain may be related to
digestive tract infections.
He then performed further tests on the duodenal area, which is closely linked to the liver and gallbladder:
1.
PET-CT: It can be seen that the intestinal wall in the duodenal area is thickened and glucose metabolism is increased
.
Fig.
4 PET-CT duodenal area
2.
Gastroscopy: see a deep ulcer on the side of the duodenal ball descending junction papilla, size 2.
5cm×2.
0cm, yellow and white moss after the bottom, and a fistula can be seen in the center
.
Tissue biopsy, acid-fast bacilli found, no evidence of
tumors.
Fig.
5 Gastroscopic duodenal area
At this point, the truth of dualism has finally come to
light.
We can deduce that tuberculosis infection in the duodenal bulb leads to dilation, thickening, and elevation of bile duct enzymes and CRP, accompanied by typical clinical manifestations of tuberculosis: low-grade fever, fatigue, poor nutrition, and wasting
in the afternoon.
Therefore, the patient's final diagnosis is:
1.
Duodenal tuberculosis infection;
2、SS；
3.
Fibromyalgia;
4.
Diabetes
.
Later, after half a year of anti-tuberculosis treatment, the patient no longer had fever, liver enzymes recovered, weight regained, imaging improved, gastroscopic duodenum was reviewed, ulcers healed, scarring, and oral hydroxychloroquine treatment
was started.
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