第480例——膜性肾病合并糖尿病肾病,肾病综合征,反复高热  

The 480th case:membranous nephropathy combined with diabetic nephropathy,nephrotic syndrome,and recurrent fever

作　　者：罗慧婷 陈罡[1] 李雪梅[1] Luo Huiting;Chen Gang;Li Xuemei(Department of Nephrology,Peking Union Medical College Hospital,Peking Union Medical College,Chinese Academy of Medical Sciences,Beijing 100730,China)

机构地区：[1]中国医学科学院,北京协和医学院,北京协和医院肾内科,100730

出　　处：《中华内科杂志》2020年第11期925-928,共4页Chinese Journal of Internal Medicine

基　　金：中央高校基本科研业务费专项资金(3332018005)。

摘　　要：患者男,66岁。因水肿10个月,发热15 d就诊。患者2型糖尿病病史10年,10个月前以肾病综合征起病,肾活检诊断膜性肾病合并糖尿病肾病,初始予利妥昔单抗(1 g,第1天和第20天)联合环磷酰胺(100 mg/d)及泼尼松(60 mg/d)治疗,此后1个半月内泼尼松逐渐减量至17.5 mg/d,膜性肾病达到临床部分缓解。然而患者出现高热伴咳嗽咳痰、双手轻度震颤,结合肺部影像学诊断为社区获得性肺炎,予厄他培南(1 g/d)后调整为莫西沙星(0.4 g/d)+头孢他啶(2 g,2次/d)抗感染治疗2周,期间体温恢复正常,但停用抗菌药物后再次出现高热(39℃),考虑混合性感染可能,但反复血、痰病原学检测均未见明确病原菌,经验性升级抗菌药物治疗无效,再度仔细询问病史发现患者存在鸽子接触史,进一步行血及脑脊液检测,隐球菌抗原阳性,诊断肺部隐球菌病合并隐球菌脑膜炎,调整为静脉滴注氟康唑(200 mg,2次/d)+口服氟胞嘧啶(1 g,3次/d)治疗,体温逐渐降至正常,后未再次出现发热。A 66-year-old male presented with edema for 10 months and high fever for half a month.The patient was diagnosed with type 2 diabetes for 10 years.Renal biopsy revealed membrane nephropathy combined with diabetic nephropathy.A combination regimen with rituximab(1 g,day 1 and day 20),cyclophosphamide(100 mg/d)and prednisone(60 mg/d)was initiated.The dose of prednisone was gradually reduced to 17.5 mg/d within 1.5 months after partial remission of nephrotic syndrome.However,the patient was re-admitted due to high fever,productive cough and mild hand tremor.The lung imaging suggested the diagnosis of community-acquired pneumonia.Ertapenem(1 g/d)was empirically administrated and adjusted to moxifloxacin(0.4 g/d)plus ceftazidime(2 g,2 times/d)for two weeks.The patient responded and temperature came back to normal.But the fever relapsed after the withdrawal of antibiotics.Mixed infections were suspected,but blood and sputum samples were negative for pathogens.Antibiotics were not effective.The patient recalled a history of pigeon exposure.Positive cryptococcus antigen in blood culture and cerebrospinal fluid unmasked the diagnosis of pulmonary cryptococcosis and cryptococcal meningitis.Fluconazole(200 mg,2 times/d)and oral flucytosine(1 g,3 times/d)were given and effective.

关 键 词：肾病综合征 发热 隐球菌病 

分 类 号：R587.2[医药卫生—内分泌] R692[医药卫生—内科学]