狂犬病并发纵隔及皮下气肿误诊为纵隔感染1例并文献复习  

Literature review of 1 case of rabies complicated with mediastinal and subcutaneous emphysema misdiagnosed as mediastinal infection

作　　者：焦介 刘杰[1] 杨霈龙 张曦木[1] 陈昭光 李泽世 宋青[1] 赵建辉[1] JIAO Jie;LIU Jie;YANG Peilong;ZHANG Ximu;CHEN Zhaoguang;LI Zeshi;SONG Qing;ZHAO Jianhui(Hainan Hospital of PLA General Hospital,Sanya,Hainan 572013,China)

机构地区：[1]解放军总医院海南医院重症医学科,海南三亚572013

出　　处：《中华医院感染学杂志》2025年第4期533-538,共6页Chinese Journal of Nosocomiology

基　　金：海南省自然科学基金面上项目(823MS165,824MS173);海南省临床医学中心建设项目(琼卫医涵[2021]276号)。

摘　　要：目的 探讨1例狂犬病误诊为纵膈感染的原因,提高临床诊断准确性,减少狂犬病的误诊漏诊率。方法 对解放军总医院海南医院收治的1例狂犬病误诊为纵膈感染患者病历资料进行总结和回顾性分析。结果 患者男,21岁,主因发热咽痛3天伴呼吸困难2天、抽搐1天入院。实验室检验提示白细胞、中性粒细胞、降钙素原升高、转氨酶、乳酸脱氢酶、肌酐等指标升高、凝血功能紊乱。胸部CT提示颈部皮下及纵膈气肿,初步考虑咽部感染向纵膈蔓延导致纵膈感染合并严重脓毒症。急诊手术行颈部清创引流及气管切开术,术中未发现感染病灶,术后予以广谱抗菌药物抗感染、持续肾脏替代治疗、补液等对症支持治疗,患者症状无缓解,还出现意识障碍、抽搐,大汗,口腔及气管切开处流涎明显。追问病史,患者既往3年前被野狗咬伤足部,结合病史及临床表现,临床诊断为狂犬病。结论 自发性纵膈气肿是狂犬病罕见的临床表现,可以发生在狂犬病早期,易导致临床误诊及不恰当的治疗,临床需提高对狂犬病的认识,详细询问病史,细致查体,整体分析临床症状,对于有纵膈气肿的新住院患者应考虑狂犬病可能,谨防误诊。OBJECTIVE To explore the causes for misdiagnosis of 1 rabies case as the mediastinal infection so as to raise the accuracy of clinical diagnosis and reduce the misdiagnosis and missed diagnosis rate of rabies.METHOD The medical record of 1 case of rabies who was misdiagnosed as mediastinal infection and was treated in Hainan Hospital of PLA General Hospital was summarized and retrospectively analyzed.RESULTS The case,male,21 years old,presented the hospital with fever and sore throat for 3 days,expiratory dyspnea for 2 days and convul-sions for 1 day.The result of clinical laboratory test showed that the white blood cell,neutrophils,procalcitonin,transaminase,lactic dehydrogenase and creatinine were elevated,indicating the disorder of coagulation function.The chest CT revealed subcutaneous and mediastinal emphesema in the neck,initially considering that a pharynge-al infection spreading to the mediastinum induced the mediastinal infection complicated with severe sepsis.Emer-gency surgery for neck debridement,drainage and tracheotomy were performed,no infection foci were found dur-ing the surgeries.The symptoms of the patient did not relieve after the symptomatic and supportive therapies including broad-spectrum antibiotics for anti-infection,continuous renal replacement therapy and fluid infusion were given to the patient,and the patient started to have disturbance of consciousness,convulsions,profuse sweating and significant salivation from the mouth and tracheostomy site.Upon further inquiry into the medical history,it was revealed that the patient had been bitten on the foot by a stray dog 3 years ago and was clinically diagnosed as rabies based on the medical history and clinical manifestations.CONCLUSIONS Spontaneous mediastinal emphysema is an uncommon clinical manifestation for rabies and may also emerge during the early stage of rabies,which may lead to clinical misdiagnosis and improper treatment.It is necessary for the clinicians to raise the awareness of rabies,inquiry the medical history in detail,mak

关 键 词：狂犬病 纵膈气肿 皮下气肿 纵膈感染 

分 类 号：R373[医药卫生—病原生物学]