原创 华山感染
The original Hampshire infection.
一切的结果，都不是偶然。
The result of everything is no accident.
再小的疏漏，终将会作祟。
Smallest slips, they'll end up sneaking around.
今天讲个20年前一颗钉子的故事。
Today's story of a nail 20 years ago.
01
腿脚肿胀，长钉作祟
The legs are swollen and the nails are swollen.
2018年3月29日，感染科金教授的诊室迎来了一位令人印象深刻的病人-阿华。
On 29 March 2018, an impressive patient, Ah Wah, arrived in Professor Kogin's clinic.
正值不惑之年的阿华，却是坐着轮椅进了诊室，原来他的整个右下肢都明显肿胀了起来，已经影响到了行走。阿华一见金教授便忙不迭地说：“医生，我的腿肿了，在外面打了好几天针却一直不见好，您快帮忙看看吧！”
He came into the clinic in a wheelchair, and his entire right lower limbs were obviously swollen, affecting his walking. Professor Kim was busy and said, "Doctor, my legs are swollen, but I've been out there for a few days and I'm not good."
“您别急，先说说怎么回事。”
"Don't worry, tell me what's going on."
“唉，说起来，我的右边大腿外侧从5年前开始就起了个小肿块了。也不大，就跟鸡蛋似的，但没有那么光滑，摸上去不软不硬，也不红，也不肿，更别说影响走路了。我这不是工作忙吗，就也没注意。结果3月15日那天，右边膝盖以上的地方突然就肿起来了，那个小包块是肿得最明显的。有一点点疼，但不影响走路。”
“Ah, speaking of which, the outer side of my right thigh has been swollen since five years ago. It's not big, it's like an egg, but it's not so smooth, it's not hard, it's not red, it's not swollen, it doesn't matter. I'm busy at work, I'm not paying attention. On March 15th, the top of my right knee suddenly swollen, and that little bag is the most visible. It hurts a little, but it doesn't affect walking.”
“发病之前有没有受寒受凉，或是休息不好呢？”
"Has the cold been cold before the onset of the disease, or has the rest been bad?"
阿华说道：“我是做餐饮的，要说疲劳，每天都很疲劳，凌晨两、三点就要起床了，晚上十点多睡，每天也就休息三到四小时吧。很长时间都是这样了。”
He said, "I'm a cook, I'm tired, I'm tired every day, I wake up at 2 or 3 a.m., sleep at 10 p.m., and I take three or four hours a day. It's been a long time."
金教授点了点头，追问道：“当时肿胀的地方有发热或发红吗？您有没有别的不舒服，比如怕冷、发热，或者咳嗽、咳痰等等？”
Professor Kim noded his head and asked, "Is there any heat or red in the swollen place? Are you uncomfortable with anything else, like cold, heat, cough, cough, cough, etc.?"
“都没有！但我还是有点担心，就到医院去做了检查，您看看。”
"No, but I'm a little worried, so I went to the hospital for a check-up. Look."
血常规：白细胞：13.3×10^9/L，中性粒细胞：77.6%；红细胞：4.58×10^12/L；血小板：403×10^9/L；
Blood convention: White cells: 13.3 x 109/L, neutral particle cells: 77.6%; red cells: 4.58 x 1012/L; platelet: 403 x 109/L;
B超检查：右大腿外侧见无回声区，大小约157×44mm，内透声欠佳。
B hypercheck: No echo area on the outside of the right thigh, size of approximately 157 x 44 mm, poor internal sound.
“我知道了，后来你是怎么治疗的？”金教授耐心询问。
"I know, and then how did you treat it?" Professor Kim patiently asked.
“唉，外面医院给我开了红霉素和止痛片，但我吃了没啥效果，我就自己跑到小诊所里吊了1周的头孢呋辛。结果啊，这个肿非但没有消，反而越来越厉害，而且开始发红发痛了，一抬腿就疼得难以忍受，后来路也没法走。我又到外面医院拍了个片子，结果他们说我骨髓炎，还说是我以前骨折打的钢钉引起的，让我做手术呢。”
"Ah, the outside hospital gave me redicillin and painkillers, but when I ate nothing, I went to the clinic to hang my head for a week. As a result, the swelling didn't go away, it got worse, it started with red hair, it hurt too much to lift my legs, and then I couldn't walk. And I took another film at the outside hospital, and they said, "I had my bone marrow, and I said, "I had a steel nail that broke my bones and let me do my surgery."
“您因为骨折打过钢钉吗？是什么时候的事呢？”金教授一边询问，一边查看外院报告。3月21日患者右股骨正侧位及右膝关节正侧位平片示:右股骨骨折术后，股骨头密度不均匀，股骨大粗隆旁斑片状致密影。
"Did you hit the nails because of the fracture?" Professor Kim asked and looked at the report of the courtyard.
“那真的还挺早了。”阿华回忆道，“二十五年前，我还是个大小伙子呢，因为打球把腿摔骨折了，当时植入了钢钉。可是过了一年去复查的时候，医生说我骨折还没愈合，让我过阵子再去看。结果我后面忘记了，钢钉就这样一直放着，没有拿出来。也不影响我生活，渐渐地也就不重视了。”
"That's really early." And he recalled, "Twenty-five years ago, I was a big boy, because I broke my leg in a ball game, and I was implanted in a steel nail. But after a year of review, the doctor said that I had not healed my fractures, so I went through it. And then I forgot that the nails were still there, and they didn't come out. And they didn't affect my life.
“别的毛病还有吗？高血压、糖尿病这一类的？”
"Is there anything else? High blood pressure, diabetes?"
“高血压10年了，以前最高的时候有170/110mmHg呢，现在每天吃一片氨氯地平，控制得还不错。”
"Haemorrhage has been high for 10 years, with 170/110 mm Hg at its highest, and now eats a single amino flat every day and controls it well."
金教授意识到，阿华的病情比较严重，需要住院进行详细体检和规范用药。由于是手术植入，目前考虑阳性球菌感染可能性大，经验性地换用万古霉素1.0g 静滴q12h。几天后，阿华觉得肿胀稍有改善，但皮肤仍有发红，皮温仍较高，体温高峰升高至39.5℃，伴有畏寒、寒战。复行B超示：右大腿股骨中段骨质破坏，右股骨周围巨大囊性包块，建议进一步检查。于是在4月4日，阿华被收治我科住院，高岩医生时任主治医生。
Professor King is aware of the severity of Ahhua’s condition and the need for a detailed medical examination and regular medication in the hospital. Due to surgical implantation, the possibility of positive bacterium infections is currently being considered, with an empirical shift of 1.0 g of vagmicillin q12h. A few days later, Ahhua felt a slight improvement in swelling, but the skin was still red, the skin temperature was still high and the temperature rose to 39.5°C, accompanied by fear of cold and cold.
右下肢肿胀明显，无法屈膝及行走
The lower right limbs are so swollen that they can't bend their knees and walk.
入院后详细体格检查及辅助检查如下：
Detailed medical and auxiliary examinations after admission are as follows:
体格检查：
Medical examination:
T：38.2℃，P：92次/分，R：16次/分，BP：123/86mmHg，身高(cm)：175，
T:38.2°C, P: 92 minutes, R: 16 minutes, BP: 123/86mmHg, height (cm): 175,
神志清楚，发育正常，对答切题，轮椅推入病房，皮肤巩膜无黄染。双肺呼吸音清晰。心率90次/分，律齐；腹平坦，腹壁软，全腹无压痛，无肌紧张及反跳痛，肝脾肋下未触及，肝肾脏无叩击痛，左侧下肢无水肿，右侧下肢肿胀明显，右侧大腿中段外侧，及右侧小腿皮温升高，皮肤张力高，伴活动受限，右足肿胀明显。
The spirit is clear, the growth is normal, the answers are normal, the wheelchair is put into the ward, the skin is non-yellow. The bipulmonary respiratory sound is clear. Heart rate is 90 times per cent, rhysic; the stomach is flat, the stomach is soft, the stomach is free from stress, there is no muscle stress and counter-dip. There is no contact under the liver and spleen, there is no prostration in the liver and kidney, there is no swelling in the lower left leg, there is a sharp swelling of the lower right leg, there is an increase in the temperature of the middle leg of the right thigh, and there is a high skin tension, there is limited companion activity, and there is a marked swelling of the right foot.
辅助检查：
Auxiliary inspection:
血常规：
Blood convention:
2018.03.26：白细胞：23.59×10^9/L、中性粒细胞%90.1%、血红蛋白123g/L、血小板370×10^9/L。
208.03.26: White cells: 23.59 x 109/L, neutral particle cells %90.1%, haemoglobin 123g/L, platen 370 x 109/L.
2018.03.27：白细胞23.99×10^/L、中性粒细胞%91.2%、血红蛋白119g/L、血小板373×10^9/L。
2018.03.27: White cell 23.99 x 10/L, neutral particle cell %91.2%, haemoglobin 119g/L, plate 373 x 109/L.
2018.03.29：白细胞17.27×10^9//L、中性粒细胞%84.6%、血红蛋白119g/L、血小板468×10^9/L。
2018.03.29: White cells 17.27 x 109/L, neutral particle cells %84.6%, haemoglobin 119g/L, platelet 468 x 109/L.
2018.04.01：白细胞14.0×10^9//L、中性粒细胞%85.2%、血红蛋白111g/L、血小板437×10^9/L。
208.04.01: White cell 14.0 x 109/L, neutral particle cell %85.2%, haemoglobin 111g/L, plate 437 x 109/L.
2018.03.26：ESR121mm/h。CRP：414 mg/L、血沉:121mm/h
2018.03.26: ESR 121mm/h. CRP: 414 mg/L, haemorrhage: 121mm/h
2018.03.29：CRP: 448mg/L, 2018.04.01：CRP: 70mg/L
2018.3.16:患者于上海市嘉定中心医院行彩超检查：右大腿外侧见无回声区，大小约157×44mm，内透声欠佳。
2018.3.16: The patient was over-checked at Kading Central Hospital in Shanghai: a non-recorded area on the outside of the right thigh, the size of which is about 157 x 44 mm, with poor internal dialysis.
2018.3.21.上海市第六人民医院:右股骨正侧位及右膝关节正侧位平片示:右股骨骨折术后，股骨头密度不均匀，股骨大粗隆旁斑片状致密影。
208.3.21. Shanghai City Sixth People's Hospital: a tablet showing the front side of the right femur and the front side of the right knee joint: after the fracture of the right femur, the density of the femur is uneven, and the specks of the coarse side of the femur are visible.
2018.04.03：超声：右大腿股骨中段骨质破坏，右股骨周围巨大囊性包块，建议进一步检查。
2018.04.03: Ultrasound: damage to the middle of the right thigh femur, large cystic bags around the right femur, recommended for further examination.
02
明确病菌，针对用药
Identification of pathogens, medications.
阿华的诊断并不复杂，骨髓炎和右下肢感染都是明确的，但目前的问题在于，阿华用了半个月的抗生素，症状一直没有好转，因此亟需明确病原菌及其药敏情况，否则若抗感染效果不佳，则面临着截肢可能，造成终身残疾。
The diagnosis of A-hwa is not complex, and both osteoporosis and right lower limb infections are clear, but the problem is that A-hwa has spent half a month of antibiotics and the symptoms have not improved, so there is an urgent need to clarify the pathogen and its drug-sensitive condition, or face amputation if the anti-infection is not effective, resulting in permanent disability.
基于初试万古霉素有效，入院后，继续予万古霉素并联合美罗培南加强抗感染治疗。入院后B超提示右大腿、小腿囊性占位，伴感染可能，故4月4日于B超引导行右侧大腿穿刺置管引流，引流出黄色脓液，脓液送细菌培养（需氧+厌氧）及真菌培养和二代测序。高医生告诉阿华，病灶部位脓液的充分引流对感染的控制也至关重要，因此，4月5日我们再次在阿华右小腿穿刺置管引流，引流液为血性脓液，无明显异味。
Based on the validity of the first test of vs. vs. vs. vs. vs. vs. vs. vs. vs. vs. vs. vs. U.S.A.
4月7日，阿华的脓液二代测序报告回报，检出路邓葡萄球菌。根据经验，万古霉素治疗路邓葡萄球菌有效，且阿华感染在控制中，故未调整抗生素方案。同时与细菌室沟通，告知二代测序结果，请细菌室老师关注培养情况。
On April 7, A-hwa's sepsis second generation sequences report the return and check out the cretins. According to experience, Vancusin is effective in treating Ludun fungi and A-hwa is in control, so the antibiotics programme has not been adjusted.
4月11日，细菌室也传来消息：培养瓶中见菌落生长，与常见金黄色葡萄球菌等阳性球菌相比生长较缓慢，且菌落形态略不同。结合二代测序结果，细菌室老师鉴定确为“路邓葡萄球菌”。
On April 11, the bacterial room also reported that the culture bottle saw the growth of the fungus, which was slower and slightly different from the positive bacterium, such as common gold-coloured grapes. In conjunction with the second-generation sequenced results, the bacterial room teacher identified it as "Ludon raisins".
4月13日脓液细菌培养及药敏结果回报：路邓葡萄球菌，且对庆大霉素、苯唑西林、红霉素、克林霉素、复方SMZ、左氧氟沙星均敏感。根据药敏结果，调整抗菌药方案为青霉素钠640万单位 静滴 q8h联合阿米卡星0.6g 静滴qd。截止4月23日，右大腿引流量2548ml，右小腿引流量1756ml，总计4304ml。之后3天，阿华右腿无引流管无脓液流出，下肢肿胀、疼痛明显缓解，可屈膝活动，无发热等不适。
On April 13, the bacterium culture and drug-sensitive results in return: Ludun grape fungi, and sensitive to gentroxin, phenoxin, redicillin, Clinicillin, complex SMZ, and left-oxyfluorose stars. Depending on the drug-sensitive results, the antibacterial programme is 6.4 million units of sodium penicillin q8h combined with amika star 0.6g qd. As of April 23, the flow of the right thighs was 2548 ml, the flow of the right leg was 1756 ml, totalling 4304 ml.
考虑到阿华体温正常，白细胞回复至正常范围，血沉、CRP等相关炎症指标恢复正常或接近正常，便为阿华拔除了引流管。这一切有效的治疗都为阿华取出髓内钉创造了最好的条件。
Given the normal temperature of Ahwa, the return of white cells to the normal range, and the return to normal or near normal indicators of related inflammations such as haemorrhage, CRP, all these effective treatments have created the best conditions for Ahwa to take out the marrow nails.
03
取出钢钉，根除感染
Take out the nails and get rid of the infection.
感染控制后，阿华特别开心，开始考虑出院回家，高医生见状马上拦住了他，对他强调：“你腿里的髓内钉放了20多年了，这次引起了感染，还好治疗及时才没导致更严重的后果。如果继续这样放任不管，日后难免会病情反复，最终酿成恶果。髓内钉的取出是清除病原菌的关键。”
After the infection had been contained, Ah Wah was particularly happy to start thinking about getting out of the hospital, and he was stopped immediately by Dr. Gao, who stressed to him: “It's been more than 20 years since the impregnation of the marrow nails in your leg, which caused the infection this time, and it was better to treat them in a timely manner that did not lead to more serious consequences. If this continues, it is inevitable that the disease will be repeated and eventually turn into an evil effect. The removal of the marrow nails is the key to the eradication of the pathogen.”
然而，这颗钉子却并不是那么容易能取出的。由于阿华的髓内钉已经植入了20余年，在大部分医院的骨科已经无相应的器械取出该型号的髓内钉。因此待阿华体温控制平稳后，金教授联系到上海市第六人民医院骨科会诊，专家建议通过择期手术取出髓内钉。4月25日， 阿华便出院转至上海市第六人民医院骨科住院，维持原抗感染方案，于4月26日终于取出了植入20年的髓内钉（图8），并于股骨缺损部位予抗菌骨髓泥填塞固定治疗。
However, the nail was not so easy to remove. As Ahwa’s marrow nail had been implanted for more than 20 years, the marrow nail was removed from most hospitals without the corresponding instrumentation. So, after Ahwa’s body temperature was stabilized, Professor Kim contacted the Osteoporology Clinic at Shanghai’s Sixth People’s Hospital, and the expert recommended that the marrow nail be removed through an opt-in operation. On 25 April, Ahua went to Shanghai’s Sixth People’s Hospital to hospitalize and maintain a programme of anti-infection.
手术并不是终点，足够的抗菌疗程是彻底铲除遗留细菌的关键。术后阿华返回我院继续抗感染治疗，总疗程3个月后停药。历时数月，阿华终于又能独立行走、行动自如了。半年后，阿华于六院骨科随访右下肢手术后情况，伤口愈合好，无感染复发。
The surgery is not the end point, and adequate antibacterial treatment is the key to the complete elimination of the remaining bacteria. After the surgery, Ah-hwa returned to our hospital to treat the infection and stopped his medication three months later. For months, Ah-hwa was able to walk and act on his own. Six months later, after six Osteoporosis visits, the wounds were better and no infections were repeated.
背景知识
Background knowledge
路邓葡萄球菌
Ludun raisins.
本段为医学专业知识，非医疗圈的小伙伴可以划至页面底部直接看采访哦~
This section is about medical expertise, and small partners in non-medical circles can go to the bottom of the page to see the interview.
路邓(登)葡萄球菌（S. lugdunensis）是葡萄球菌属中凝固酶阴性葡萄球菌成员，凝固酶阴性葡萄球菌作为人体皮肤表面正常寄居菌群之一，被认为是无侵袭性的低毒力的条件致病菌，路邓葡萄球菌是1988年法国的Lyon通过DNA分析分化后首次描述的，其菌落通常为溶血性，粘性的，黄色或棕褐色的。48小时培养后直径约2-4mm。也可以具特有的干草样气味。常被认为是污染菌，因此实验室一般只将其鉴定到凝固酶呈阴性葡萄球菌水平上，而不再作为进一步鉴定。
Lugdun's (S. Lugdunensis) is a member of the nectar fungi of the vine bacterium, which is considered to be one of the normal host strains of the skin of the human skin and is considered to be an invasive, low-toxic condition; Ludun's quinoccus, which was first described in 1988 by Lyon in France through DNA analysis, is usually soluble, viscous, yellow or brown. It is approximately 2-4 mm in diameter after 48 hours of culture. It can also be characterized as a unique taste of dry grass samples.
在血琼脂平板上，35℃培养18-24小时可出现直径1-4mm的菌落，有β溶血现象，色泽变异较大，有黄色、金色、在血琼脂平板上，35℃培养18-24小时可出现直径1-4mm的菌落，有β溶血现象，色泽变异较大，有黄色、金色、乳白色或无色，菌落光滑有光泽或粗糙暗淡。药敏实验与金黄色葡萄球菌相似，对多粘菌素B/黏菌素、萘啶酸和氨曲南天然耐药。
On hemolygen flats, 35 °C develops 1 - 4 mm bacterium in diameter for 18 - 24 hours, beta soluble blood phenomena, high color variability in colours, yellow, gold, and hemolycol flats, and 1 - 4 mm bacterium in diameter for 35 °C, beta soluble blood phenomena, high colour variability, yellow, gold, milk white or colorless, and smooth or pale.
路邓葡萄球菌与多种感染密切相关，包括脓肿、心内膜炎、腹膜炎、中枢神经系统感染、骨髓炎、关节炎、腹膜炎、眼内炎、尿路感染等。路邓葡萄球菌主要定植于腹股沟区域，因此主要引起皮肤软组织感染。可引起医疗操作相关性感染，最常见的是感染性心内膜炎，人工换瓣膜术后和起搏器相关的感染；骨关节感染中也有相关报道；法国学者对医院4年培养到的凝固酶阴性葡萄球菌分类，其中1.8%为路邓葡萄球菌168例感染患者中67例（39.9%）来源于骨和关节感染，其中64.1%感染来源于假体或植入物。
Ludun fungi are closely related to a variety of infections, including abscess, meningitis, peritoneal infestation, central nervous system infections, osteoporosis, arthritis, perineitis, ophthalmosis, urinary tract infections, etc. Ludun fungi are mainly located in the grove area, leading to skin soft tissue infections. They can cause infections related to medical operations, most commonly those associated with an infectious endocrine, after an artificial changing of the valves and pacemaker-related infections; there are also reports of osteoporosis infections; French scholars have classified the gelized nectar fungible fungibles that have been developed in hospitals for four years, of which 1.8 per cent are 67 (39.9 per cent) of the 168 cases of Ludun cinoccal infections originating from bone and joint infections, 64.1 per cent of which are from prostheses or implants.
路邓葡萄球菌是较其他凝固酶阴性葡萄球菌更有侵袭性，易导致局部感染；治疗疗程目前无足够的数据，主要根据感染部位，侵袭范围，治疗疗效等综合判断文献报道：抗感染总疗程6周至3个月不等。
Ludun cylinococcus is more invasive and prone to local infections than other sequestered nectar fungi; the treatment process is currently not sufficiently disaggregated, based mainly on the location of the infection, the extent of the attack, the combination of therapeutic effects, etc., is reported: the total treatment against infection varies from six weeks to three months.
热病治疗方案：首选：苯唑西林/萘夫西林或青霉素G；次选：注射用一代头孢或万古霉素或替考拉宁；其他：75%对青霉素敏感；疗程：长骨内固定未提及疗程，脊柱内固定3个月。我们根据患者病情，给予患者3个月疗程治疗。
Thermal disease treatment programme: preferred: silin/silin or penicillin G; sub-option: injection of a generation of nitro or vancusin or koranin; other: 75% sensitivity to penicillin; treatment: fixed in the long bones without reference to the course and fixed in the spinal column for three months. We give the patient three months of treatment depending on the patient's condition.
女神说
The goddess said,
高岩 副主任医师
High Rock, deputy director.
参考文献
References
1. Klotchko A, Wallace MR, Licitra C, et al. Staphylococcus lugdunensis: An Emerging Pathogen[J]. Southern medical journal. 2011,104(7):509-514
2. Eliazbeth babu and John Oropello. Staphylococcus lugdunensis: the coagulase-negative staphylococcus you don't want to ignore[J]. Expert Rev Anti Infect Ther, 2011,9(10), 901-907
3. Douiri N, Hansmann Y, Lefebvre N, et al. Staphylococcus lugdunensis: A Virulent Pathogen Causing Bone and Joint Infections[J]. Clinical Microbiology and Infection. 2016, 22(8):747-748
4. Becker K et al. Coagulase-negative staphylococci[J]. Clin Microbiol Rev,2014,27(4):870-926
5. 周庭银，章强强，临床微生物学诊断与图解[M]，第4版，上海科学技术出版社，2017。
5. Bank of Zhou, Xiang Jian, Clinical Microbiology Diagnosis and Diagnosis [M], 4th ed., Shanghai Science and Technology Press, 2017.
编选自《翁心华疑难感染病和发热病例2019》
It's based on "Sympathic and Heating Cases 2019."
病例原作者｜高岩 邵凌云 金嘉琳 张文宏
The author of the case is Tsai High Rock, Jingarin, Zhang Wen Hong.
病例编写｜谢亦然
And so is the case report.
图文编辑｜谢亦然 李发红
And so does the editor of the graphics, Lee Ha-Hung.
视频拍摄及剪辑｜谢亦然 李发红
Video shoots and clips of thanks, as do Lee Hair Hung.
统筹｜李发红
He's in charge. He's in charge. He's in charge. He's in charge. He's in charge.
审核｜高岩
Review of the thugs.
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