本文介紹一位38歲中國武漢的男性,在今年1月20日因為發燒一天而住院。入院時的體溫38.1°C、CRP正常(0.56mg/dL)、白血球數稍高(10,060 cells/μL)、淋巴球數正常(1490 cells/μL)。許多呼吸道病毒的檢查,包括:流感、腺病毒、呼吸道融合病毒、副流感病毒等皆呈陰性。胸部電腦斷層則發現在雙側下肺葉出現毛玻璃樣病變(ground-glass opacities)。

雖然給予5天抗生素(moxifloxacin [0·4 g/day]),接著5天抗病毒藥物(ribavirin [0·5 g/day])以及類固醇(methylprednisolone [40 mg/day])治療,但是該病患仍持續高燒(最高體溫38·5°C)、咳嗽、喘。其痰液經RT-PCR檢查證實感染COVID-19。

入院後第11天,病患出現心絞痛、心悸合併呼吸喘鳴音(wheezing)。胸部電腦斷層檢查除了雙側肺部有多處毛玻璃樣變化外,也伴隨肺實質化病變(parenchymal consolidation)及肺小葉間隔增厚的現象(interlobular septal thickening),同時發現自發性縱膈腔肺氣腫及皮下氣腫(Spontaneous pneumomediastinum、subcutaneous emphysema)。

醫師停止類固醇治療,但持續使用ribavirin共計14天。此外也給予氧氣、抗生素(cefoperazone–tazobactam [2 g/8 h])、支氣管擴張劑(theophylline [0·2 g/12 h])等。該病患還同時接受每日三次經由氣霧方式投予的人類重組干擾素(recombinant human interferon alfa-1b)治療共14天。

入院後第25天,病患已退燒、咳嗽症狀改善、呼吸音也恢復正常。COVID-19 RT-PCR檢查結果為陰性。電腦斷層檢查縱膈腔肺氣腫已經改善、肺實質化病變範圍縮小,但是出現纖維化及左下葉肺實質破壞後產生充滿氣體的囊狀區(pneumatocele)。

入院後第30天RT-PCR結果仍然維持陰性,因此安排病患出院並於門診追蹤。

雖然自發性縱膈腔肺氣腫往往是自限性的疾病,但是仍會對循環和呼吸造成嚴重的影響。此病例報告特別指出感染COVID-19的病人在疾病惡化時需要密切留意此併發症的可能性。

(財團法人國家衛生研究院 齊嘉鈺醫師摘要整理)

A 38-year-old man from Wuhan, China, was admitted to the Central Hospital of Wuhan (Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China), on Jan 20, 2020, with a 1-day history of fever without dizziness, cough, and headaches. On presentation, his temperature was 38·1°C. Laboratory tests showed a C-reactive protein concentration of 0·56 mg/dL (normal range 0·00–0·60] mg/dL). Complete blood count showed elevated leukocytes (10 060 cells per μL [normal range 3500–9500 cells per μL]), neutrophils (7550 cells per μL [1800–6300 cells per μL]), and monocytes (990 cells per μL [100–600 cells per μL]), while the lymphocyte count (1490 cells per μL) was in the normal range (1100–3200 cells per μL). The patient was negative for influenza A and B viruses, adenovirus, respiratory syncytial virus, and parainfluenza 1, 2, and 3 viruses. Chest CT showed multiple ground-glass opacities in the lower lobes bilaterally.
The patient was given antibacterial, antiviral, and corticosteroid treatments (moxifloxacin [0·4 g/day] for 5 days, followed by ribavirin [0·5 g/day] and methylprednisolone [40 mg/day] for 5 days) via intravenous drop infusion. However, after 10 days, the patient had persistent fever (highest temperature 38·5°C), cough, and shortness of breath. The patient was diagnosed with coronavirus disease 2019 (COVID-19) on the basis of RT-PCR analysis of sputum samples. On day 11, the patient developed exertional angina with cardiac palpitations along with respiratory wheezing. Chest CT revealed multiple ground-glass opacities with bilateral parenchymal consolidation and interlobular septal thickening. Spontaneous pneumomediastinum and subcutaneous emphysema were also observed (figure).

Author:Changyu Zhou, Chen Gao, Yuanliang Xie, et al.
原文連結: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30156-0/fulltext