每日一题_2022.08.01

A 29-year-old man with no significant medical history is admitted to the medical ICU with acute liver failure. He was healthy until he started having nausea about 10 days ago and noted throughout the week that his eyes were turning yellow and his urine was very dark. He also reports fever, headache, and general malaise. He denies IV drug abuse and has one tattoo from five years ago. He says that he drinks socially and often has one beer nightly after a day of work cleaning sewers. He denies any toxic ingestion, does not take medications, and has no family history of liver disease. On examination, he is alert and oriented with stable vital signs and is afebrile. His entire body is jaundiced, and his abdomen is soft without ascites. Laboratory assessment shows: white blood cell count 24,400/μL, hematocrit 35 g/dL, platelets 122,000/μL, sodium 140 mEq/L, potassium 4.0 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen 101 mg/dL, creatinine 4.05 mg/dL, total bilirubin 45 mg/dL, direct bilirubin 34 mg/dL, aspartate aminotransferase 192 U/L, alanine aminotransferase 227 U/L, alkaline phosphatase 73 U/L, and acetaminophen level negative.

Which of the following is/are the most appropriate next step(s) in management?

A. Obtain hepatitis panel and start IV lamivudine.

B. Consult a nephrologist for urgent dialysis.

C. Obtain ethanol level and urine drug screen and start prednisone for probable alcoholic hepatitis.

D. Start IV penicillamine and notify transplant surgery.

E. Start IV doxycycline and continue supportive care.

答案解析：

该患者患有钩端螺旋体病。最初的症状可能是千变万化的，类似于流感。最严重的形式是 Weil 病，它可导致肾衰竭、肝衰竭、肺出血、脑膜炎和死亡。最常通过接触皮肤屏障破坏的啮齿类动物尿液传播。患者在下水道工作，因此他可能以这种方式联系。尽管明确的死亡率获益尚不确定，但推荐使用抗生素如多西环素。除抗生素外的支持治疗是主要的治疗方法。

考虑到他的职业，该患者可能感染了甲型肝炎/戊型肝炎，但治疗通常是支持性的。此外，他的转氨酶不像预期的那样高急性肝炎。拉米夫定可考虑用于急性乙型肝炎感染，但不是标准治疗。鉴于其症状的急性性质，肝豆状核变性不太可能发生；因此青霉胺和移植是不正确的。他将来可能需要透析，但考虑到他的电解质和正常的精神状态（尽管尿素氮升高），不需要紧急透析。他的病史以及临床和实验室检查结果不太支持急性酒精性肝炎。泼尼松对酒精性肝炎的疗效尚不明确，但可能对他的病情不利。

正确答案：E