每日一题_2022.08.29

A 68-year-old man with a recent sinus infection presents to the emergency department minimally responsive. Per report, he has had headache and nausea and was vomiting all day. Temperature is 37°C (98.6°F), heart rate 90 beats/min, blood pressure 145/90 mm Hg, respiratory rate 12 breaths/min. On examination, pupils are equal, round, and reactive. He mumbles to verbal stimulation, localizes to noxious stimulation in the right upper and lower extremities, and withdraws to noxious stimulation in the left upper and lower extremities. Head CT reveals an irregular area of low density in the right frontoparietal region with minimal mass effect. Brain MRI with gadolinium shows a similar hyperintense lesion on T2 and diffuse ring enhancement; the lesion is hyperintense on diffusion-weighted imaging. Neurosurgery is consulted, and he is admitted to the neurology ICU.

Which of the following is the most appropriate treatment while awaiting neurosurgery evaluation?

A. Dexamethasone

B. Ceftriaxone and vancomycin

C. Metronidazole and vancomycin

D. Ceftriaxone and metronidazole

答案解析：

该患者的脑脓肿可能继发于鼻窦感染的直接扩散。 脑脓肿患者通常不会发烧。 区分脓肿和肿瘤的 MRI 成像特征是弥散加权成像的高信号。 地塞米松将是治疗肿瘤的正确方法，但仅适用于脑脓肿，具有显着的占位效应，因为其缺点是包膜形成减慢、心室破裂风险增加以及抗生素对脓肿的渗透减少。 鼻窦扩张导致脑脓肿患者的最佳抗生素方案是头孢曲松和甲硝唑，包括需氧链球菌、厌氧链球菌、嗜血杆菌属、非脆弱拟杆菌属和梭杆菌属。 头孢曲松和万古霉素，或甲硝唑和万古霉素不能提供足够的覆盖。

正确答案：D