每日一题_2022.09.24

A 64-year-old, 70-kg man with a medical history significant for hypertension, diabetes mellitus, and coronary artery disease is admitted to the hospital for progressive shortness of breath, retrosternal chest pain during the past 48 hours, and weakness and paresthesia starting in the lower extremities and now in the upper extremities. Vital signs are: heart rate 120 beats/min, respiratory rate 32 breaths/min, blood pressure 90/48 mm Hg, and oxygen saturation 92%. Arterial blood gas analysis reveals: pH 7.48, pCO2 30 mm Hg, pO2 66 mm Hg. A bedside pulmonary function testing reveals a negative inspiratory force -10 cm H2O and a vital capacity of 0.4 L. On examination, his mental status is normal, without signs of aphasia or neglect, cranial nerves are normal, motor examination reveals asymmetric weakness with 2/4 in lower extremities and 3/5 in the upper extremities. There is areflexia with proprioceptive loss in the lower extremities. White blood cells are 7,800/μL, blood urea nitrogen 28 mg/dL, creatinine 1.0 mg/dL, sodium 140 mEq/L. Cerebrospinal fluid analysis reveals glucose of 78 mg/dL, protein 78 mg/dL and cell count of 2 lymphocytes.

Which of the following is/are the best immediate intervention(s) for this patient?

A. IV ceftriaxone and vancomycin

B. Intubation and mechanica lventilation

C. IV gammaglobulin

D. Plasma exchange

答案解析：

患者描述了伴有反射消失和本体感觉丧失的上行感觉异常和虚弱的发作。这张图片是急性炎症性脱髓鞘性多发性神经根神经病 (AIDP) 的特征。检查时，他表现出心脏和呼吸不稳定的迹象。心动过速、低血压、胸痛和轻度低氧血症表明他需要立即插管进行机械通气。床边肺功能测试表明吸气努力不足，动脉血气表明即将发生呼吸衰竭的初步阶段。尽管 AIDP 的治疗很可能是静脉注射免疫球蛋白 (IV Ig) 或血浆置换，但该患者管理的第一步是保护他的气道并帮助他的通气。类固醇未显示对 AIDP 的管理有任何益处。

美国神经病学学会指南指出：1) 血浆置换或 IV Ig 治疗可加速 AIDP 的恢复，2) 血浆置换和 IV Ig 的有益效果是相同的，3) 将这两种治疗结合是无益的，以及 4)不推荐糖皮质激素治疗。最后，由于脑脊液研究没有显示脑膜炎的证据，因此不建议使用抗生素。

正确答案：B