每日一题_2024.03.14

An 82-year-old man presented to the emergency department with a 3-year history of progressive generalized weakness. Four months before presentation, a left adrenal mass had been identified incidentally on computed tomography (CT) that had been performed to evaluate an episode of chest pain. During the month preceding presentation, he had lost 8 kg of weight and had become unable to sit up in bed. Physical examination was unremarkable. Laboratory studies were notable for a white-cell count of 2700 per cubic millimeter (reference range, 3700 to 10,500), a normal adrenal axis, and negative testing for HIV. Owing to concern for cancer, positron-emission tomography–CT of the whole body was performed and showed an adrenal mass on each side with fluorodeoxyglucose (FDG) uptake (left image shows a coronal view), a 17-cm-long spleen without FDG uptake (asterisk in left image), and no other abnormal findings. Subsequent biopsy of the left adrenal mass showed necrotizing granulomatous inflammation with intracellular fungal organisms (middle, arrows; hematoxylin and eosin staining) that stained positive with Grocott’s methenamine silver (right). The organism causing this disease is predominantly found in what geographic regions?

一名82岁的男性患者因为持续3年的进行性全身乏力症状前来急诊科就诊。在就诊前4个月，CT检查发现了左侧肾上腺肿块，当时是为了评估胸痛发作而进行的检查。在就诊前一个月，他体重减轻了8公斤，并且无法坐起来。体格检查未见异常。实验室检查显示白细胞计数为每立方毫米2700（参考范围为3700至10,500），肾上腺轴正常，HIV检测呈阴性。由于担心癌症，进行了全身正电子发射断层扫描（PET-CT），显示双侧肾上腺肿块摄取了氟脱氧葡萄糖（FDG）（左图显示冠状位），脾脏长度17厘米，未摄取FDG（左图中的星号），并且没有其他异常发现。随后对左侧肾上腺肿块进行了活检，显示坏死性肉芽肿性炎症，并有细胞内真菌样生物体（中图，箭头；用伊红和伊红溶液染色呈阳性）（右图）。导致这种疾病的病原体主要分布在哪些地理区域？

A. Central and mideastern United States & Central America 美国中部和中部及中美洲

B. Central and South America 中南美洲

C. Southeast Asia, southern China, & eastern India 东南亚、中国南部和印度东部

D. Southwestern United States 美国西南部

E. Ubiquitously in soil throughout the globe在全球土壤中无处不在

答案解析：

诊断为慢性进行性播散性组织胞浆菌病。组织胞浆菌特别喜欢生长在富含鸟类或蝙蝠粪便的有机物质中。虽然全世界范围内都有疾病的广泛报道，但最多报告的病例集中在美国俄亥俄河和密西西比河流域地区。开始使用伊曲康唑进行治疗。

正确答案：A