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目的:报道1例恶性疟疾并发弥漫性血管内凝血(DIC)的救治成功体会,并文献复习。方法:赴非洲施工的男性中国公民,回国3d后出现寒战、高热,伴有全身皮肤、黏膜出血点、紫癜,并进展为淤斑、牙龈出血,呕吐咖啡渣样胃内容物、红黑色大便。体检:T40.5℃,P110次/min,R22次/min,BP90/60mmHg(1mmHg=0.133kPa)。急性病容,意识清晰,中度贫血貌,全身皮肤、黏膜可见散在出血点、紫癜及淤斑,牙龈出血。双侧瞳孔等大等圆,对光反射迟钝。颈项强直(-)。双肺呼吸音增粗,未闻及干、湿性啰音穆善耄拊右簟8谷恚?压痛,肝脏肋下3cm,脾脏肋下5cm。生理反射存在,病理反射未引出。入院2d后出现明显头痛、意识障碍、少尿。血常规提示贫血和渐进性血小板下降。尿常规发现尿蛋白和红、白细胞。心电图正常,腹部B超发现肝、脾稍增大。粪常规消化道出血。肝、肾功能及出、凝血功能异常。血片发现红细胞内恶性疟环状体,考虑为恶性疟原虫感染。入院诊断:脑型恶性疟疾并发急性消化道大出血、亚临床DIC。结果:入院后给予磷酸氯喹片首剂1.0g,第2、3天0.5g,分别口服,体温不能控制。使用抗生素预防和控制感染,给予质子泵抑制剂、输注血小板混悬液及常规止血剂控制消化道出血的同时,使用青蒿素类抗疟药。双氢青蒿素片:首剂160mg,6h后160mg,以后每日80mg,连续口服7d。第4天体温开始下降,并逐渐恢复到正常体温。同时给予输注血小板混悬液及止血治疗后,血小板上升,控制DIC。但消化道出血仍不能完全控制,作电子肠镜提示肠黏膜息肉出血,给予息肉高频电凝切除。行保护肝、肾等对症、支持治疗后,患者肝、肾功能恢复后出院。随诊体温持续正常。结论:早期确立诊断、早期使用青蒿素类抗疟药物和强化支持对症治疗可以提高恶性疟疾的抢救成功率。
Objective: To report the successful treatment of one case of malignant malaria complicated by diffuse intravascular coagulation (DIC) and to review the literature. Methods: Male Chinese citizens who went to Africa to work in China had chills, fever and systemic skin and mucous membrane bleeding, purpura, and ecchymosis, gingival bleeding and vomiting of coffee residue-like stomach contents and red and black stools. Physical examination: T40.5 ℃, P110 times / min, R22 times / min, BP90 / 60mmHg (1mmHg = 0.333kPa). Acute illness, clear consciousness, moderate anemia appearance, body skin, mucous membranes visible scattered bleeding point, purpura and ecchymosis, bleeding gums. Big pupils and other bilateral round, slow reflection of light. Neck stiffness (-). Double lung breath tone thickening, unheard of and dry, wet rales Mu Shan 耄 拊 right 簟 8 Valley 恚 ? Tenderness, liver rib 3cm, spleen rib 5cm. Physiological reflex exists, the pathological reflex did not lead. 2d after admission obvious headache, disturbance of consciousness, oliguria. Blood shows anemia and progressive thrombocytopenia. Urine proteinuria and red, white blood cells found. Normal ECG, abdominal B-found liver, spleen slightly increased. Dung conventional gastrointestinal bleeding. Liver, kidney function and out, coagulation dysfunction. Blood film found within the erythrocytic ring of falciparum malaria, considered for Plasmodium falciparum infection. Admission diagnosis: cerebral malaria complicated with acute gastrointestinal bleeding, subclinical DIC. Results: After admission, the first dose of chloroquine phosphate tablets was given to 1.0 g, the first and second days to 0.5 g, respectively, oral, body temperature can not be controlled. Use of antibiotics to prevent and control infections, given proton pump inhibitors, infusion of platelet suspensions and conventional hemostatic agents to control gastrointestinal bleeding, while using artemisinin-based antimalarial drugs. Dihydroartemisinin tablets: the first dose of 160mg, 6h after 160mg, after daily 80mg, continuous oral 7d. Body temperature began to decline on the 4th day, and gradually returned to normal body temperature. At the same time given infusion of platelet suspension and hemostasis, the platelets rise, control DIC. However, gastrointestinal bleeding is still not completely controlled, for intestinal colonoscopy prompted polyp bleeding, polyp electrosurgical excision. Line to protect the liver, kidney and other symptomatic, supportive treatment, patients with liver and kidney function was discharged after discharge. Follow-up body temperature continued to normal. Conclusion: Early diagnosis, early use of artemisinin-based anti-malarial drugs and intensive support symptomatic treatment can improve the success rate of rescue of malaria.