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Lancet:这名患者的诊断扑朔迷离,你能诊断正确吗?——案例报道

2016-10-09 Seven L 译 MedSci原创

患者女,32岁,腰背疼痛、大腿沉重、间歇性发热和寒战2周。 既往史包括三叉神经痛、焦虑(近期服用奎硫平)。 查体:体温39°C,余正常。 实验室检查:C-反应蛋白升高(CRP; 118 mg/L),包括肝功能、肾功能在内的生化指标和其他血常规指标都未见明显异常。 考虑急性肾盂肾炎,予以广谱抗生素治疗;但患者的血培养、尿培养均是无菌的,泌尿系统CT也是正常的,于是停止了抗生素

患者女,32岁,腰背疼痛、大腿沉重、间歇性发热和寒战2周。

既往史包括三叉神经痛、焦虑(近期服用奎硫平)。

查体:体温39°C,余正常。

实验室检查:C-反应蛋白升高(CRP; 118 mg/L),包括肝功能、肾功能在内的生化指标和其他血常规指标都未见明显异常。

考虑急性肾盂肾炎,予以广谱抗生素治疗;但患者的血培养、尿培养均是无菌的,泌尿系统CT也是正常的,于是停止了抗生素治疗。

患者持续发烧,背部、大腿的不适在增加,进一步检查结果显示:血清肌酸激酶升高(CK; 30·51 μkat/L),有可能是喹硫平相关恶性综合征,但是停止使用喹硫平后,患者的症状无缓解。

再次复发血液和尿液分析、咽拭子、脑脊液等,均没有发现任何微生物。胸片和超声心动图检查均正常。血清补体(C3、C4)浓度正常,自身抗体均为阴性。

入院后1周,血红蛋白从入院时的126 g/L下降到93 g/L,并出现了轻微中性粒细胞减少(0·9 × 109/L)和血小板减少(110 × 109/L)。

铁相关检查提示炎症性疾病,但血清铁蛋白是不成比例的升高(34 844 pmol/L),在接下来的一周具有明显的波动(最低494 pmol/L,最高45 301 pmol/L),CK浓度也出现了显著波动(最低7·43 μkat/L;最高23·86 μkat/L)。血清乳酸脱氢酶浓度也升高了(10·55 μkat/L)。

基于这些结果,考虑为肌炎,可能为副肿瘤性。高铁蛋白血症和血细胞减少支持噬血细胞性淋巴组织细胞增多症(HLH)的诊断。

18F-FDG PET-CT显像:没有发现肌肉或器官(包括淋巴结、肝、脾)的异常,但是中轴骨骼对FDG摄取不均匀。



脊柱MRI显示骨髓信号异常,与FDG摄取区域一致,在髂腰肌和闭孔外肌两侧的片状肌肉和筋膜水肿。针极肌电图显示右侧股四头肌无自发活动,但早期持续时间短的多相运动单位电位增加,提示肌病。

肌肉活检显示非特异性萎缩但无炎症、血管炎、营养不良、代谢和线粒体肌病。

骨髓活检显示骨髓细胞纤维化改变,但没有形态学和免疫组化特征的恶性肿瘤,且没有发现噬血细胞现象,不太支持HLH的诊断(可能性HScore 70%)。

临时诊断为特发性炎症性肌病,予以静脉注射甲基强的松龙免疫抑制治疗。

出乎意料的是,在首次类固醇治疗前,30%的骨髓细胞出现了异常核型: −43–45,XX,–5,–10,–15,add(15)(p10), −22, + mar1, + mar2, + mar3[cp8]/46,XX[18],意味着可能是浸润性肿瘤性疾病。

首次活检后10天,重复骨髓采样,以确定恶性细胞表型,仍观察到相同特征。

患者开始类固醇治疗,但症状无改善;随着患者骨髓抑制的进展(Hb 80 g/L, 中性粒细胞 0·5 × 109/L,血小板 50 × 109/L),我们考虑这是一个非淋巴髓系恶性肿瘤。

因此,在第4周,我们第三次采取骨髓样本。环钻活检样本显示坏死、高级别肿瘤几乎完全取代了骨髓。



CD2、胞质CD3、CD30、穿孔素、TIA-1的表达,提示恶性T细胞表型。CD4、CD5、CD7、CD8、T细胞受体(TCR)-γ和ALK-1均未检出,但TCR-β1表达,加上TdT负染色,排除T细胞急性淋巴细胞性白血病,提示诊断为外周T细胞非霍奇金淋巴瘤

开始对患者进行化疗(环磷酰胺、阿霉素、长春新碱和泼尼松[CHOP]),患者症状迅速改善。三个周期后,患者PET检查时,FDG信号正常化,达到形态学和细胞遗传学缓解。鉴于患者的非典型表现,以及类固醇不敏感的疾病,我们打算进行同种异体移植,但不幸的是,患者的疾病复发,并且再次化疗治疗无效,最终患者死亡。

原始出处:

Josh T Coats,et al.An unusual extranodal T-cell non-Hodgkin lymphoma.Lancet.Volume 388, Issue 10049, 10–16 September 2016, Pages 1127–1128

本文系梅斯医学(MedSci)原创编译整理,转载需授权!

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    2017-03-29 howi
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    2016-12-12 医学界的小学生

    不错的病历

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-19 青青河边草格格

    学到了

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-18 青青河边草格格

    赞一个

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-17 青青河边草格格

    赞一个

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-16 青青河边草格格

    赞一个

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    2016-11-15 青青河边草格格

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  8. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-14 青青河边草格格

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  9. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-13 青青河边草格格

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  10. [GetPortalCommentsPageByObjectIdResponse(id=1828640, encodeId=6ffc182864040, content=<a href='/topic/show?id=1b6210686b2' target=_blank style='color:#2F92EE;'>#Lancet#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10686, encryptionId=1b6210686b2, topicName=Lancet)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3f0227, createdName=howi, createdTime=Wed Mar 29 07:41:00 CST 2017, time=2017-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=162215, encodeId=6a4216221574, content=不错的病历, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e2811993998, createdName=医学界的小学生, createdTime=Mon Dec 12 17:43:50 CST 2016, time=2016-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156738, encodeId=2f27156e3890, content=学到了, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 19 07:11:27 CST 2016, time=2016-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156569, encodeId=8a5615656995, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Fri Nov 18 10:42:52 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156385, encodeId=7b9315638599, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=122, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Thu Nov 17 11:30:48 CST 2016, time=2016-11-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156020, encodeId=5eb71560201c, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Wed Nov 16 07:13:30 CST 2016, time=2016-11-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155874, encodeId=e0181558e4e7, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Tue Nov 15 12:07:09 CST 2016, time=2016-11-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155729, encodeId=137b155e2921, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Mon Nov 14 17:54:32 CST 2016, time=2016-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155404, encodeId=e5e115540416, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sun Nov 13 08:55:42 CST 2016, time=2016-11-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=155316, encodeId=714715531633, content=赞一个, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/0E8FE3AB433C664DAC1344E414F0FAF0/100, createdBy=e19b1934544, createdName=青青河边草格格, createdTime=Sat Nov 12 20:29:26 CST 2016, time=2016-11-12, status=1, ipAttribution=)]
    2016-11-12 青青河边草格格

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非霍奇金淋巴瘤(NHL)是一种始于淋巴细胞的肿瘤,是美国第六大最常见的癌症类型。发病原因尚不明确,但至今未发现其风险因素,如免疫系统抑制和暴露于某些感染。早期症状包括腋窝、颈部和腹股沟淋巴结肿大,伴有发热、胸痛、盗汗、体重减轻等。 在过去的30年里,NHL的发病率急剧上升。例如,在1990 - 2012年,以色列NHL的发病率上升了27%。目前研究人员尚不清楚发病率提高的原因,但它却引发了一系列的

BMJ:令人费解的面部肿胀——病例报道

女性患者,24岁,因服用阿莫克拉后不久出现面部肿胀和吞咽困难而就诊。体格检查发现患者口面部肿胀,窦性心律过速。经抗过敏治疗后临床症状好转而出院,但是5天后出现了呼吸窘迫。胸片显示大的纵膈肿块(如下图所示),经活组织检查后确诊为非霍奇金淋巴瘤(NHL)。阿莫克拉并不是导致其口面部肿胀的原因。立即对患者进行通气支持,静脉注射,类固醇,别嘌呤醇以及紧急化疗。3-8%的纵膈NHL患者会发生上腔静脉综合征,

2016NCCN临床实践指南:非霍奇金淋巴瘤(2016.V3)发布

2016年5月,美国国家综合癌症网络(NCCN)发布了非霍奇金淋巴瘤指南2016年第三版,指南更新摘要如下:慢性淋巴细胞白血病/小淋巴细胞淋巴瘤滤泡性淋巴瘤边缘区淋巴瘤 套细胞淋巴瘤弥漫性大B细胞淋巴瘤伯基特淋巴瘤淋巴母细胞性淋巴瘤艾滋病相关性B细胞淋巴瘤毛细胞白血病原发性皮肤B细胞淋巴瘤外周T细胞淋巴瘤 蕈样真菌病/ Sezary综合征原发性皮肤CD30+T细胞淋巴组织病T细

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