Patient female, 22 years old. Due to recurrent fever for over a year and weakness in both lower limbs for over 20 days, he was admitted to our hospital on October 26, 2016. The patient experienced recurrent fever without any obvious cause more than a year ago (May 2015), with a maximum body temperature of 40 ° C. Laboratory examination in an external hospital showed a blood routine white blood cell count of 1.04 × 10 9/L [(3.50~9.50) × 10 9/L], reticulocyte ratio 0.0145 (0.80-2.00), hemoglobin 92 g/L (110-150 g/L), platelet count 72 × 10 9/L [(100~350) × 10 9/L]; Detection of EB virus DNA in peripheral blood 416 × 10 3 copies/ml; Abdominal ultrasound shows that the right oblique diameter of the liver is 16.10 cm, the inner diameter of the portal vein is 1.30 cm, the thickness of the spleen at the splenic hilum is 7.40 cm, the inner diameter of the splenic vein is 1 cm, the lateral position is 16 cm below the splenic rib, and the supine position is 5 cm above the midline of the spleen, indicating liver enlargement, diffuse changes in the liver parenchyma, enlarged spleen, and mild dilation of the portal vein system; Chest CT shows multiple nodular shadows in both lungs, indicating inflammatory changes; Bone marrow cytology examination showed three lines of proliferative bone marrow, with an increase in the proportion of red blood cells; Bone marrow biopsy indicates that bone marrow hyperplasia is generally normal, while tertiary hyperplasia with mild abnormalities in megakaryocyte morphology; JAK2 V617F quantification 0%, CALR Exon9 and MPL Exon10 mutations negative; Flow cytometry showed an increase in the proportion of granulocytes, nuclear shift to the left, and downregulation of CD13 expression; Immunohistochemical staining showed a count of 1391 CD41+megakaryocytes, including 1238 normal megakaryocytes. Neutrophil alkaline phosphatase (NAP) and glycogen periodate Schiff (PAS) staining were negative, and the positive rate of sideroblasts was 2% (27%~94%). Clinically, EB virus infection was considered, and anti infection, liver protection, and intravenous immunoglobulin (specific plan unknown) treatment were given. After 2 months, the fever symptoms gradually relieved. Afterwards, regular blood routine examinations showed a decrease in whole blood cell count; Abdominal ultrasound shows that the liver and spleen are enlarged, and the portal vein system continues to expand. More than 20 days ago, the patient had no obvious cause of weakness in both lower limbs, and when walking, both lower limbs were heavy and stiff, with symptoms gradually worsening; Before the 14th day, it is necessary to walk with assistance and not squat on your own, as there may be occasional falls; Symptoms slightly relieved 7 days ago, with no dizziness, headache, nausea, vomiting, blurred vision, blurred speech, coughing when drinking water, numbness in limbs, or bowel and bowel movements during the course of the disease. The MRI examination of the thoracic spine in the external hospital (October 19, 2016) showed diffuse patchy abnormal signal shadows in the thoracic spinal cord, suggesting the possibility of inflammatory demyelinating lesions. In order to seek further diagnosis and treatment, we have sought medical attention at our hospital, where the outpatient department is admitted as a "spinal cord disease". Since the onset of the disease, the patient's mental state, sleep, and diet have been tolerable, their bowel movements have been normal, and their weight has not significantly decreased. They deny immune colors such as dry eyes, dry mouth, hair loss, rash, joint swelling and pain, and Raynaud's phenomenon. There is no special history, personal history, or family history. After admission, the patient underwent physical examination with a body temperature of 37.2 ° C, pulse rate of 80 beats/min, respiration rate of 23 beats/min, and blood pressure of 105/64 mm Hg (1 mm Hg=0.133 kPa). One small lymph node is palpable under the right jaw, the size of a soybean, with good mobility, tough texture, and no tenderness. The abdomen is soft, without tenderness, the liver is not palpable under the ribs, the spleen is large, and about 8 cm below the ribs. Neurological examination: clear consciousness, fluent language, normal visual acuity and field of vision, bilateral pupils of equal size and circle, with a diameter of approximately 4 mm, sensitive to light reflex, and no abnormalities in the remaining cranial nerves; Both upper limbs have muscle strength of level 5 and normal muscle tone, while both lower limbs have muscle strength of level 5 and increased muscle tone; Acupuncture sensation and tuning fork vibration sensation are normal; Bilateral finger nose test, rapid rotation movement, and stable heel knee tibia test; Active limb tendon reflex; Positive Hoffmann sign on the right and negative on the left, positive Rossolimo sign on both sides, positive Babinski sign and Chaddock sign on both sides, positive ankle clonus on both sides, and negative Romberg sign; Having a spasmodic gait; Negative meningeal stimulation sign. Neuropsychological tests: The Simplified Intelligence State Examination Scale (MMSE) scores 24 points, and the Montreal Cognitive Assessment Scale (MoCA) scores 23 points. Auxiliary laboratory examination: Blood routine white blood cell count 0.80 × 10 9/L, neutrophil count 0.49 × 10 9/L [(2.00~7.50) × 10 9/L], reticulocyte count 99.70 × 10 9/L [(24-84) × 10 9/L], reticulocyte ratio 0.0241, hemoglobin 114 g/L, platelet count 45 × 10 9/L, erythrocyte sedimentation rate (ESR) 2 mm/h (0-20 mm/h); Blood smear: Red blood cells vary slightly in size, white blood cells have generally normal morphology, and platelets are rare. Blood chemistry total bilirubin 26.50 μ Mol/L (5.10~22.20 μ Mol/L), direct bilirubin 10.40 μ Mol/L fever, liver, spleen, and lower limb weakness
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