一例有趣的慢性阻塞性肺疾病加重并伴有颅内高压和高碳酸血症脑病混合症状的病例

Chaoneng Wu, Mendez Gustavo, Gandhi Aaron, Kambhatla Sujata, Siddiqui Furqan, Pasha Amin, Madhavan Ramesh
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摘要

背景:特发性颅内高压(IIH 或假性脑瘤)有两大主要病症:视力丧失的乳头水肿和致残性头痛。颅内静脉高压(IVH)是 IIH 的基本机制。虽然传统上认为 IIH 仅局限于中枢神经系统,但有证据表明 IIH 是一种与心肺功能紊乱相关的全身性疾病,而人们对这种疾病的认识还远远不够。病例报告:一名患有慢性阻塞性肺病(COPD)的 60 岁女性因呼吸困难入院,随后出现昏迷,pH 值为 7.01,pCO2 为 158 mmHg。患者插管后出现持续性颈项强直、短暂的肌阵挛发作,脑电图呈阴性,头部 CT 检查呈阴性。腰椎穿刺(LP)显示开口压力升高(35 cmH2O),脑脊液(CSF)检查正常。取出 40 毫升 CSF 后,她的颈部僵硬症状有所改善。大容量腹腔穿刺术后第二天的眼科检查未发现视力下降或乳头水肿。患者的临床症状有所改善,两天后拔管。她的超声心动图显示右心室扩张并伴有肺动脉高压。患者出院回家。讨论IIH 不同于高碳酸血症脑病,其特点是颅内压增高并伴有乳头水肿、视力减退和头痛。高碳酸血症引起的颅内静脉流量增加和肺动脉高压引起的中心静脉压升高以及随之而来的流出阻力会导致 IVH。高碳酸血症脑病主要表现为认知改变。在本病例中,头部 CT 扫描阴性的颈部僵硬引发了对 IIH 的检查。结论深入了解慢性阻塞性肺病与 IIH 之间的关系至关重要。目前还没有足够的证据建议对慢性阻塞性肺病患者进行常规眼部检查,以确定是否存在乳头水肿,也没有足够的证据建议对新诊断的 IIH 患者进行肺功能检查。但是,我们强烈建议对怀疑患有 IIH 的 COPD 患者在进行 LP 检查之前及时进行眼科检查,以避免不必要的手术,同时改善临床预后。
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An Interesting Case of COPD Exacerbation Presenting with Mixed Features of Intracranial Hypertension and Hypercapnic Encephalopathy
Background: Idiopathic intracranial hypertension (IIH or pseudotumor cerebri) has two major morbidities: papilledema with visual loss and disabling headache. Intracranial Venous Hypertension (IVH) is a fundamental mechanism of IIH. Although traditionally considered limiting to the central nervous system, evidence suggests IIH as a systemic disease associated with cardiorespiratory disorders, which has been far less comprehended. Case Report: A 60-year-old female with Chronic Obstructive Pulmonary Disease (COPD) was admitted for dyspnea and developed a coma with a pH of 7.01 and pCO2 of 158 mmHg. She was intubated and had persistent nuchal rigidity, a brief myoclonus episode with a negative electroencephalogram, and negative CT head studies. A Lumbar Puncture (LP) revealed elevated opening pressure (35 cmH2O) with normal Cerebral Spinal Fluid (CSF) studies. Her nuchal rigidity improved after the removal of 40 mL CSF. The ophthalmology examination the next day after her the large volume LP didn’t show visual loss or papilledema. The patient improved clinically and was extubated two days later. Her echocardiogram showed a dilated right ventricle with pulmonary hypertension. The patient was discharged home. Discussion: IIH is different from hypercapnic encephalopathy and characterized by increased intracranial pressure with papilledema, vision loss, and debilitating headache. Hypercapnia-induced increased intracranial venous flow and pulmonary hypertension-caused elevated central venous pressure with consequent outflow resistance lead to IVH. In hypercapnic encephalopathy, the presentation is mostly cognitive changes. In this case, nuchal rigidity with a negative CT head scan triggered the investigation of IIH. Conclusion: A deep understanding of the relationship between COPD and IIH is vital. There is insufficient evidence to recommend routine eye examinations in COPD patients for papilledema and to conduct a pulmonary function test for a newly diagnosed IIH patient. However, we highly suggest a timely ophthalmology exam prior to performing an LP in COPD patients with suspecting IIH to avoid unnecessary procedures and meanwhile improve clinical outcomes.
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