目的:分析 1 例罕见的限制性马拉色菌致血流感染患者的临床诊疗过程,为临床此类罕见感染疾病的诊治提供参考。方法与结果:该患者 2 周前被猫抓伤后反复发热,入院后仍持续发热,检查显示血清白细胞计数和降钙素原均正常,仅 C 反应蛋白升高,结合患者的临床症状,临床排除了呼吸道和尿路的感染,且未发现其他明显的感染灶,临床先经验性予阿奇霉素;2 d 后,真菌 D-葡聚糖检查结果异常（222.53 pg/mL）;临床药师会诊发现,患者近期存在糖尿病血糖控制不佳且有服用糖皮质激素的情况,因而可能免疫功能较差,综合患者前期检查结果,怀疑患者的发热可能是由猫抓伤致真菌侵入血液所致的血流感染引起的,遂建议加用氟康唑进行抗真菌治疗;第 2 天,患者体温明显回落,且第 3 天患者血标本的二代测序结果为限制性马拉色菌（序列数为 29）,基本印证了临床药师的判定;最后,患者在用氟康唑治疗 10 d 后出院。结论:对于不明原因发热的患者,临床医生和药师应充分结合患者的临床表现和各种检查结果,以及经验性抗感染治疗的反馈,以准确判断患者的感染部位和可能病原菌,从而更有针对性、更有效地为患者开展治疗。
Abstract
Objective: To analyze the clinical diagnosis and treatment process of a patient with rare bloodstream infection caused by Malassezia restricta, and provide reference for the clinical diagnosis and treatment of such rare infectious diseases. Methods and Results: The patient had recurrent fever after being scratched by a cat 2 weeks ago, and continued to have fever after admission. The examination showed that the WBC count and procalcitonin in serum were normal, and only the C-reactive protein (CRP) increased. According to the patient's clinical symptoms, the respiratory tract and urinary tract infections were clinically ruled out, and no other obvious foci of infection were found. Clinically, azithromycin was given empirically; 2 days later, the fungal D-glucan test results were abnormal (222.53 pg/mL); the clinical pharmacist consultation revealed that the patient had recently suffered from poor control of blood glucose in diabetes and had taken glucocorticoids, so his/her immune functions might be poor. Based on the patient's previous examination results, it was suspected that the patient's fever was possibly caused by bloodstream infection when fungi invaded the blood as a result of cat scratch, so it was suggested to add fluconazole for antifungal treatment; on the 2nd day, the patient's body temperature dropped apparently, and on the 3rd day, the next-generation sequencing results of the patient's blood samples showed that the bacterium was Malassezia restricta (sequence number: 29), which basically confirmed the judgment of the clinical pharmacist; finally, the patient was discharged from the hospital 10 days after treatment with fluconazole. Conclusion: For any patient with fever of unknown origin, clinicians and pharmacists should accurately determine the patient's infection site and possible pathogenic bacteria according to the patient's clinical manifestations and various examination results, as well as feedback from empirical anti-infective treatment, so as to provide more targeted and effective treatment for the patient.
关键词
不明原因发热 /
血流感染 /
限制性马拉色菌 /
药学监护 /
氟康唑
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Key words
fever of unknown origin /
bloodstream infection /
Malassezia restricta /
pharmaceutical care /
fluconazole
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参考文献
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脚注
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基金
*1无锡市科技发展医疗卫生指导性计划（No.NZ2019004）
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