Význam rehabilitace a její vliv na orgánové funkce u ... fileNynější onemocnění: Postupná...

Neobvyklá příčina perzistující hypertermie, hyperpyrexie

Josef Polák

Klinika anesteziologie, resuscitace a intenzivní medicíny

Univerzita Karlova v Praze, Lékařská fakulta v Hradci Králové

Fakultní nemocnice Hradec Králové

Anamnéza

73-letá žena

OA: myeloproliferativní syndrom – polycythemia vera

arteriální hypertenze, astma bronchiale, fibrilace síní

FA: Litalir, Concor, Valzap, Ecobec AA: penicilin

SA: důchodkyně, bydlí v bytě, zcela negativní cestovatelská

anamnéza

Abusus: kouření neguje

Nynější onemocnění:

Postupná progrese dušnosti, febrilie (38-39°C), hospitalizována na interním oddělení spádové nemocnice.

Laboratorně nízké markery zánětu, neprokázána plicní embolie (CTAG), zjištěny známky postižení plicního interstitia, klinické a laboratorní známky srdečního selhávání

Pro známky exacerbace bronchiálního astmatu podávány systémové kortikoidy. Pro další progresi dušnosti intubována, zahájena UPV, přeložena na LO KARIM FN Hradec Králové

Průběh: 1.-10.den

- při přijetí: pacientka v kontaktu, UPV, oběh bez podpory, febrilní TT 39°C.

- výsledky vyšetření: laboratorně CRP 20, leu 15tis, PCT 6, bronchoskopie s BAL, TEE, UZ břicha a hrudníku - bez patologie

- kontrastní CT krku, hrudníku, břicha - hepatosplenomegalie

- přes empirickou ATB léčbu (Meronem, Ciphin, Edicin, Biseptol, Mycomax) progrese febrilií nad 42°C, nereagující na antipyretika a fyzikální chlazení, zahájena CRRT

- klinicky – porucha vědomí, zhoršení plicních funkcí, podpora oběhu katecholaminy

Hypertermie - selhání termoregulace při působení vnějších i vnitřních vlivů

-- dlouhodobá expozice slunci, pobyt v horkém prostředí

-- hypersenzitivita na některé látky

-- tělesná námaha, porucha prokrvení, metabolismu

-- srdeční selhávání

-- poškození hypotalamu, tyreotoxikoza, feochromocytom;

-- ektodermální dysplazie (chybí potní žlázy)

-- maligní hypertermie

Hyperpyrexie - přenastavení termoregulačního centra

- tělesná teplota nad 40 (41) °C axilárně - endogenní pyrogeny při infekci, zánětlivém procesu (revmatické

onemocnění) nebo malignitě. - exogenní pyrogeny

Diferenciální diagnostika hyperpyrexie 46 common conditions

Alcohol Withdrawal

Animal Bites

Arm Cellulitis

Bacterial Gastroenteritis

Bacterial Pharyngitis

Bacterial Pneumonia

Bladder Infection

Bronchiolitis

Bronchitis

Cellulitis

Cervical Lymphadenitis

Chronic Bronchitis

Croup

Deviated Septum

Enlarged Prostate

Food Poisoning

Foot Cellulitis

Gastroenteritis

Gingivitis

Hand Cellulitis

Herpes Genitalis

Influenza

Insect Bite

Laryngitis

Leg Cellulitis

Otitis Externa

Otitis Media

Periodontal Disease

Pharyngitis

Pleuritis

Pneumonia

Sinusitis

Skin Abscess

Skin Infections

Teething

Tonsillitis

Upper Respiratory Infections in

Children

Upper Respiratory Infections

Urinary Tract Infection

Urinary Tract Infections in Children

Venereal Disease in Males

Venereal Disease

Viral Gastroenteritis

Viral Pharyngitis

Viral Syndrome

Wound Infection

58 somewhat common conditions

Alcoholic Hepatitis

Appendicitis

Axillary Lymphadenitis

Bartholin's Cyst

Biliary Colic

Breast Abscess

Caffeine Overdose

Campylobacter Enteritis

Canker Sores

Carbuncle

Cat Bites

Cocaine Abuse

Decubitus Ulcer

Dental Abscess

Diverticulitis

Dog Bites

Drug Dermatitis

Drug Side Effect

Epilepsy

Epstein Barr Infection

Erythema Infectiosum

Facial Cellulitis

Febrile Seizure

Finger Tenosynovitis

Gallbladder Disease

Gallstones

Giardia Infection

Haemophilus Pneumonia

Hand, Foot and Mouth Disease

Heat Illness

Hemorrhagic Cystitis

Hepatitis A

Hepatitis B

Hepatitis

Hernias

Herpangina

Herpes Gingivostomatitis

Immune System Deficiency

Inguinal Lymphadenitis

Lymphadenitis

Lymphangitis

Mastitis

Miscarriage

Mononucleosis

Mycoplasma Infection

Narcotic Withdrawal

Postpartum Infection

Purulent Rhinitis

Roseola

Rotavirus

Skin Ulcer

Staph Infections

Streptococcal Tonsillitis

Swine Flu

Traveler's Diarrhea

Viral Exanthem

Viral Hepatitis

Viral Pneumonia

78 uncommon conditions

Acanthamoeba Infection

Actinomycosis

AIDS

Allergic Alveolitis

Allergic Bronchopulmonary

Aspergillosis

Anorectal Foreign Body

Arbovirus Infection

Arenavirus Infection

Aspergillosis

Aspiration Pneumonia

Atelectasis

Bacterial Endocarditis

Bacterial Meningitis

Bartholin's Abscess

Bladder Stone

Brown Recluse Spider Bite

California Group Virus

Chicken Pox

Chlamydia Pneumonia

Chlamydia Trachomatis

Chronic Fatigue Syndrome

Chronic Pancreatitis

Circumcision Problems

Crohn's Disease

Cytomegalovirus Infection

Cytomegalovirus Intestinal Infection

Cytomegalovirus Pneumonia

Deep Venous Thrombosis

Drug Withdrawal

Endometritis

Epididymitis

Fungal Lung Infection

Heat Exhaustion

Hepatitis C

Hepatomegaly

Herpes Zoster

HIV Infection

Human Bite

Immunization Reaction

Incarcerated Hernia

Incarcerated Inguinal Hernia

Incisional Hernia

Inguinal Abscess

Inguinal Hernia

Intestinal Obstruction

Irritant Inhalational Injury

Klebsiella Pneumonia

Low Neutrophil Count

Meningitis

Mesenteric Lymphadenitis

Orchitis

Osteomyelitis

Pancreatitis

Parotitis

Pelvic Inflammatory Disease

Perianal Abscess

Polymyalgia Rheumatica

Post Dental Surgery Complications

Post Operative Wound Complications

Proctitis

Prostatitis

Rheumatoid Arthritis

Rodent Bites

Salmonella Infection

Scarlet Fever

Seizures

Sialadenitis

Sickle Cell Anemia

Skin Foreign Body

Squamous Cell Carcinoma of the

Lung

Staphylococcus Pneumonia

Streptococcus Pneumonia

Tick Borne Illness

Tonic Clonic Seizure

Umbilical Cord Infection

Umbilical Hernia

Ventral Hernia

Viral Meningitis

Yellow Fever

http://www.freemd.com/alcohol-withdrawal/overview.htm



http://www.freemd.com/animal-bites/overview.htm



http://www.freemd.com/arm-cellulitis/overview.htm



http://www.freemd.com/bacterial-gastroenteritis/overview.htm



http://www.freemd.com/bacterial-pharyngitis/overview.htm



http://www.freemd.com/bacterial-pneumonia/overview.htm



http://www.freemd.com/bladder-infection/overview.htm



http://www.freemd.com/bronchiolitis/overview.htm

http://www.freemd.com/bronchitis/overview.htm

http://www.freemd.com/cellulitis/overview.htm

http://www.freemd.com/cervical-lymphadenitis/overview.htm



http://www.freemd.com/chronic-bronchitis/overview.htm



http://www.freemd.com/croup/overview.htm

http://www.freemd.com/deviated-septum/overview.htm



http://www.freemd.com/enlarged-prostate/overview.htm



http://www.freemd.com/food-poisoning/overview.htm



http://www.freemd.com/foot-cellulitis/overview.htm



http://www.freemd.com/gastroenteritis/overview.htm

http://www.freemd.com/gingivitis/overview.htm

http://www.freemd.com/hand-cellulitis/overview.htm



http://www.freemd.com/herpes-genitalis/overview.htm

http://www.freemd.com/herpes-genitalis/overview.htm

http://www.freemd.com/influenza/overview.htm

http://www.freemd.com/insect-bite/overview.htm



http://www.freemd.com/laryngitis/overview.htm

http://www.freemd.com/leg-cellulitis/overview.htm

http://www.freemd.com/leg-cellulitis/overview.htm

http://www.freemd.com/otitis-externa/overview.htm

http://www.freemd.com/otitis-externa/overview.htm

http://www.freemd.com/otitis-media/overview.htm

http://www.freemd.com/periodontal-disease/overview.htm



http://www.freemd.com/pharyngitis/overview.htm

http://www.freemd.com/pleuritis/overview.htm

http://www.freemd.com/pneumonia/overview.htm

http://www.freemd.com/sinusitis/overview.htm

http://www.freemd.com/skin-abscess/overview.htm

http://www.freemd.com/skin-abscess/overview.htm

http://www.freemd.com/skin-infections/overview.htm

http://www.freemd.com/skin-infections/overview.htm

http://www.freemd.com/teething/overview.htm

http://www.freemd.com/tonsillitis/overview.htm

http://www.freemd.com/upper-respiratory-infections-in-children/overview.htm








http://www.freemd.com/upper-respiratory-infections/overview.htm





http://www.freemd.com/urinary-tract-infection/overview.htm





http://www.freemd.com/urinary-tract-infections-in-children/overview.htm








http://www.freemd.com/venereal-disease-in-males/overview.htm






http://www.freemd.com/venereal-disease/overview.htm



http://www.freemd.com/viral-gastroenteritis/overview.htm



http://www.freemd.com/viral-pharyngitis/overview.htm



http://www.freemd.com/viral-syndrome/overview.htm



http://www.freemd.com/wound-infection/overview.htm



http://www.freemd.com/alcoholic-hepatitis/overview.htm



http://www.freemd.com/appendicitis/overview.htm

http://www.freemd.com/axillary-lymphadenitis/overview.htm



http://www.freemd.com/bartholins-cyst/overview.htm

http://www.freemd.com/bartholins-cyst/overview.htm

http://www.freemd.com/biliary-colic/overview.htm



http://www.freemd.com/breast-abscess/overview.htm



http://www.freemd.com/caffeine-overdose/overview.htm



http://www.freemd.com/campylobacter-enteritis/overview.htm



http://www.freemd.com/canker-sores/overview.htm



http://www.freemd.com/carbuncle/overview.htm

http://www.freemd.com/cat-bites/overview.htm



http://www.freemd.com/cocaine-abuse/overview.htm



http://www.freemd.com/decubitus-ulcer/overview.htm



http://www.freemd.com/dental-abscess/overview.htm



http://www.freemd.com/diverticulitis/overview.htm

http://www.freemd.com/dog-bites/overview.htm

http://www.freemd.com/dog-bites/overview.htm

http://www.freemd.com/drug-dermatitis/overview.htm



http://www.freemd.com/drug-side-effect/overview.htm





http://www.freemd.com/epilepsy/overview.htm

http://www.freemd.com/epstein-barr-infection/overview.htm





http://www.freemd.com/erythema-infectiosum/overview.htm



http://www.freemd.com/facial-cellulitis/overview.htm



http://www.freemd.com/febrile-seizure/overview.htm



http://www.freemd.com/finger-tenosynovitis/overview.htm



http://www.freemd.com/gallbladder-disease/overview.htm



http://www.freemd.com/gallstones/overview.htm

http://www.freemd.com/giardia-infection/overview.htm



http://www.freemd.com/haemophilus-pneumonia/overview.htm



http://www.freemd.com/hand-foot-and-mouth-disease/overview.htm









http://www.freemd.com/heat-illness/overview.htm



http://www.freemd.com/hemorrhagic-cystitis/overview.htm



http://www.freemd.com/hepatitis-a/overview.htm

http://www.freemd.com/hepatitis-b/overview.htm

http://www.freemd.com/hepatitis/overview.htm

http://www.freemd.com/hernias/overview.htm

http://www.freemd.com/herpangina/overview.htm

http://www.freemd.com/herpes-gingivostomatitis/overview.htm

http://www.freemd.com/herpes-gingivostomatitis/overview.htm

http://www.freemd.com/immune-system-deficiency/overview.htm





http://www.freemd.com/inguinal-lymphadenitis/overview.htm



http://www.freemd.com/lymphadenitis/overview.htm

http://www.freemd.com/lymphangitis/overview.htm

http://www.freemd.com/mastitis/overview.htm

http://www.freemd.com/miscarriage/overview.htm

http://www.freemd.com/mononucleosis/overview.htm

http://www.freemd.com/mycoplasma-infection/overview.htm



http://www.freemd.com/narcotic-withdrawal/overview.htm



http://www.freemd.com/postpartum-infection/overview.htm



http://www.freemd.com/purulent-rhinitis/overview.htm



http://www.freemd.com/roseola/overview.htm

http://www.freemd.com/rotavirus/overview.htm

http://www.freemd.com/skin-ulcer/overview.htm

http://www.freemd.com/skin-ulcer/overview.htm

http://www.freemd.com/staph-infections/overview.htm



http://www.freemd.com/streptococcal-tonsillitis/overview.htm



http://www.freemd.com/swine-flu/overview.htm



http://www.freemd.com/travelers-diarrhea/overview.htm



http://www.freemd.com/viral-exanthem/overview.htm



http://www.freemd.com/viral-hepatitis/overview.htm



http://www.freemd.com/viral-pneumonia/overview.htm



http://www.freemd.com/acanthamoeba-infection/overview.htm



http://www.freemd.com/actinomycosis/overview.htm

http://www.freemd.com/aids/overview.htm

http://www.freemd.com/allergic-alveolitis/overview.htm



http://www.freemd.com/allergic-bronchopulmonary-aspergillosis/overview.htm





http://www.freemd.com/anorectal-foreign-body/overview.htm





http://www.freemd.com/arbovirus-infection/overview.htm

http://www.freemd.com/arbovirus-infection/overview.htm

http://www.freemd.com/arenavirus-infection/overview.htm



http://www.freemd.com/aspergillosis/overview.htm

http://www.freemd.com/aspiration-pneumonia/overview.htm



http://www.freemd.com/atelectasis/overview.htm

http://www.freemd.com/bacterial-endocarditis/overview.htm



http://www.freemd.com/bacterial-meningitis/overview.htm



http://www.freemd.com/bartholins-abscess/overview.htm



http://www.freemd.com/bladder-stone/overview.htm



http://www.freemd.com/brown-recluse-spider-bite/overview.htm






http://www.freemd.com/california-group-virus/overview.htm





http://www.freemd.com/chicken-pox/overview.htm



http://www.freemd.com/chlamydia-pneumonia/overview.htm



http://www.freemd.com/chlamydia-trachomatis/overview.htm



http://www.freemd.com/chronic-fatigue-syndrome/overview.htm





http://www.freemd.com/chronic-pancreatitis/overview.htm



http://www.freemd.com/circumcision-problems/overview.htm



http://www.freemd.com/crohns-disease/overview.htm

http://www.freemd.com/crohns-disease/overview.htm

http://www.freemd.com/cytomegalovirus-infection/overview.htm



http://www.freemd.com/cytomegalovirus-intestinal-infection/overview.htm





http://www.freemd.com/cytomegalovirus-pneumonia/overview.htm



http://www.freemd.com/deep-venous-thrombosis/overview.htm





http://www.freemd.com/drug-withdrawal/overview.htm



http://www.freemd.com/endometritis/overview.htm

http://www.freemd.com/epididymitis/overview.htm

http://www.freemd.com/fungal-lung-infection/overview.htm





http://www.freemd.com/heat-exhaustion/overview.htm



http://www.freemd.com/hepatitis-c/overview.htm

http://www.freemd.com/hepatomegaly/overview.htm

http://www.freemd.com/herpes-zoster/overview.htm

http://www.freemd.com/herpes-zoster/overview.htm

http://www.freemd.com/hiv-infection/overview.htm

http://www.freemd.com/hiv-infection/overview.htm

http://www.freemd.com/human-bite/overview.htm



http://www.freemd.com/immunization-reaction/overview.htm



http://www.freemd.com/incarcerated-hernia/overview.htm



http://www.freemd.com/incarcerated-inguinal-hernia/overview.htm





http://www.freemd.com/incisional-hernia/overview.htm



http://www.freemd.com/inguinal-abscess/overview.htm



http://www.freemd.com/inguinal-hernia/overview.htm



http://www.freemd.com/intestinal-obstruction/overview.htm



http://www.freemd.com/irritant-inhalational-injury/overview.htm





http://www.freemd.com/klebsiella-pneumonia/overview.htm



http://www.freemd.com/low-neutrophil-count/overview.htm





http://www.freemd.com/meningitis/overview.htm

http://www.freemd.com/mesenteric-lymphadenitis/overview.htm



http://www.freemd.com/orchitis/overview.htm

http://www.freemd.com/osteomyelitis/overview.htm

http://www.freemd.com/pancreatitis/overview.htm

http://www.freemd.com/parotitis/overview.htm

http://www.freemd.com/pelvic-inflammatory-disease/overview.htm





http://www.freemd.com/perianal-abscess/overview.htm



http://www.freemd.com/polymyalgia-rheumatica/overview.htm



http://www.freemd.com/post-dental-surgery-complications/overview.htm






http://www.freemd.com/post-operative-wound-complications/overview.htm






http://www.freemd.com/proctitis/overview.htm

http://www.freemd.com/prostatitis/overview.htm

http://www.freemd.com/rheumatoid-arthritis/overview.htm



http://www.freemd.com/rodent-bites/overview.htm



http://www.freemd.com/salmonella-infection/overview.htm



http://www.freemd.com/scarlet-fever/overview.htm



http://www.freemd.com/seizures/overview.htm

http://www.freemd.com/sialadenitis/overview.htm

http://www.freemd.com/sickle-cell-anemia/overview.htm




http://www.freemd.com/skin-foreign-body/overview.htm




http://www.freemd.com/squamous-cell-carcinoma-of-the-lung/overview.htm










http://www.freemd.com/staphylococcus-pneumonia/overview.htm



http://www.freemd.com/streptococcus-pneumonia/overview.htm



http://www.freemd.com/tick-borne-illness/overview.htm





http://www.freemd.com/tonic-clonic-seizure/overview.htm





http://www.freemd.com/umbilical-cord-infection/overview.htm





http://www.freemd.com/umbilical-hernia/overview.htm



http://www.freemd.com/ventral-hernia/overview.htm



http://www.freemd.com/viral-meningitis/overview.htm



http://www.freemd.com/yellow-fever/overview.htm



Diferenciální diagnostika hyperpyrexie 201 rare conditions

Abdominal Abscess

Abdominal Sepsis

Acute Glomerulonephritis

Acute Intermittent Porphyria

Acute Interstitial Nephritis

Adenocarcinoma of the Bronchus

Adult Still's Disease

Amebic Dysentery

Anhidrosis

Anorectal Fistula

Anthrax

Aspirin Overdose

Atrial Myxoma

Atypical Mycobacterial Infection

Babesiosis

Balantidiasis

Bird Flu

Blastomycosis

Blue Diaper Syndrome

Boutonneuse Fever

Brain Abscess

Brucellosis

Bubonic Plague

Budd-Chiari Syndrome

Burkitt Lymphoma

Cat Scratch Disease

Cavernous Sinus Thrombosis

Chagas Disease

Chikungunya Disease

Cholangiocarcinoma

Cholangitis

Cholera

Chronic Persistent Hepatitis

CMV Esophagitis

Coccidioidomycosis

Colorado Tick Fever

Congo Hemorrhagic Fever

Cryptococcal Infection

Cryptococcal Meningitis

Cryptosporidium Enterocolitis

De Quervain's Thyroiditis

Dengue Fever

Diabetes Insipidus

Diphtheria

Discitis

Discoid Lupus

Disseminated Intravascular Coagulation

Dressler's Syndrome

Drug Induced Lupus

Ebola Hemorrhagic Fever

Echinococcus

Ehrlichiosis

Empyema

Encephalitis

Eosinophilic Pneumonia

Epiglottitis

Equine Encephalitis

Erysipelas

Erythema Nodosum

Ewing's Sarcoma

Extraintestinal Amebiasis

Fabry's Disease

Familial Mediterranean Fever

Femoral Hernia

Fournier Gangrene

Gallbladder Cancer

Gangrene

Hairy Cell Leukemia

Hantavirus

Heatstroke

Hemolytic Uremic Syndrome

Henoch-Schonlein Purpura

Hepatitis D

Hepatitis E

Herpes Encephalitis

Herpes Esophagitis

High Altitude Pulmonary Edema

Histoplasmosis

Hodgkin's Disease

Hookworm Infection

Hyperoxaluria

Incarcerated Ventral Hernia

Inhaled Foreign Body

Intussusception

Japanese Encephalitis

Juvenile Rheumatoid Arthritis

Kawasaki Disease

Large Cell Carcinoma of the Lung

Legionnaire's Disease

Leishmaniasis

Leptospirosis

Leukemia

Listeriosis

Liver Cancer

Ludwig's Angina

Lung Abscess

Lung Cancer

Lupus

Lyme Disease

Lymphogranuloma Venereum

Lymphoma

Malaria

Malignant Neuroleptic Syndrome

Marburg Hemorrhagic Fever

Mastoiditis

Measles

Meckel's Diverticulum

Mesenteric Vascular Occlusion

Mesothelioma

Moraxella Pneumonia

Mumps

Myocarditis

Necrotizing Fasciitis

Necrotizing Vasculitis

Neuroblastoma

Nocardia Infection

Non-Hodgkin Lymphoma

Norwalk Virus Infection

Nose Foreign Body

Ovarian Cancer

Ovarian Torsion

Perforated Bowel

Perforated Ulcer

Periarteritis Nodosa

Pericarditis

Periorbital Cellulitis

Perirectal Abscess

Peritonitis

Peritonsillar Abscess

Phlebotomus Fever

Pilonidal Abscess

Pneumoconiosis

Pneumocystis Pneumonia

Polio

Popcorn Workers Lung

Prostate Cancer

Pseudomembranous Colitis

Psittacosis

Psoriatic Arthritis

Pulmonary Actinomycosis

Pulmonary Alveolar Proteinosis

Pulmonary Embolism

Pyelonephritis

Q Fever

Rabies

Rat Bite Fever

Relapsing Fever

Renal Artery Occlusion

Renal Cell Carcinoma

Retropharyngeal Abscess

Rheumatic Fever

Rift Valley Fever

Rocky Mountain Spotted Fever

Rubella

Sarcoidosis

SARS

Schistosomiasis

Scurvy

Sepsis

Septic Arthritis

Septic Thrombophlebitis

Serotonin Syndrome

Shigella Infection

Silicosis

Silo Filler's Disease

Small Cell Carcinoma of the Lung

Smallpox

Splenic Abscess

St Louis Encephalitis

Stevens Johnson Syndrome

Syphilis

Takayasu's Arteritis

Tapeworm

Temporal Arteritis

Tetanus

Thrombotic Thrombocytopenic Purpura

Toxic Epidermal Necrolysis

Toxic Inhalations

Toxic Megacolon

Toxic Shock Syndrome

Toxoplasmosis

Transitional Cell Carcinoma

Transverse Myelitis

Trichinosis

Tropical Sprue

Tuberculosis

Tubo-Ovarian Abscess

Tularemia

Typhoid Fever

Typhus

Ulcerative Colitis

Vincent's Stomatitis

Volvulus

Von Hippel-Lindau Disease

Waldenstrom's Macroglobulinemia

Wegener's Granulomatosis

West Nile Virus

Whooping Cough

Wilms Tumor

Wilson's Disease

http://www.freemd.com/abdominal-abscess/overview.htm



http://www.freemd.com/abdominal-sepsis/overview.htm



http://www.freemd.com/acute-glomerulonephritis/overview.htm



http://www.freemd.com/acute-intermittent-porphyria/overview.htm





http://www.freemd.com/acute-interstitial-nephritis/overview.htm





http://www.freemd.com/adenocarcinoma-of-the-bronchus/overview.htm







http://www.freemd.com/adult-stills-disease/overview.htm





http://www.freemd.com/amebic-dysentery/overview.htm



http://www.freemd.com/anhidrosis/overview.htm

http://www.freemd.com/anorectal-fistula/overview.htm



http://www.freemd.com/anthrax/overview.htm

http://www.freemd.com/aspirin-overdose/overview.htm

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Průběh: 10.-20.den - pro poruchu vědomí provedeno CT mozku – negativní

- funkce štítné žlázy – v normě, lumbální punkce negativní

- revmatologický screening

- při hypertermii prudký vzestup PCT (326), CRP, trombocytopenie

- mikrobiologie negativní

Terapie

- z indikace bronchiální obstrukce znovu nasazeny kortikoidy

- během 5 dnů ústup febrilií a multiorgánové dysfunkce, výrazný pokles PCT, CRP, vysazena ATB

- dominuje těžká neuromyopatie kriticky nemocných (EMG) s ventilačním selháním

Další vyšetření

- po vysazení kortikoidů následuje opět vzestup teplot a leukocytů. CRP a PCT nízké.

- kontrolní CT trupu bez nového nálezu, revmatologie negat

- MR mozku a krční páteře– nezobrazena neurohypofyza, komplexní endokrinologické vyšetření bez funkční patologie, neprokázána příčina febrilního stavu

- mikrobiologie dosud negativní, známky reaktivace HSV infekce

podávána antivirotika

- ORL, stomatologické, gynekologické a infektologické vyšetření bez známek fokusu infekce

Mikrobiologie

- chřipka A a B, adenoviry, CMV, VZV, Chlamydie, Legionela, Aspergilus, Pneumocysta, TBC

- hepatitidy A-C, bruceloza, tularemie, listerie, leptospiry, ricketsiozy, HIV 1,2, borelie, EBV, střevní parazité

- Trichineloza, echinokokoza, cysticerkoza, jaterní fascilioza

- Leishmanioza, malarie

- Nozokomiální infekce – močová (Enterobacter cloacae)

Konziliární vyšetření

- v dalším průběhu febrilie jen sporně reagují na kortikoterapii, dále nepodávány. Známky zánětu trvale nízké.

- vyšetření značenými leukocyty – splenomegalie, není indikována splenectomie

- revmatologické konzilium negativní (neprokázán MAS)

- neurologické konzilium: CT a MR mozku, LP, EMG – bez průkazu zdroje teplot

- imunologické konzilium: neprokázán primární ani sekundární imunodeficit

Hematologické konzilium

- základní diagnoza – polycythemia vera

- hemoglobin 80g/l, leu 5,5tis, elevace LDH

- provedena sternální punkce a trepanobiopsie:

-- chronické myeloproliferativní onemocnění s pokročilou fibrozou

- doporučena paliativní péče – substituce erytrocytů,….

Prognoza nepříznivá

Myeloproliferativní syndrom Polycytemia vera

Definice:

- klonální proliferace kmenové hematopoetické buňky, která se diferencuje

převážně do erytrocytární řady

- charakterizována vysokým počtem erytrocytů → zvýšená viskozitu krve →

arteriální trombozy, …

Příznaky:

- bolesti hlavy, vředová choroba, pruritus

- krvácivé/trombotické komplikace, hepatosplenomegalie

Terapie:

- léčebné venepunkce, erytrocytafereza

- INF-a, hydroxyurea, anagrelid, léčba pruritu

Riziko vzniku akutní leukemie

Přechod do myelofibrozy, pokles krevních elementů, zvýšené teploty, váhový úbytek

Další průběh

- překlad do spádové nemocnice (55.den pobytu)

-- klinický stav při překladu:

- při vědomí, subfebrilní, intermit febrilní do 39°C, podpůrně ventilovaná, intermit spontánní ventilace, oběh stabilní, kvadrupareza až plegie

- následně progrese febrilií (43°C), nereagující na antipyretika a fyzikální chlazení, exitus letalis (hospitalizace celkem cca 3 měsíce)

- sekční nález: hepatosplenomegalie, edém plic a mozku, „kardiopulmonální selhání“

Závěr

- Příčina perzistujího febrilního stavu (hyperpyrexie) není zcela jasná

- polycythemia vera ve fázi přechodu do myelofibrozy

- podíl interkurentních infekcí

Děkuji za pozornost

Date post:	07-Aug-2019
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