2016年 · 第96卷第03期

The successful development of the first CT by Hounsfield in 1972 is considered to be one of the most important achievements of radiodiagnostics after Roentgen discovered X-ray^[1]。 In the past 40 years, CT has experienced from initially only used for brain examination to whole body CT, single-slice spiral CT, multi-slice spiral CT, volume CT, energy spectrum CT, until the latest Revolution CT, which can perfectly integrate fast scanning, low radiation dose and ultra-clear images. With the rapid development of various software and hardware technologies, the application of CT in thoracic diseases is undergoing rapid transformation.

A male patient, born in 1986, was admitted to hospital on May 8, 2014 due to "recurrent centripetal obesity with purple lines on full moon face for 9 years". The patient began to have weight gain with full moon face, acne, purple lines, and fatigue without obvious inducement in December 2005. On February 13, 2006, the patient went to hospital A. Blood cortisol was increased, rhythm disappeared, and adrenocorticotropic hormone (ACTH) was increased (Table 1), 24-h urine free cortisol (24-h UFC) 1 206 μ g/24 h (normal reference value: 30.15~129.13 μ g/24 h), high-dose dexamethasone inhibition test (dexamethasone 2 mg, once/6 h ×8 times) showed that 24-h UFC decreased by 53.4% compared with the basal value, and sellar region enhanced MRI (Figure 1) shows "left deviation of the pituitary stem, suspected low-intensity shadow on the right side of the pituitary gland, excluding pituitary microadenoma", and the clinical diagnosis is "Cushing's disease". On March 17, 2006, transnasal sphenoidal pituitary tumor resection was performed. The pathology showed "anterior and posterior pituitary tissue", and the postoperative symptoms did not improve significantly compared with before. On August 31, 2006, the results showed that the circadian rhythm of blood cortisol disappeared and ACTH was within the normal range (Table 1), adrenal CT plain scan showed "left adrenal gland full" (Figure 2)。 Laparoscopic left adrenalectomy was performed on September 30, 2006. The postoperative pathology showed "nodular hyperplasia of left adrenal gland", and the postoperative symptoms improved significantly. In January 2008, centripetal obesity, acne and purple lines appeared again. On September 16, 2008, he went to Hospital C. The blood cortisol rhythm disappeared and ACTH was significantly increased (Table 1), 24 h UFC 1 068.5 μ g/24 h, low-dose dexamethasone inhibition test was not inhibited, 8 mg high-dose dexamethasone inhibition test was not inhibited (decrease 22%), sellar area enhanced MRI showed "postoperative changes of pituitary tumor". Bilateral inferior petrosal sinus venous blood sampling (BIPSS) was performed. The ACTH ratio of peripheral, left and right inferior petrosal sinuses was 70.1/70.6, 74.8/79.5 and 78.1/80.4 pmol/L, respectively<2。 Considering the possibility of "ectopic ACTH syndrome (EAS)", no clear lesion was found in the examination, and oral ketoconazole was given to treat. After 1 week, the hematuria cortisol decreased significantly, and the medication was interrupted for 3 years, during which the weight was controlled. At the end of 2012, he was discontinued due to ketoconazole deficiency, and he again experienced weight gain with acne. At the end of 2013, he started oral bromocriptine treatment, but the efficacy was not good, and he discontinued it voluntarily in February 2014.

A 51-year-old male was admitted to the Department of Nephrology of Guangzhou Red Cross Hospital on July 20, 2011 due to "low back pain, oliguria and shortness of breath for 17 h". From July 4 to 19, 2011, the patient underwent anti-tuberculosis treatment in the local chest hospital due to pulmonary tuberculosis. The regimen was pasniazid tablets 600 mg, once a day; Althioisonicotinamide tablets 200 mg, 3 times/d; Levofloxacin 0.5 g, once/d. On July 19th, at 10 a.m., because the drug sensitivity test showed that rifampicin was sensitive, 450 mg of rifampicin capsules were taken orally. At 11 a.m., dull pain in the waist, accompanied by shortness of breath, fatigue and chills, and then the fever reached 39.4℃. The local hospital considered rifampicin allergic reaction and gave hormone therapy. In the afternoon of the same day, soy sauce-colored urine was discharged with decreased urine output. Blood tests included creatinine 299 μ mol/L (normal reference value: 62-115 μ mol/L), sodium 146 mmol/L (normal reference value: 135-145 mmol/L), potassium 3.8 mmol/L (normal reference value: 3.5-5.5 mmol/L), total carbon dioxide 9.3 mmol/L (normal reference value: 22-28 mmol/L), alanine aminotransferase 48 U/L (normal reference value: 0-45 U/L), aspartate aminotransferase 477 U/L (normal reference value: 0-45 U/L), total bilirubin 73 μ mol/L (normal reference value: 5.1-23.9 μ mol/L), indirect bilirubin 71.4 μ mol/L (normal reference value: 1.7-6.8 μ mol/L), and 400 ml of sodium bicarbonate solution were supplemented. After being transferred to our hospital at 4 o'clock the next morning. He had been suffering from tuberculosis for 2 years and had two stages of anti-tuberculosis treatment in a local chest hospital (both with rifampicin). Deny history of taking lipid-lowering drugs and ethanol. Physical examination at admission: blood pressure 180/110 mmHg (1 mmHg =0.133 kPa), 35 breaths/min, body temperature 38 ℃. Frightened, irritable. The skin and sclera were mildly yellowed, and there were many ecchymosis on the skin all over the body. A large number of dry and wet rales were smelled in both lungs, and the heart rate was 136 beats/min, and the rhythm was uniform. The abdomen was flat and soft, without tenderness and rebound pain, the liver and spleen were not touched under the costs, and there was no percussion pain in the kidney area. There was no edema in both lower limbs and lumbosacral region.

A 22-year-old female was admitted to our department on 11 November 2011 due to "precordial pain with asthma for 1 week". Half a month before admission, the patient was given oral antibiotics in another hospital due to "red eyes and whole body rash". The specific medication was unknown, and the symptoms of eye disease and rash improved. However, after 1 week, the patient developed sharp pain in the precordial area, which was aggravated by deep breathing, accompanied by palpitations, asthma, fever (body temperature unmeasured), nausea and vomiting, no sore throat and no diarrhea. The patient has lost 7 kg in the past month. He has denied a history of infectious diseases such as hepatitis, schistosomiasis and tuberculosis in the past. His boyfriend is in the active stage of syphilis, and the patient has a history of sexual contact with him.

Extracellular vesicles are a kind of vesicle-like structure that is released from cells into the extracellular space and is wrapped by lipid bilayers and contains protein and nucleic acid components. There are many types of extracellular vesicles, which are different in size, density, sedimentation force and specific markers. Press van der Pol et al.^[1]Extracellular vesicles can be roughly classified into three types: exosomes, microvesicles (MV) and apoptotic bodies.

Cushing's disease is a functional pituitary adenoma (PAs) with adrenocorticotropic hormone (ACTH) secretion – pituitary adrenocorticotropic adenoma (ACTH-PAs), accounting for about 14% of all pituitary adenomas and about 70% of Cushing's syndrome^[1,2]。 The incidence rate of this disease is 39/million in European and American countries, and there is still a lack of large-scale epidemiological data in China^[3]。 Early diagnosis of Cushing's disease is very difficult and prone to misdiagnosis. Patients often see a doctor for a variety of serious complications due to hypercortisolemia, such as hypertension, diabetes, hyperlipidemia, osteoporosis and mental depression. In terms of treatment, for the vast majority of Cushing's patients, pituitary adenoma resection through nasosphenoidal approach is still the first choice of clinical treatment. Radiotherapy, pasireotide, ketoconazole and other drugs are often used as adjuvant treatment for refractory Cushing's disease^[4]。 Although the literature reports that the success rate of surgical operation is 65% ~90%, the recurrence rate of tumor is 3% ~47%, the average recurrence time is 16~49 months, and the prognosis of recurrence patients is poor, and the mortality rate is high^[5]。 At present, the pathogenesis of Cushing's disease is not fully understood. In recent years, the molecular level research on Cushing's disease mainly focuses on the occurrence and development of tumors, tumor invasiveness and hormone secretion, etc. This paper will review the current association analysis of genotype and phenotype of Cushing's disease, potential drug targets and other molecular level research as follows.

Brucellosis is a zoonotic infectious disease, which is a systemic, infectious and allergic disease caused by Brucella infection. The incidence of brucellal spondylitis (BS) in brucellosis is 2% to 65%^[1,2,3]It is suppurative inflammation caused by its infection of intervertebral disc and vertebral body tissue. The onset segment is more common in lumbar vertebra, followed by thoracolumbar segment and cervical vertebra. The pathological manifestation is mainly inflammatory changes of intervertebral disc^[3,4]。 Its occurrence has obvious regional characteristics, and the clinical symptoms can be manifested as lumbar back pain and fever^[5,6,7]。 The progress of clinical treatment of BS is reviewed.