2017年 · 第56卷第10期

brucellosis (brucellosis) is a zoonotic infectious disease caused by Brucella infection, which is a natural epidemic disease; Brucella can infect humans as well as animals such as cattle, sheep, pigs and dogs. It is not difficult to diagnose brucellosis in patients with symptoms such as fever, hyperhidrosis, joint pain and enlargement of liver, spleen and lymph nodes in the endemic area of brucellosis; However, in recent years, with the overall acceleration of China's economic integration, the opportunity of exposure to diseased livestock meat, milk and leather products in non-epidemic areas has increased, and the reported brucellosis in non-epidemic areas has increased significantly, which has become one of the infectious diseases with the fastest increasing reported incidence rate. It is worth noting that the clinical manifestations of brucellosis are diverse, and atypical cases of brucellosis in non-traditional epidemic areas are easily misdiagnosed, and early diagnosis and treatment will significantly improve the prognosis. Two articles published in Peking Union Medical College Hospital, "Clinical Analysis of 20 Cases of Neurobrucellosis" and "Clinical Characteristics Analysis of Six Cases of Brucella Endocarditis and Literature Review", show that both patients with neurobrucellosis and patients with brucella endocarditis have experienced a long time (24 days ~36.5 months) from onset to diagnosis, mostly several months; Patients have different clinical manifestations; Improving clinicians' ability to diagnose and differentiate brucellosis is of great significance to improve patients' prognosis. Therefore, our journal specially invited Professor Zhang Wenhong to write a monograph "Clinical diagnosis and treatment of complex brucellosis needs urgent attention", pointing out that "brucellosis is no longer a local endemic infectious disease, but a disease with sporadic and atypical clinical manifestations all over the country. The timely progress of various organs is slow, but the long-term damage is great, and the misdiagnosis rate is extremely high. At present, it is urgent to improve the understanding of brucellosis by doctors in various departments, not only infectious disease doctors, but also the clinical microbiology departments of major hospitals, especially clinical hospitals in non-epidemic areas, should arrange technical reserves for brucellosis diagnosis; If early diagnosis and treatment can be achieved, brucellosis is an infectious disease with good prognosis and low recurrence rate. "Stay tuned!

brucellosis, referred to as brucellosis, also known as brucellosis and "wavy fever", is a zoonotic infectious disease caused by Brucella infection, which is a natural epidemic disease; Brucella can infect humans and animals such as cattle, sheep, pigs and dogs^[1]。 The clinical manifestations of brucellosis are fever, hyperhidrosis, joint pain and enlargement of liver, spleen and lymph nodes with different severity. It is not difficult to diagnose brucellosis in patients with these symptoms in endemic areas of brucellosis. However, in recent years, with the overall acceleration of China's economic integration, the opportunity of exposure to diseased livestock meat, milk and leather products in non-epidemic areas has increased, and the reported brucellosis in non-epidemic areas has increased significantly; And in non-epidemic areas, complex brucellosis, which does not start with joint pain and hyperhidrosis, is often misdiagnosed for a long time. Complex brucellosis mainly refers to brucellosis with various complications, such as central nervous system involvement, endocarditis, osteoarthritis and other complications. There are many clinical misdiagnoses of complex brucellosis, and the clinical prognosis is poor. The central nervous system infection and endocarditis caused by brucellosis reported in this issue are the types of complex clinical manifestations, and the prognosis is extremely poor if it cannot be diagnosed and treated early. At present, clinical departments urgently need to pay attention to the clinical harm of complex brucellosis from the following aspects, so as to achieve early diagnosis and treatment.

Somatization psychological disorder is a group of neurosis characterized by persistent worry or belief in the dominant concept of various physical symptoms, that is, this psychological disorder is prominently manifested by a variety of somatization symptoms, with common symptoms such as fatigue, dizziness, headbloating, insomnia, chest tightness, shortness of breath, palpitations, heart discomfort, abdominal distension, back pain and other unfixed parts. Or even if sometimes some kind of somatic lesion does exist, it often fails to explain the nature and extent of the symptoms complained of, and its notion of pain and advantage. These symptoms of patients can be very stubborn. Although patients are often accompanied by anxiety or depression, they rarely go (or are reluctant to go) to psychiatric specialists. Instead, they choose general hospitals for diagnosis and treatment. Because of different physical symptoms, they will go to different specialties when seeing a doctor. They often have repeated examinations without results, long-term treatment is ineffective, medical expenses are high, and they are in pain for a long time. The data showed that in the outpatient department of non-psychiatric general hospital, patients had different degrees of psychological problems, and the total incidence rate was about 41.2%, and in the outpatient department of cardiology, it was 30% ~40%^[1,2]。 A large part of them are somatized psychological disorders, and misdiagnosis and mistreatment are common.

Example 1A 51-year-old male patient. Due to intermittent general fatigue for 10 years, he was admitted to hospital on October 18, 2016 with an increase in blood pressure for 3 years. The patient developed general fatigue 10 years ago, accompanied by polydipsia, and his daily water consumption was about 4 000 ml. No diagnosis and treatment were made. Three years ago, blood pressure was measured at 210/140 mmHg (1 mmHg =0.133 kPa) and irregularly treated with "reserpine". Two years ago, blood potassium was found to be low, and potassium chloride sustained-release tablets were used to supplement potassium orally, but the effect was not good. Admission physical examination: body temperature 35.5 ℃, pulse 50 beats/min, breathing 18 beats/min, blood pressure 188/126 mmHg, no abnormalities found in heart, lung and abdomen examination, muscle strength of limbs grade V. Auxiliary examination: admission troponin T 0.17 μ g/L (Roche electrochemiluminescence method, normal<0.05 μ g/L), troponin 0.05~0.1 mg/L was re-examined 24 h after admission, and the re-examination was negative 48 h after admission. Serum potassium 2.19 mmol/L. Blood gas analysis: blood pH 7.48, PaO₂81 mmHg, PaCO₂48 mmHg, base excess (BE) 12.2 mmol/L. Cortisol (determined by electrochemiluminescence immunoassay) (0:00, 08:00, 16:00): 101.40 nmol/L (reference value<50.00 nmol/L), 360.90 nmol/L (reference values 171.00-536.00 nmol/L), 179.20 nmol/L (reference values 64.00-327.00 nmol/L). The 24h urine potassium, urine sodium and urine chloride were measured at 80.20 mmol/L, 241.00 mmol/L and 235.00 mmol/L, respectively. Adrenocorticotropin (electrochemiluminescence immunoassay, normal reference range : 9.36-82.29 pmol/L) (0:00, 08:00, 16:00): 36.52 pmol/L, 51.77 pmol/L, 38.40 pmol/L. After normal serum potassium, renin (orthostatic position) was 2.69 pmol/L (reference value 5.20-49.40 pmol/L), angiotensin II (orthostatic position) was 10.31 pmol/L (reference value 5.20-49.40 pmol/L), and aldosterone (orthostatic position) was 245.51 pmol/L (reference value 52.00-403.00 pmol/L). The results of the Kaibotong test are shown inTable 1。 Electrocardiogram showed sinus bradycardia, extensive ST-T changes. Cardiac color ultrasound showed left atrial enlargement (anterior-posterior diameter 38 mm), left ventricular hypertrophy (anterior-posterior diameter 51 mm at the end of diastole, ventricular septal thickness 14 mm), and decreased left ventricular diastolic function (grade I). Plain CT scan and enhancement of the adrenal gland: left adrenal nodule. Retroperitoneal laparoscopic resection of left adrenal tumor was performed after definite diagnosis and treatment, and the operation was smooth. The pathological results were reported as: adrenocortical adenoma. Renin, angiotensin, aldosterone, serum potassium and blood pressure returned to normal after operation, troponin was negative, and ST segment depression was observed in ECG.

The patient was a 65-year-old female. He was admitted to hospital in January 2016 for the main reason of "abdominal distension and pain for 11 days". The patient felt total abdominal distension and pain without obvious trigger before 11 days, mainly in the lower abdomen, and then gradually aggravated, accompanied by nausea and vomiting, without diarrhea. Then he went to the local hospital and tested his blood amylase: 466 U/L. Upper abdominal CT scan showed multiple swollen lymph nodes in the abdominal cavity; Pleural effusion and peritoneal effusion on both sides. The local hospital was admitted to the hospital with "acute pancreatitis" and given symptomatic supportive treatment such as fasting, acid inhibition, enzyme inhibition and fluid rehydration. The patient felt that the abdominal distension and pain gradually worsened, and the serum amylase level continued to be high, so he was transferred to our center for treatment. Past history: In May 2013, he underwent "total hysterectomy + left adnexectomy + pelvic partial peritoneal resection + pelvic and abdominal tumor lesion resection + abdominal para-aortic lymph node dissection + omentectomy + appendectomy + partial rectal resection" due to ovarian cancer, and was treated with regular chemotherapy in a local hospital for 7 times (details unknown). Physical examination at admission: Shenqing, body temperature 37.1 ℃, pulse 99 beats/min, breathing 18 beats/min, blood pressure 140/85 mmHg (1 mmHg =0.133 kPa); A surgical scar about 20cm long was seen in the middle and lower abdomen, with tenderness in the lower abdomen (+), no rebound pain and muscle tension, no mass, no palpation of the liver and spleen under the costs, no percussion pain in the liver and kidney areas, Murphy's sign (-), positive mobile voiced sound, and bowel sounds 3 times/min. After admission, enhanced CT showed: postoperative changes of ovarian cancer with multiple abdominal metastases; Multiple nodules below the gastric antrum and peritoneal thickening in the lower abdomen, considering the possibility of metastasis; A large amount of fluid in the abdominal cavity and a small amount of fluid in the pelvic cavity (Figure 1)。 Laboratory tests: serum amylase 404.5 U/L (normal value 0~110 U/L), urinary amylase 3 230 U/L (normal value 0~800 U/L), blood lipase 59.8 U/L (normal value 0~60 U/L), C-reactive protein 54.32 mg/L, CA125 2 425 U/ml, blood lipid and blood calcium were not abnormal. Combined with the patient's past history of ovarian cancer, evidence of extensive tumor metastasis on enhanced CT, obvious elevation of CA125, elevated blood amylase but normal lipase, it is considered that persistent hyperamylasemia and peritoneal effusion are caused by extensive metastasis of ovarian cancer. After informing the family, he was transferred to the oncology department for further chemotherapy.

June 2017Scientific ReportsA study "Quantification of serum anti-HBc antibodies can be used as an evaluation index of liver inflammation in patients with chronic hepatitis B with normal ALT" led by the research team of Professor Wang Guiqiang, Department of Infectious Diseases and Center of Liver Diseases, Peking University First Hospital was published online [Zhou J, Song L, Zhao H, et al. Serum hepatitis B core antibody as a biomarker of hepatic inflammation in chronic hepatitis B patients with normal alanine aminotransferase. Sci Rep, 2017, 7 (1): 2747.]^[1]。 This study is a prospective, multicenter cohort study, which is the first to explore whether anti-HBc can be used as a non-invasive assessment index of the degree of liver damage in patients with chronic hepatitis B, especially those with normal ALT, through a large sample.

Urinary tract infections are clinically common, ranking second among community infections. In the United States, more than 8 million people see patients for urinary tract infections every year. About 40% to 50% of adult women have suffered from urinary tract infections in their lifetime. About 27% to 48% of healthy women will have recurrent urinary tract infections despite the absence of anatomical abnormalities of the urinary tract^[1]。 Urinary tract infection is also one of the important nosocomial infections, accounting for about 35% ~45% of nosocomial infections. It is the main cause of nosocomial infections and bacteremia in the United States. About 50% ~80% of nosocomial urinary tract infections are caused by indwelling urinary catheters or other devices^[2]。 Complicated urinary tract infection refers to a concomitant disease of urinary tract infection accompanied by the risk of acquiring an infection or treatment failure, such as structural or functional abnormalities of the genitourinary tract, or other underlying diseases. There are two criteria for diagnosing complex urinary tract infections, positive urine culture and including at least one of the following concomitant factors: indwelling catheter, stent tube, or intermittent bladder catheterization; Residual urine>100 ml; Obstructive urinary tract disorders of any cause, such as bladder outlet obstruction, neurogenic bladder, stones, and tumors; vesicoureteral reflux or other functional abnormalities; Urinary diversion; Chemotherapy or radiotherapy injury to urothelium; Perioperative and postoperative urinary tract infections; Renal insufficiency, transplanted kidney, diabetes and immunodeficiency, etc. When clinically dealing with complex urinary tract infections, empirical treatment or irregular application of antimicrobial drugs before obtaining drug susceptibility test results often lead to the emergence of drug resistance, which has changed the distribution of pathogenic bacteria of urinary tract infections in recent years. Therefore, the treatment failure caused by improper selection of antimicrobial drugs is inevitable. The following is an interpretation of the common misunderstandings in the diagnosis and treatment of complex urinary tract infection combined with clinical cases.

Invasive candidiasis is a common nosocomial infection with a high mortality rate, and candidemia is the main type of infection. Candidaemia ranked 4th among ICU bloodstream infections, with a mortality rate of 40%^[1]The risk factors for its occurrence include immunosuppression, ICU admission, broad-spectrum antibacterial drug application, Candida colonization, and are closely related to iatrogenic factors such as abdominal surgery, indwelling catheter, and parenteral nutrition^[2]。

Acinetobacter baumannii is a non-fermenting gram-negative conditional pathogen, which is widespread in nature and hospital environment, and it has strong resistance to humidity and heat, ultraviolet rays and chemical disinfectants. Conventional disinfection can only inhibit its growth but not kill it, so it is easy to cause respiratory tract infection, bacteremia, skin and soft tissue infection, urinary tract infection, central nervous system infection and other nosocomial infections in severe patients^[1]It is currently recognized as one of the important pathogens that cause widespread serious nosocomial infections. In recent years, its detection rate and drug resistance rate have been increasing year by year, and it has become a worldwide epidemic^[1]It has brought great challenges to clinical anti-infective treatment. The current status of Acinetobacter baumannii infection, drug resistance mechanism and several new antibacterial drugs with anti-Acinetobacter baumannii activity developed in recent years are summarized below.

frontotemporal dementia (FTD), mainly manifested by progressive impairment of behavior, executive ability and language, is one of the common causes of early-onset dementia before the age of 65. According to different clinical manifestations, it can be divided into behavioral variant FTD (BV-FTD), progressive non-fluent aphasia (PNFA) and semantic dementia (SD). The etiology and pathogenesis of FTD are unclear so far, and may be related to the abnormal deposition of various proteins, which in turn are directly related to gene mutations. The study found that 30% ~50% of FTD had a positive family history, of which 10% ~30% were autosomal dominant, and the rate of carrying disease-causing genes in patients with strong positive family history (that is, 3 or more immediate relatives in the family are sick) can be as high as 88%^[1]Therefore, FTD is closely related to genetics.

The 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis has been officially published in October of 2016, five years after the publication of the previous version. Revised contents in the new guideline are summarized in this review.

[Website]http: / /www.jiasociety.org/index.php/jias/index

[Website]http: / /www.iasociety.org/