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288
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DOI：
10.1097/01.ccm.0000551042.44049.2f
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发表时间：
2019-01
影响因子：
8.8
通讯作者：
N. Sawal;Ritu Modi;G. Johri
中科院分区：
文献类型：
--
作者：
N. Sawal;Ritu Modi;G. Johri
方法：40岁男性，以脑病和两年慢性腹泻史为主诉，因肾功能衰竭、严重低钠血症(124例)、低钾血症(1.7例)、低磷血症(0.9例)和正常阴离子间隙代谢性酸中毒(NAGMA)住进ICU。尽管积极的电解质替代和开始小苏打滴注，他在持续性水样腹泻的背景下继续有Nagma和电解质异常。最初的实验室对HIV具有重要意义，CD4计数为558，因此进行了感染性检查，但并不显著。由于黑便的报道，乙状结肠镜检查以评估巨细胞病毒性结肠炎，发现一个13毫米的直肠粘膜下息肉，被鉴定为分化良好的类癌神经内分泌肿瘤。尽管获得了干净的切缘，患者仍持续有腹泻和EUS检查，这表明有更深的组织侵犯，但这被认为是灼伤的伪影。尽管5-HIAA水平正常，但进行了奥曲肽扫描，发现直肠没有摄取，但局限于左上腹。CT腹部显示左上象限肠系膜肿块起源于胰腺尾部，EUS活检证实为转移扩散的VIP瘤。患者最终开始服用奥曲肽和洛哌丁胺，并注意到他的腹泻和电解质紊乱的显著改善。结果：虽然血管瘤很罕见，但可以导致严重的、有时是致命的选择性粒细胞异位症。这个病例强调了即使在免疫受损的宿主中，保持对潜在的神经内分泌恶性肿瘤的临床怀疑的重要性。在这些情况下，临床医生应该有一个较低的门槛来获得成像或诊断测试，以排除非感染性病理，避免危及生命的并发症。
Methods: A 40-year old male presenting with encephalopathy and a two-year history of chronic diarrhea was admitted to the ICU for renal failure, severe hyponatremia (124), hypokalemia (1.7), hypophosphatemia (0.9) and normal anion gap metabolic acidosis (NAGMA) with pH of 6.8 on ABG. Despite aggressive electrolyte replacement and initiation on a bicarbonate drip he continued to have NAGMA and electrolyte abnormalities in the setting of persistent, watery diarrhea. Initial labs were significant for HIV with a CD4 count of 558, so infectious work-up was performed but was unremarkable. Due to reports of melena, sigmoidoscopy was done to evaluate for CMV colitis and revealed a 13mm submucosal rectal polyp identified as a well-differentiated carcinoid neuroendocrine tumor. Despite obtaining clean margins the patient continued to have diarrhea and EUS was done which suggested deeper tissue invasion however this was felt to be cautery artifact. Despite normal 5-HIAA levels, an octreotide scan was done and revealed no rectal uptake but localized to the left upper quadrant. CT abdomen revealed a left upper quandrant mesenteric mass arising from the pancreatic tail and EUS biopsy identified a VIPoma with metastatic spread. The patient was eventually started on octreotide and loperamide and noted significant improvement of his diarrhea and resolution of his electrolyte disorders.Results: VIPomas although rare, can cause severe and sometimes fatal dyselectrolytemias. This case highlights the importance of maintaining a clinical suspicion for underlying neuroendocrine malignancy even in immunocompromised hosts. In these cases, clinicians should have a low threshold for obtaining imaging or diagnostic testing to rule out non-infectious pathologies and avoid life-threatening complications.