《新英格兰医学杂志》每周医学图片赏

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先简短介绍
《新英格兰医学杂志》（The New England Journal of Medicine，NEJM）创刊于1812年，是世界上连续出版时间最久的医学期刊，每年发行 52期，每周四出版，年页码数为3400页。杂志隶属于马萨诸塞州医学会。杂志主要提供重要的、未被刊登过的研究成果、临床发现以及观点。注重文章的实用性，文章多为指导临床实践。
杂志有非常严格的审稿程序，稿件的处理流程通常需10—12周。来稿的刊用率约为7%。
177个国家超过50万名的医师、学生、研究人士、以及其他医学专家构成了该杂志的读者群体。在美发行量为20万册，其中约有1.29万名在校生订户。69%的订户年龄在50岁以下。

美国科技信息所（ISI）2007年发布了2006年期刊影响因子统计数据（2007年还未公布），《新英格兰医学杂志》的影响因子为51.296，在6000余种SCI杂志中位居第二名（仅次与 CA: A Cancer Journal for Clinicians，SCIENCE和NATURE的影响因子分别为30.028 和26.681），影响因子高通常表明该期刊发表的研究成果对以后的观点影响大。

NEJM 每期中固定的栏目“Images in Clinical Medicine”，以图文结合的形式报道临床病例，内容短小精悍，极为精彩。

出于个人兴趣，我将每周翻译这个栏目，为把个人学习的过程与大家分享，特开此贴，以伺同好。

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★目录★

华支睾吸虫	Clonorchis sinensis	2楼
舌异位甲状腺	Lingual Thyroid	3楼

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华支睾吸虫Clonorchis sinensis / Opisthorchis sinensis

男患，62岁，主诉乏力、发热及腹部绞痛7天。自述近期生吃过胡瓜鱼pond smelt（池沼公鱼Hypomesus olidus）。化验肝功能结果异常，表现为下面几项结果升高：天冬氨酸转氨酶（350 IU/L），丙氨酸转氨酶（352 IU/L），碱性磷酸酶（204 IU/L），γ-谷氨酰转移酶（434 IU/L），总胆红素（6.4 mg/dL[109 祄ol/L]），总胆红素（3.9 mg/dL[67祄ol/L]）。白细胞计数亦升高（13000/mm[sup]3[/sup]），伴有嗜酸性粒细胞增多（27%）。腹部CT扫描可见胆总管扩张，但没有明确的充盈缺损。考虑到病人可能存在急性胆管炎，给予十二指肠镜检查，检查过程中发现明显突出的大乳头。在导管插入胆总管后，突然大量的叶状的蠕虫突现出来（视频），并随后被确认为华支睾吸虫。经给予吡喹酮praziquantel治疗后，病人很快的顺利恢复。华支睾吸虫病clonorchiasis的临床表现可以反映出蠕虫的负荷以及感染的时间。华支睾吸虫可以在胆道系统中存在几十年，长期的感染可与胆管癌的发病相关。急性胆管炎和胰腺炎虽少见却是华支睾吸虫感染的严重并发症。

原文

A 62-year-old man reported having had fatigue, fever, and cramping abdominal pain for 7 days. He also reported that he had recently eaten raw pond smelt (Hypomesus olidus). The results of liver-function tests were abnormal, showing elevated levels of aspartate aminotransferase (350 IU per liter), alanine aminotransferase (352 IU per liter), alkaline phosphatase (204 IU per liter), -glutamyltransferase (434 IU per liter), total bilirubin (6.4 mg per deciliter [109 祄ol per liter]), and conjugated bilirubin (3.9 mg per deciliter [67 祄ol per liter]). The white-cell count was also elevated (13,000 per cubic millimeter), and there was eosinophilia (27%). A computed tomographic scan of the abdomen showed dilatation of the common bile duct without definite filling defects. Given our concern that the patient might have acute cholangitis, a duodenoscopy was performed, and a prominent major papilla was discovered. After cannulation of the common bile duct, numerous leaf-shaped worms popped out (see video) and were subsequently identified as Clonorchis sinensis (also called Opisthorchis sinensis). The patient was given praziquantel and had a quick and uneventful recovery. The clinical manifestations of clonorchiasis tend to reflect the worm burden and the duration of infection. Clonorchis may persist in the biliary tree for decades, and prolonged infestation is associated with the development of cholangiocarcinoma. Acute cholangitis and pancreatitis are rare but important complications of C. sinensis infestation.

Park DH and Son H-Y. Clonorchis sinensis. N Engl J Med 2008;358:e18

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舌异位甲状腺 Lingual Thyroid


一名4岁半的女孩被带到门诊来评估身体发育情况。一般体格检查均正常，除了在她的舌根偶然发现的一个包块（箭头所指）。她的身高和体重在同年龄的女孩中排在后25%。根据生化检查结果可以诊断甲状腺功能减退Hypothyroidism：血清促甲状腺激素 55mU/L（正常值 0.7-6.4），甲状腺素 3.5礸/dL[45 nmol/L]（正常值 6.0-14.2[77-183]）。[99mTc]高锝酸钠扫描显示舌根处99mTc浓聚，支持存在舌异位甲状腺；同时在颈部没有核素摄取。给予应用左旋甲状腺素 Levothyroxine来治疗甲状腺功能减退。经治疗后，甲状腺功能恢复正常，而舌异位甲状腺的大小没有明显改变。在胚胎发育早期，甲状腺形成于舌根，随后下降至颈部，通常在第7周前完成。甲状舌管thyroglossal duct 临时的将下降中的甲状腺连接到舌根。一旦下降未发生，就会导致舌异位甲状腺。

原文

A healthy girl, 4 1/2 years of age, was brought to our clinic for an assessment of her growth. A general physical examination was normal except for an incidental mass noted at the base of her tongue (arrow). Her height and weight were at the 25th percentile for age and sex. Hypothyroidism was diagnosed on the basis of biochemical findings: a serum thyrotropin level of 55 mU per liter (normal range, 0.7 to 6.4) and a thyroxine level of 3.5 礸 per deciliter (45 nmol per liter) (normal range, 6.0 to 14.2 [77 to 183]). A [99mTc]sodium pertechnetate scan showed increased 99mTc uptake at the base of the tongue, which was consistent with the presence of a lingual thyroid; there was no uptake over the neck. Levothyroxine was prescribed to treat the hypothyroidism. After treatment, euthyroidism was achieved without a marked change in the size of the lingual thyroid. Early in embryonic development, the thyroid gland forms at the base of the tongue, and subsequently descends into the neck, typically by the 7th week. The thyroglossal duct temporarily connects the descending thyroid gland to the base of the tongue. If descent does not occur, a lingual thyroid may result.

Moaddab, Mohammad Hassan, Siavash, Mansour. Lingual Thyroid. N Engl J Med 2008; 358: 1712

wrocky

楼主辛苦了

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巴贝斯虫病 Babesiosis

一位34岁男患，因发热（最高体温40℃）伴寒战3天来急诊室就诊。实验室检查提示溶血性贫血，血红蛋白为8.6 g/dL。该病人在12年前，即1994年确诊结节硬化性霍奇金淋巴瘤，IIIB期Nodular sclerosing Hodgkin's lymphoma, stage IIIB，并在那时接受脾切除手术。近期，他有去马萨诸塞州，奥勒冈州，夏威夷，佛罗里达，伊利诺州，南非和哥斯达黎加的旅游史。外周血涂片显示在红细胞内可见大量细胞内微生物，几乎3%的红细胞内存在寄生虫。其形态大多数呈环形，少见为四分体tetrads（细箭头）。这些被称为马尔他十字Maltese cross的结构是巴贝斯虫病的特异性病例表现，并可以此与主要的鉴别诊断疟疾相鉴别。在含有四分体的那个红细胞的右下象限可看见一个深圆的小体，叫做豪周氏小体Howell–Jolly bodies（粗箭头），其存在表明细胞核清除不完全。豪周氏小体常见于功能性无脾的病人，而且他们特别易感于严重巴贝斯虫和荚膜菌感染。仅利用这一个红细胞，我们就可以做出诊断同时理解根本的发病机制。我们的病人接受为期7天的治疗，应用药物为阿奇霉素azithromycin和阿托伐醌atovaquone。发热很快消退，血细胞比容也最终恢复正常。

原文

A 34-year-old man came to the emergency room with a 3-day history of fevers (peak temperature, 40°C), accompanied by shaking chills. Laboratory tests revealed a hemolytic anemia, with a hemoglobin level of 8.6 g per deciliter. Nodular sclerosing Hodgkin's lymphoma, stage IIIB, had been diagnosed 12 years earlier, in 1994, and the patient underwent splenectomy at that time. He had traveled recently to Massachusetts, Oregon, Hawaii, Florida, and Illinois and to South Africa and Costa Rica. The peripheral-blood smear shows numerous intracellular organisms in red blood cells, with nearly 3% of erythrocytes harboring parasites. Multiple ring forms are seen, as well as rare tetrads (thin arrow). These so-called Maltese cross formations are essentially pathognomonic of babesiosis, since they are not seen in malaria, the primary consideration in the differential diagnosis. The dark, round body in the right lower quadrant of the red blood cell with the tetrad is a Howell–Jolly body (thick arrow), an erythrocyte inclusion representing an incompletely extruded nucleus. Howell–Jolly bodies are seen in patients with functional asplenia, and such patients are particularly susceptible to serious babesial and encapsulated bacterial infections. This single red cell provides both a diagnosis and an understanding of the underlying pathogenesis. Our patient received a 7-day course of treatment with azithromycin and atovaquone. His fever subsided rapidly, and his hematocrit eventually returned to normal.

Kyle N and Elizabeth B. Babesiosis. N Engl J Med 2008;358:e19

补充一段资料，便于理解

豪周氏小体（Howell-Jolly Bodies）：在晚幼红细胞浆内和成熟红细胞内含单个或多个紫红的包含物为核碎片或染色体残留物。此物具有 DNA 物质，是严重溶血、MDS、脾切除后等出现。

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疟疾合并血红蛋白尿 Hemoglobinuria with Malaria

一位其他方面健康的30岁男性病人，因发热达39℃及尿色加深2天来诊（此病例曾报道于Bhatt et al., East African Medical Journal 1994;71:755-7）。在入院前未行任何药物治疗。入院时实验室检查发现血红蛋白为7.6 g/dL，血清尿素氮为4.8 mmol/L（0.13 mg/dL），肌酐为89 祄ol/L（1.0 mg/dL）。总胆红素为15 祄ol/L（0.88 mg/dL），直接胆红素为1 祄ol/L（0.06 mg/dL）。尿干化学分析urinary dipstick test 显示潜血为阳性，但显微镜检未发现红细胞（尿干化学分析不能鉴别红细胞与血红蛋白）。血涂片显示5%红细胞受染恶性疟原虫Plasmodium falciparum。经治疗后病人的尿液颜色逐渐转淡，从入院时（T0或零小时）的深棕色转为入院后42小时的黄色（T42）。他的病情好转得益于应用奎宁quinine进行治疗，最初经静脉给药之后改为口服，整个疗程共7天。住院时间为48小时。28天回报的葡萄糖-6-磷酸脱氢酶glucose-6-phosphate dehydrogenase（G6PD）结果非常低。黑水热Black-water fever常与应用抗疟药特别是奎宁有关，但这位病人尿色加深的症状出现在应用奎宁之前，不支持此诊断。考虑到许多非洲人是G6PD缺乏的杂合体，并被认为可以抵抗疟疾，这可能是造成溶血的原因。

An otherwise healthy 30-year-old man had been ill for 2 days when he presented with a temperature of 39°C and reported passing dark urine (his case was noted in Bhatt et al., East African Medical Journal 1994;71:755-7). He reported taking no medication before coming to the hospital. Laboratory evaluation on admission was notable for a hemoglobin level of 7.6 g per deciliter, a serum urea nitrogen level of 4.8 mmol per liter (0.13 mg per deciliter), and a creatinine level of 89 祄ol per liter (1.0 mg per deciliter). The total bilirubin level was 15 祄ol per liter (0.88 mg per deciliter), and the conjugated bilirubin level 1 祄ol per liter (0.06 mg per deciliter). A urinary dipstick test was positive for blood but microscopical examination showed no red blood cells (the dipstick test used could not differentiate red blood cells from hemoglobin). The blood smear showed 5% parasitemia of red blood cells with Plasmodium falciparum. Progressive clearance of his urine is shown, from dark brown on admission (T0, or zero hour) to yellow 42 hours after admission (T42). His condition improved on treatment with quinine, initially administered intravenously and then orally for a total of 7 days. He stayed in the hospital for 48 hours. The qualitative glucose-6-phosphate dehydrogenase (G6PD) level 28 days later was very low. Black-water fever is most often associated with the use of antimalarial medication, especially quinine, but in this patient, dark urine developed before quinine therapy, making this diagnosis less likely. As many Africans are heterozygotes for G6PD deficiency, which is thought to provide protection against malaria, this may be the cause of his hemolysis.

Martin T. Hemoglobinuria with Malaria. N Engl J Med 2008;358:1837

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恶性高血压引起脑干及基底部改变
Changes in the Brain Stem and Fundus in Malignant Hypertension

53岁男患因双侧眼球后疼痛及视物模糊4周就诊。测量血压为220/135 mmHg；神经系统查体未见明显阳性体征。病人否认高血压病史且未应用药物治疗。眼底检查发现双侧视盘水肿disk edema，脂质渗出lipid exudate（Panel A，短箭头），棉絮状斑cotton-wool spots（Panel A，长箭头），视神经水肿swollen optic nerve（Panel B，长箭头）以及视网膜出血retinal hemorrhages（Panel B，短箭头）。 脑磁共振液体衰减反转恢复fluid-attenuated inversion recovery (FLAIR)成像显示在脑桥和中脑出现孤立异常高信号（Panel C，箭头），钆gadolinium 增强扫描无增强（Panel D，箭头）。经过良好的控制血压，4周后再次扫描脑干及基底部影像恢复正常（Panel E，箭头）
原文

A 53-year-old man presented with a 4-week history of bilateral retrobulbar headache and blurred vision. His blood pressure was 220/135 mm Hg; his neurologic examination was unremarkable. He had no history of hypertension and was not taking any medication for its treatment. Fundus examination showed bilateral disk edema, lipid exudate (Panel A, short arrow), cotton-wool spots (Panel A, long arrow), a swollen optic nerve (Panel B, long arrow), and retinal hemorrhages (Panel B, short arrow). Magnetic resonance imaging of the brain showed an isolated hyperintense abnormality on fluid-attenuated inversion recovery (FLAIR) p_w_picpath in the pons and midbrain (Panel C, arrow) that did not enhance with gadolinium (Panel D, arrow). Good control of blood pressure was established, and the appearance of the fundus and brain stem returned to normal (Panel E, arrow) 4 months later.

Lee MS, Tienor BJ. N Engl J Med. 2008 May 1;358(18):1951.

关于fluid-attenuated inversion recovery (FLAIR)的讨论，请参见http://readfree.net/bbs/read.php?tid=4603447

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脂腺痣 Nevus Sebaceus of Jadassohn

一位14岁女患，由母亲带来医院就诊，述头皮上一处小胎痣近来突然快速增长。伴有愈加剧烈的搔痒，同时造成严重的精神压力。病人其他方面正常。查体在头皮处可见一处大的分叶、疣状病变。这些病变偏好于头皮处，典型表现为出生后的孤立、无毛的斑点或小斑块。通常它们不造成问题，直到进入青春期，因为激素分泌引起疣状或结节状改变，同时在尺寸上生长增大，有时会变得相当引人注目。考虑到病变的大小和位置以及存在恶变，特别是转变为基底细胞癌的风险，随后不久，病人被转入整形外科行手术切除。手术成功切除病变，组织学检查确定诊断为脂腺痣。.

原文

A 14-year-old girl came to the hospital with her mother, stating that a small birthmark on the scalp had recently started growing rather rapidly. It was increasingly pruritic and caused the patient considerable emotional distress. She was otherwise healthy. On examination a large multilobulated, verrucous lesion was seen on the scalp. The findings were consistent with nevus sebaceus. These lesions have a predilection for the scalp and typically appear early in life as a solitary, hairless patch or small plaque. Often they do not cause problems until the patient reaches adolescence, as hormonal factors induce a verrucous or nodular change and the lesion grows in size, occasionally rather dramatically. Given the size and location of the lesion and the risk of malignant transformation, especially to basal-cell carcinoma, later in life, the patient was referred to plastic surgery for excision. The lesion was successfully excised, and histologic examination confirmed the diagnosis of nevus sebaceus of Jadassohn.

Ibrahim SF, Tu JH. N Engl J Med. 2008 May 1;358(18):e20.