Dr. Gyanprakash A. Ketwaroo (Medicine): A 77-year-old man with a history of ischemic
cardiomyopathy was admitted to this hospital in midspring because of increasing
dyspnea, weakness, and diaphoresis.
The patient had been in his usual state of health until 3 days before admission,
when weakness, loss of appetite, fatigue, and diarrhea developed, followed by
progressive shortness of breath. On the morning of admission, he awoke with dyspnea,
which was worse when he was lying flat; he was unable to catch his breath
or get out of bed. He was diaphoretic and felt nauseated and weak, with no chest
pain, fever, or cough.
The temperature was reportedly 37.8°C.
患者は入院前の3日前までは通常の健康状態であったが、脱力感、食欲不振、疲労ならびに下痢の症状が発生した後、呼吸が困難になりだした。患者は入院日の朝に、呼吸困難によってい覚醒した。この症状は、横になると悪化し、呼吸もできなければ、ベッドから起き上がることもできなかった。患者は多量の汗をかき、吐き気があるとともに脱力感をうったえた。胸部の痛み、発熱、咳の症状は無かった。
体温は37.8°Cであった。
当該患者は収容三日前までは健康状態に問題はなかったが、衰弱、食欲減退、疲労、下痢を発症し、続いて進行性息切れに見舞われた。収容の朝、患者は呼吸困難とともに目覚め（寝そべると悪化した）、正常に呼吸することができず、ベッドから出ることもできなかった。彼は発汗し、吐き気と脱力感を覚えたが、胸に痛みはなく、発熱および咳も出なかった。
体温は３７．８度と報告があった。
患者の容態は、入院の3日前まで平常であったが、入院時には、進行性息切れに続いて衰弱、食思不振、疲労と下痢が発現していた。入院当日の朝、患者は呼吸困難で覚醒した。症状は横になっているほうが重かった。患者は息ができず、ベッドから出ることができなかった。患者は発汗性で、吐き気を催し、衰弱していたが、胸の痛み、発熱、咳はなかった。
報告によると、体温は37.8℃であった。
His wife administered
acetaminophen and called emergency medical services personnel. On their arrival, the
patient’s skin was cool and pale, he spoke in sentences of three or four words, and
he used accessory respiratory muscles. The blood pressure was 160/90 mm Hg, the
pulse 96 beats per minute, the respiratory rate 40 breaths per minute, and the oxygen
saturation 90 to 91% while he was breathing ambient air. Basilar rales extended
a third to half of the way up both lung fields, and the abdomen was distended.
Oxygen (5 liters per minute) was administered by a nonrebreather mask, and
oxygen saturation increased to 99%. He was taken to another hospital.
On examination, the temperature was 37.2°C, the blood pressure 152/79 mm Hg,
the pulse 93 beats per minute , the respiratory rate 24 to 30
breaths per minute, and the oxygen saturation 100% while the patient was breathing
supplemental oxygen through a nonrebreather mask. There were coarse rales
bilaterally, the skin was cool and diaphoretic, and respiratory support with bilevel
continuous positive airway pressure was added transiently on arrival, with symptomatic
improvement. Electrocardiography revealed atrial fibrillation with intermittent
pacing and bifascicular block, with ST-segment depression, T-wave inversion,
and Q waves in leads V1 and V2, which were reportedly unchanged from
5 months before.
A chest radiograph reportedly revealed mild pulmonary edema
and moderate cardiomegaly. The serum levels of total bilirubin, creatine kinase
MB isoenzymes, and troponin I were normal; other laboratory-test results are
shown in A
. Nitroglycerin and furosemide were administered intravenously,
and acetaminophen was given, as well as the patient’s usual doses of digoxin,
ezetimibe, levothyroxine, lisinopril, sotalol, and
acetylsalicylic acid. The systolic blood pressure
decreased to below 100 mm Hg; the intravenous
nitroglycerin was stopped, and sublingual and
cutaneous nitrate preparations were administered
thereafter. Approximately 6 hours after
arrival, the patient was transferred by ambulance
to this hospital.
患者が通常服用するジゴキシン、エゼチミブ、レボチロキシン、リジノプリル、ソタロール、アセチルサリチル酸(アスピリン）の他に、ニトログリセリンとフロセミドが静脈内に投与され、アセトアミノフェンが与えられた。最高血圧は100ｍｍHg以下に下がった；静脈内へのニトログリセリン投与は停止され、その後は舌下と皮膚への硝酸塩調合剤が投与された。到着から約6時間後、患者は救急車でこの病院へと搬送された。
The patient had ischemic cardiomyopathy,
which was associated with an anteroseptal myocardial
infarction 30 years earlier. He had
arrhythmias, including atrial flutter and ventricular
tachycardia, for which an implantable
cardioverter–defibrillator had been placed.
Nine months before admission, atrial fibrillation
had developed and an ablation procedure
was performed; sinus rhythm had predominated
since then. The patient also had hypothyroidism,
hyperlipidemia, hypercholesterolemia, and hypertension,
and he had had a transient ischemic
attack, a stroke while he
was receiving therapeutic anticoagulation, a diverticular
bleed 2 months before admission, and
an appendectomy 3 months before admission.
Infectious Diarrhea
Elderly patients account for the majority of diarrheal
deaths in some series, especially if Clostridium
difficile is the pathogen.7,8 I would consider
the classic pathogenic Enterobacteriaceae (Escherichia
coli, campylobacter, shigella, salmonella,
yersinia), Listeria monocytogenes, and less likely,
C. difficile in the differential diagnosis. The absence
of an antecedent history of questionable food exposure
or any friends or family members who are
similarly ill, however, dampens the enthusiasm
for an Enterobacteriaceae infection. The elderly
are at increased risk for invasive listeria infections,
although the classic presentation includes
vomiting, which this patient does not have;
病原体への感染から、特にクロストリジウム－ディフィシレ菌が病原体の場合に発生する下痢による死亡者の大半は、高齢の患者である。7，8 私は、識別診断から、認識されている病原体である腸内細菌 (大腸菌、 カンピロバクター、赤痢菌, サルモネラ、エルシニア)、リステリア、また、可能性は少ないが、クロストリジウム・ディフィシルではないかと推察する。原因となりえる食物を摂取したか、家族や友人が同様な症状を持っているかどうかなどの質問がなされない場合、積極的大腸菌を病原体とした感染と推測されない場合が多い。
高齢者は、侵襲性のリステリア感染症に感染するハイリスクグループである。頻繁に見られる症状に含まれるのは、嘔吐（ただし患者が次を持たない:
This patient lived in a wooded area of the Northeast
and presented in midspring, so we should
pay particular attention to human infections that
result from tick exposure. This patient could be
at risk for Lyme disease; however, there is no history
of the early localized skin manifestations of
Lyme disease, and a disseminated infection leading
to myocarditis without concomitant neurologic
findings would be rare. Diarrhea raises the
possibility of typhoidal tularemia, but this patient
does not have the cholestasis, jaundice, or
pulmonary involvement that can be seen in severe
cases.Rocky Mountain spotted fever can
present with elevated aminotransferase levels,
thrombocytopenia, and infrequently azotemia, but
