【作者】 秦楠；

【导师】 王克玉；

【作者基本信息】 山东大学 ， 皮肤病与性病学（专业学位）， 2020， 硕士

【摘要】 目的:皮肤海鱼分枝杆菌感染因临床表现缺乏特异性,在诊断上存在一定难度,本文旨在分析该病的发病诱因、临床表现、诊断方法,治疗及预后,提高临床医生对该病的整体认识,有助于拓宽诊疗思路,对该疾病进行及时诊断及治疗。方法:回顾性分析山东大学齐鲁医院皮肤科收治的2例皮肤海鱼分枝杆菌感染患者的病史、临床表现、辅助检查方法、诊断治疗经过及随访。通过检索CNKI、Pubmed、Elsevier等数据库复习相关文献,并重点对2005年——2020年国内外共92例临床资料较为完整的病例报道进行回顾性分析。收集报道病例的性别、年龄、临床表现、辅助检查、治疗方案及预后等一般资料,分析病因、临床表现、实验室检查、诊断治疗及预后等问题。结果:本文报道2例皮肤海鱼分枝杆菌感染的患者,发病前有外伤史或水产品接触史,表现为散发的红斑、丘疹、结节、脓疱、溃疡,皮损组织病理改变为感染性肉芽肿,细菌培养出海鱼分枝杆菌,诊断:海鱼分枝杆菌感染,联合两种抗生素治疗有效。检索CNKI、Pubmed、Elsevier等数据库,复习相关文献,收集具有较为完整的临床资料的皮肤海鱼分枝杆菌感染病例,共92例,病例相关情况如下:1.发病年龄、性别分布在92例患者中,最小年龄为3岁,最大为82岁,平均年龄为48.6岁。病程最短为1个月,最长为60个月。92例患者中,男性患者占63例,所占百分比68.5%,女性占29例,所占百分比31.5%,其中1例患者为妊娠期妇女。2.诱因及潜伏期11例患者为水族馆工作人员或者渔民,日常接触水产品;29例患者有鱼、螃蟹或其他水生动物刺伤史,及外伤后接触水或水产品史;31例患者表示发病前曾接触过鱼等水产或清理鱼缸、游泳等活动;5例患者有外伤,但否认曾接触过水或水生动物;3例患者明确表示自己既无外伤史,也未接触水生动物及水。大多数病人并不能确定自己接触诱因之后与发病之间的明确时间,据明确表示间隔时间的患者中,潜伏期最长为2个月,最短为不超过10天。3.临床表现82例患者初发部位为上肢,初发于肢端的患者占总病例数目的72.8%。患者发病至进行有效治疗的时间1个月至5年不等。临床表现为在病原菌侵入部位出现红色或紫红色丘疹、结节或斑块,可有溃疡或脓疱。多发性病灶通常沿淋巴管呈现孢子丝菌病样排列,占全部病例的51%。向深部组织侵袭占总比例数目的30.4%。严重的病人会全身播散,这类病人在92例患者中占有5例。4.诊断组织病理学特点:组织病理检查约65.6%的患者的取材皮损可以见到典型感染性肉芽肿性损害;4例使用抗肿瘤坏死因子药物(抗TNFa)的患者的皮损中均无肉芽肿性炎症病理表现,而表现为非特异性炎症反应。抗酸染色仅有27.4%的患者为阳性。海鱼分枝杆菌培养在本次研究病例中最短出现时间为2周,最长为7周,其中67.4%为阳性,5.4%的病例中也可见抗酸染色、分枝杆菌培养结果均阴性。有31例PCR检测为阳性。5.治疗及预后所纳病例中,有6例为单药治疗取得良好效果,86例患者使用2至3种抗生素联合。10例患者进行了相应的外科治疗。疗程为3-6个月的患者占53.5%,2例患者治疗时间超过1年。2例患者最终因败血症死亡,51例患者痊愈。结论:1.皮肤海鱼分枝杆菌感染好发于职业接触或日常接触水及水产品的成年人,潜伏期常为2-4周。2.皮损多表现为典型的丘疹、结节或斑块,部分脓疱、溃疡,部分皮疹沿肢体淋巴管呈线状分布。3.组织病理特点多为感染性肉芽肿,抗酸染色阳性率不高。4.诊断需结合接触史、临床表现、组织病理学检查以及细菌培养和PCR技术。5.常采用2-3种抗生素联合治疗,疗程建议3-6个月。必要时需联合外科手术治疗。更多还原

【Abstract】 ObjectiveCutaneous infection caused by Mycobacterium marinum due to no obvious specificity,and certain difficulty exists in the diagnosis,the purpose of this paper is to analysis the incidence of the disease cause,clinical manifestation,diagnosis,treatment and prognosis,improve the overall understanding of the disease,way of thinking,help to improve diagnosis and treatment of the disease.MethodsRetrospective analysis was made on the medical history,clinical manifestations,auxiliary examination methods,diagnosis and treatment history and follow-up of 2 cases of mycobacterium marinum dermophysiae infection admitted to the department of dermatology,qilu hospital,shandong university.Relevant literatures were reviewed by searching CNKI,Pubmed,Elsevier and other databases,and a retrospective analysis was made on 92 cases with relatively complete clinical data from 2005 to 2020.General data such as gender,age,clinical manifestation,auxiliary examination,treatment plan and prognosis of the cases were collected,and the etiology,clinical manifestation,laboratory examination,diagnosis,treatment and prognosis were analyzed.ResultWe report 2 cases of cutaneous infection caused by Mycobacterium marinum,with previous history of trauma or contact with aquatic products,presenting as erythema,papules,nodules,pustules and ulcerations,and pathological changes of skin lesions to infectious granuloma.We searched CNKI,Pubmed,Elsevier and other databases,reviewed relevant literature,and collected 92 cases of mycobacterium dermal Marine fish infection with relatively complete clinical data.The cases were as follows:1.Age and sex distribution of onsetAmong the 92 patients,the youngest was 3 years old,the oldest 82 years old,and the mean age was 48.6 years old.The duration of the disease is as short as 1 month and as long as 60 months.Among the 92 patients,63 were male and 29 were female,among whom 1 was pregnant.2.Inducement and incubation period11 patients were aquarium workers or fishermen who had daily contact with aquatic products.Twenty-nine patients reported exposure to water or aquatic products after injury due to stab wounds from fish,crabs or other aquatic animals.Thirty-one patients reported having been exposed to fish or other aquatic products or cleaning fish tanks or swimming before onset.Five patients had trauma,but denied any exposure to water or aquatic animals.Three patients clearly stated that they had no history of trauma or exposure to aquatic animals or water.The incubation period,most patients can not determine the specific time between their exposure to the cause and the onset of disease,according to the time clearly stated in the patients,the incubation period is the longest 2 months,the shortest is not more than 10 days.3.Clinical manifestationsThe primary site of 82 patients was the upper limb,which accounted for 72.8%of the total cases.The time from initial onset to effective treatment varies from 1 month to 5 years.Clinical manifestations are in the pathogenic bacteria invasion site of the occurrence of reddish-brown or purplish red papules,nodules or plaques,occasionally can soften break ulceration form superficial ulcer,or contains pustules,the condition is relatively light more without conscious symptoms.Multiple foci are usually arranged in the direction of lymphatic drainage in the form of sporidiomycosis,accounting for 51%of all cases.Deep tissue invasion accounted for 30.4%of the total.Severe cases of systemic spread occurred in 5 out of 92 patients.4.The diagnosisLaboratory tests included:lesions typical of infectious granulomatous lesions were seen in about 65.6%of patients;In all 4 patients treated with anti-tumor necrosis factor(anti-tnfa),there was no pathological manifestation of granulomatous inflammation in the lesions,but non-specific inflammation.However,only 27.4%of the patients were positive for acid fast staining.In this study,the shortest time was 2 weeks,the longest time was 7 weeks,and 67.4%of the cases were positive.In 5.4%of the cases,acid-fast staining and mycobacterium marinum culture were negative.Thirty-one cases were positive by PCR.5.Treatment and prognosisOf the cases treated,6 achieved good results with single drug therapy,and 86 patients received 2 to 3 antibiotic combinations,such as amikacin,clarithromycin,ethambutol,minocycline,rifampicin,trimethoprim-sulfamethoxazole,moxifloxacin,and levofloxacin.The course of treatment was 3-6 months for 53.5%of the patients,and the treatment time of 2 patients was more than 1 year.Two patients died of sepsis and 51 were cured without scars.Conclusion1.Cutaneous infection caused by Mycobacterium marinum occurs most frequently in adults who have occupational or daily contact with water and aquatic products.The incubation period is usually 2-4 weeks.2.Most of the skin lesions are typical papules,nodules or plaques,which can be seen along the lymphatic vessels in a linear distribution.3.Most of the histopathological features are infectious granuloma,and the positive rate of acid-fast staining was not high.4.Diagnosis depends on exposure history,clinical manifestations,bacterial culture and PCR techniques5.Two or three kinds of antibiotics are commonly used in therapy.The duration of treatment is recommended to be 3-6 months.If necessary,surgical treatment should be performed.更多还原