共筆作者 李秉叡、李育珊、黃欣寧 日期 2/19 Case1

主要診斷 應該是 Melioidosis (類鼻疽)

筆記、查到的資料精華： 沒時間就看紅字吧About this case:（這可以不用看）- RLQ abdomen Intermittent dull pain for 3 months- Abdominal distension, adnexal tenderness and a 2x2cm palpable mass

→曾經懷疑過 Ovarian cyst/ Appendiceal tumorPathology： Ovary: follicular cyst T-colon: infective granulation tissue, granuloma with caseous necrosis from

mucosa to serosa, endarteritis obliterans (TB 引起的血管變化)※ Endarteritis obliterans, also called arteritis obliterans, obliterating endarteritis

or obliterating arteritis, an inflammatory condition of the intima (wall thickening) and narrow the lumen of the vessels. (type 4 hypersensitivity, deposition of immunocomplex)

Cecum: inflammatory cells, eosinophil and lymphocyte infiltration Appendix: granuloma with caseous necrosis

→病理診斷為 TB, 但是 acid-fast stain (-), 且 PCR for MTB(mycobacterium tuberculosis)(-), 也懷疑過腸胃道 TB 但 mycobacteria bovis(-), mycobacteria avian也是 unlikely 因為如果是M. avian病理上應該會看到大量的 foamy histiocytes→suspect Melioidosis

類鼻疽(Melioidosis):- Burkholderia pseudomallei (類鼻疽伯克氏菌)- Occupational exposure to soil and water

(經皮膚傷口或吸入、食入，不會人直接傳給人)- Clinically difficult to diagnosis (“Vietnamese time bomb”臨床症狀表現多元)- Gram (-) bacillus, Gram stain 菌體兩端極度濃染，呈現「安全別針狀」《病理》：Chronic melioidosis: granulomatous inflammation, multinucleate giant cell situated around a central necrotic zone (either caseous or comprise of purulent exudate)→

似 TB-鍍銀染色(+)-Wayson stain: modified methylene blue stain (rapid test) →（主任沒說，額外查的）

重要問答、主任提示Mycobacteria v.s. B. pseudomallei

M. tuberculosis

M. bovis M. avianBurkholderia pseudomallei

Microscopic finding

Granuloma, caseous necrosis

Acid-fast stain

(+) (+)

(+)numerous

mycobacteria filling macrophages (foamy

histiocytes)

(-)

Gram stain

Gram positive weak

Gram negative:

“safety-pin” apperance

鍍銀染色 (-) (+)

DiseaseTuberculosi

s(in human)

Tuberculosis (usually in animals)

Disseminated MAC(mycobacterium

avium complex) in immunocompromised

patients

Melioidosis

猜題 (真的都沒時間，就看這裡就好了！)Melioidosis 染鍍銀染色(+), acid-fast stain(-)，可以和 TB 作區分( TB 染色 : 鍍銀染色(+)且 acid-fast stain(+) )Melioidosis Gram stain 染色下看起來似「安全別針」TB 病理切片 : granuloma, caseous necrosis ( Melioidosis 看起來也像這樣 )

補充(可以不用看):

Figure 3. Clinical Events after Infection with B. pseudomallei.

藍格子: routes of infection (percutaneous inoculation, inhalation, and ingestion)紅格子: natural history of infection (asymptomatic infection, bacteremia, or reactivation of latent focus)

白色字體: 疾病的表現