简介:

昆明医科大学第一附属医院是一所集医疗、教学、科研、预防、干部保健、突发公共卫生事件应急处理和医疗急救于一体的大型综合医院，是昆明医科大学直属附属医院暨临床医学院，是国家首批住院医师规范化培训基地，省级医学科技创新基地。以名医荟萃、学科齐全、技术力量雄厚、特色专科突出、多学科综合优势强大位列云南医疗界榜首，在复旦大学医院管理研究所公布的西南区综合实力排行榜中两次位列第四。医院始建于1941年，“国立云南大学医学院附属医院”正式成立，院名横匾“云大医院”；1956年，云南大学医学院独立建院，更名昆明医学院，医院更名为昆明医学院附属医院；1963年，更名为昆明医学院第一附属医院，简称“昆医附一院”；2012年，昆明医学院更名为昆明医科大学，医院更名为昆明医科大学第一附属医院，简称“昆医大附一院”。建院80年来，一代代附一院人秉承“仁医仁术立院、真理真心育人”的宗旨，薪火相传，砥砺奋进，深得百姓的信赖和赞誉，培养的一批批医学院学生和进修学员，成为了云南乃至周边省区医疗机构的骨干力量。医院重视高端人才培养和梯队建设，有高级职称762人，博士476人、硕士1007人。有何梁何利奖获得者1人，国家百千万工程人才2人，中国医师奖获得者1人，国家级、部级、省级突出贡献专家和享受国务院、省政府特殊津贴者123名，荣获云南省人才培养激励1人。云南省“兴滇英才计划”科技领军人才1人、云岭学者6人、名医86人、产业创新人才3人、青年人才59人，省中青年学术和技术带头人后备人才及省技术创新人才72名，医学领军人才39名。何黎教授获得2016年“全国十大教书育人楷模”称号，团队2021年获“云南省黄大年式教学团队”的荣誉。荣获国家级、省部级劳模、三八红旗手、巾帼标兵等荣誉称号的先进个人不胜枚举。医疗服务实力雄厚，医院现有西昌路院区、呈贡院区2个院区，总占地455亩，总建筑面积50.41万平方米，职工6500余人，编制床位2536张，设有临床、医技科室76个。有国家级重点专科7个，省级临床重点专科24个，省级质控中心18个。设有专病门诊177种，最高日门、急诊量1.4万人次。有达芬奇机器人1台、PET/CT1台、高端直线加速器1台、核磁共振9台、CT14台、SPECT/CT1台、DSA8台等先进的诊疗设备。2022年出院病人17.1万人次，手术6.6万台次。与云南省242家州（市）、县级医院建立了医疗战略联盟。教学育人方面，博士生导师93人，硕士生导师383人。有全日制本科生3100余人、研究生1700余人。已经建成临床教学全程制度化教学管理体系和教学质量监控体系，被认定为首批国家临床教学培训示范中心临床医学专业、麻醉专业获批国家一流本科专业建设点，医学影像学专业申报国家一流本科专业建设点项目。全国青年教师教学基本功比赛连续3年获一等奖；2019年获得全国第二届MBBS英文教学讲课比赛一等奖；获全国高校微课比赛一等奖4项、二等奖6项；获全国高等院校医学影像专业教师教学基本功竞赛一等奖，近3年获云南高校教师教学创新大赛一等奖3项。近5年共有212项省级、校级教学改革项目立项；获省级、校级一流课程23门；获省政府教学成果奖二等奖5项；校级教学成果奖特等奖1项；主编、参编教材42部，发表教学论文数量在全国583家附属医院中排名第7。科学研究方面，学术团队和平台等级和数量在省内独占鳌头。被认定为国家干细胞临床研究机构、国家药物临床试验机构，获教育部协同创新中心1个、教育部创新团队1个，省级创新团队15个，院士专家工作站30个,博士后科研工作站1个。国家中医药管理局重点研究室1个，云南省临床医学研究中心10个，省重点实验室1个，省临床医学中心6个，省工程技术研究中心2个，省工程研究中心4个，省协同创新中心1个；省卫健委内设研究机构30个（研究所8个）。科研项目和科技成果数连续十余年名列全省卫生系统榜首。近5年获得国家自然科学基金项目154项；获得科技部科技支撑计划等国家级重点项目子课题32项，省部级科研项目500项，厅、市级科研项目420项；外来科研经费超过1.8亿元；获云南省科学技术奖49项，其中特等奖3项，一等奖5项、二等奖6项；获中华中医药学会科学技术一等奖、中国医院协会科技创新二等奖、中国老年保健医学会科技成果二等奖各1项；获云南省卫生科技成果奖47项；3项成果入选云南十大科技进展；作为第一或通讯作者单位在《柳叶刀-精神病学》、《Gastroenterology》期刊上发表有国际影响力论文；获国家专利授权1700余项。国际交流与合作方面，近年来公派300余名人员赴美国、英国、德国、意大利、爱尔兰等国家和地区学习进修、交流访问。接待英国GDK医疗集团、剑桥大学、哈佛大学医学院、美国佐治亚大学等51个代表团180余人来院访问、考察。聘请樊代明、黎介寿等院士以及美国、德国、法国等知名机构专家为我院客座教授；与台北医大双和医院及台湾秀传医疗体系建立友好合作关系，与香港中文大学建立院士工作站，与美国明尼苏达大学儿童心脏中心、美国慈善儿童医院和心连心基金会、美国乔治梅森大学签订合作协议；与英国NHS集团下合硕医疗机构、德国图宾根大学医学院、澳大利亚阿尔弗雷德国际创伤中心达成初步合作意向。6次赴缅甸、老挝、越南完成眼科“光明行”医疗援助活动，为1095患者进行免费手术治疗，手术成功率100%。2016年开通了外国专家绿色通道，2017年建立中美远程会诊中心，3次组建医疗队赴缅甸、老挝抗击新冠疫情医疗援助。圆满完成援乌干达医疗队任务，2次获得“全国援外医疗工作先进集体”。昆明医科大学第一附属医院，认真贯彻加强公立医院党建的精神，将党建工作与医、教、研业务、对口帮扶、精准扶贫、医德医风等工作紧密联系，秉持“爱与生命同在”的核心价值观，将努力创建“管理一流、技术一流、服务一流、设备一流、环境一流”五个一流，努力做到“患者满意、学生满意、职工满意、政府满意、社会满意”五个满意，努力建设云南引领、西部一流、全国知名、辐射南亚东南亚的高质量发展的现代化高水平医科大学附属医院。糖尿病性昏迷是糖尿病主要急性并发症,包括低血糖昏迷、糖尿病酮症酸中毒昏迷、高渗性昏迷、乳酸酸中毒昏迷。，（1）应激和感染。（2）摄水不足。（3）失水过多和脱水。（4）高糖摄入和输入。（5）药物：许多药物均可成为诱因,如大量使用糖皮质激素、噻嗪类或呋塞米(速尿)等利尿药等。（6）其他：如急、慢性肾功能衰竭,糖尿病肾病等。由于肾小球滤过率下降,对血糖的清除亦下降,也可成为诱因。，全身，糖尿病性昏迷的治疗主要是采取补液、吸氧、小剂量胰岛素治疗,同时注意纠正电解质及酸碱失衡、补钾,消除或控制诱因和防治并发症,监测生命体征。另外,糖尿病低血糖昏迷还需补充葡萄糖、给予高蛋白食品、少量多餐等对症治疗。，1.高渗性非酮症糖尿病昏迷2.临床上,对昏迷、脱水兼酸中毒、休克的患者,3.与糖尿病急性代谢紊乱1）.高渗性非酮症糖尿病昏迷2）.乳酸性酸中毒3）.乙醇性酸中毒4）.饥饿性酮症，1、忌食辛辣刺激性食物。2、忌食含糖量高的食物。3、忌食油腻食物。，（1）老年糖尿病患者若出现进行性意识障碍,或出现嗜睡、幻觉、定向障碍、偏盲、上肢拍击样震颤、癫痫样抽搐、昏迷等症状时,首先考虑高渗性昏迷；若大量进食或水分摄入不足、静脉补充高糖、利尿剂使用过量、应用糖皮质激素或氯丙嗪等药物时出现多尿和意识障碍,应考虑本病。（2）符合下列条件即可做出诊断：①血糖≥33．3mmol/L；②血钠≥145mmol/L；③血浆渗透压≥350mmol/L或有效渗透压≥320mmol/L；④无或只有轻度酮症。，。

true 周厚俊副主任医师

三级甲等昆明医科大学第一附属医院

好评率：100% 接诊量：1 平均响应：-

昆明医科大学第一附属医院微创神经外科主诊医师，治疗组组长，从事临床及科研教学工作20余年，对于神经外科疾病的微创治疗及复杂危重患者的救治管理积累了丰富的经验，尤其是颅脑、脊髓肿瘤（脑膜瘤、胶质瘤、垂体瘤、颅咽管瘤、听神经瘤等）显微手术切除，颅脑、脊髓血管疾病（脑出血显微镜下血肿清除、颅内动脉瘤的手术夹闭、脑脊髓血管畸形的显微手术切除，及脑、脊髓血管畸形的杂交/复合手术治疗，缺血性脑血管病如颈内动脉狭窄的内膜剥脱术、烟雾病的血管搭桥及颞肌贴敷术），三叉神经痛（微血管减压术及球囊压迫术）、面肌痉挛（神经电生理监测下微血管减压术）、帕金森病（脑深部电极植入术；DBS）、癫痫（电生理监测下癫痫灶切除术及迷走神经电刺激术：VNS）、梅杰综合征、斜颈等肌张力障碍的微创外科治疗、中枢性疼痛的电刺激治疗，脑积水的诊治（分流术、造瘘术）、颅脑外伤（颅内压监测及各种并发症的防治救治管理）及颅内感染性疾病等神经危重症患者的救治管理均有深入的诊治体会。为手术治疗三叉神经痛与面肌痉挛手术量最多的专家之一。主编专著二部，参编专著三部，发表论文30余篇，发明专利三项，获云南省卫生科技成果一等奖一项，主持省部级科研项目一项，参与国家级及省部级科研项目多项，多次被评为昆明医科大学三育人先进教师、昆明医科大学第一附属医院优秀党员、医德医风先进个人。

false 刘晓蕾副主任医师

三级甲等昆明医科大学第一附属医院

好评率：100% 接诊量：1 平均响应：-

记忆障碍，轻度认知障碍及痴呆，神经系统疾病并发的情感障碍及认知障碍

false 钟华主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

青光眼，儿童眼病及眼视光，白内障

true 王正文主任医师

三级甲等昆明医科大学第一附属医院

好评率：97% 接诊量：241 平均响应：-

白癜风、黄褐斑等色素障碍性皮病；银屑病、红斑狼疮等免疫性皮肤病；过敏性紫癜、荨麻疹、湿疹等过敏性皮肤病；痤疮、疤痕、胎记、激素依赖性皮炎等损容性皮肤病及性传播疾病的诊治，以高尚的医德和精湛的医术受到患者高度赞誉。

true 陈涛主任医师

三级甲等昆明医科大学第一附属医院

好评率：100% 接诊量：51 平均响应：-

昆明医科大学第一附属医院原神经内科科主任，教授，师从于世界著名癫痫病及神经遗传病学家学习，从医36年，具有丰富的临床经验。擅长癫痫、神经遗传病、脑血管病及神经疑难病诊治。

true 王枫副主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

鼻咽癌的放化疗治疗

true 谭芳主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

呼吸道感染性疾病、慢性阻塞性肺疾病、支气管哮喘、咳嗽、肺癌、肺结节、间质性肺疾病等

false 姜红燕主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

抑郁症，焦虑症，强迫症，睡眠障碍，老年精神障碍，认知障碍

true 赵培珠副主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

待完善

true 雷又鸣主任医师

三级甲等昆明医科大学第一附属医院

好评率：- 接诊量：- 平均响应：-

胸部疾病的微创诊治，擅长肺、纵隔、食管、乳腺的临床诊断及微创手术治疗，在云南省率先开展了自主呼吸非插管麻醉胸腔镜手术。

接诊医生：

2024-10-30 19:30:32

科普文章

糖尿病急性并发症知多少？

糖尿病急性并发症一般包括糖尿病酮症酸中毒、高血糖高渗状态、乳酸酸中毒、低血糖昏迷等。由于糖尿病急性并发症有可能直接威胁到患者的生命，因此需要及早预防，当发生时要及时发现和治疗。

1.糖尿病酮症酸中毒？

糖尿病酮症酸中毒（DKA）为最常见的糖尿病急症。以高血糖、酮症、和酸中毒为主要表现，是胰岛素不足和拮抗胰岛素激素过多共同作用所致的严重代谢紊乱综合征。

DKA的诊断标准包括存在血糖＞13.9mmol/L，动脉血pH＜7.30（动静脉血差值约0.02~0.15，也可取静脉血，一般不影响诊断），[HCO3-]≤18 mmol/L，阴离子间隙（AG）＞10~12mmol/L。血和尿酮阳性进一步支持DKA的诊断，有条件的机构可定量测定尿/血清β-羟丁酸，诊断阈值为＞3.0mmol/L。

在DKA管理的早期阶段应遵循几个重要步骤：

1.在开始静脉输液前采集血液进行代谢谱检测；

2.在1小时内输注1L 0.9%NaCl；

3.在开始胰岛素治疗前确保钾水平＞3.3 mEq/L（必要时静脉补钾）；

4.启动胰岛素治疗。

5.阴离子间隙纠正到正常。

治疗：

糖尿病酮症酸中毒（DKA ）的治疗原则：尽快补液以恢复血容量、纠正失水状态，降低血糖，纠正电解质及酸碱平衡失调，同时积极寻找和消除诱因，防治并发，降低病死率。

1.补液

2.胰岛素治疗

3.补液

4.纠正酸中毒

5.去除诱因，治疗并发症

如果在治疗过程中出现低血压休克、心力衰竭、肾功能衰竭、脑水肿等并发症，也要积极应对，作出处理。

2.高渗高血糖综合征

高渗高血糖综合征（HHS）是糖尿病急性代谢紊乱的另一临床类型，以严重高血糖、高血浆渗透压、脱水为特点，无明显酮症，病人可有不同程度的意识障碍或昏迷（<10%）。部分病人可伴有酮症。主要见于老年T2DM病人，超过2/3病人原来无糖尿病史。

在遇到急性感染、严重外伤、较大手术、急性心肌梗死、脑血管意外等情况，或者使用糖皮质激素、免疫抑制剂、利尿剂、甘露醇等药物、透析治疗、静脉高营养等治疗时，容易诱发高渗高血糖综合征。

一般从开始发病到出现意识障碍需要1~2周，偶尔急性起病。主要表现为脱水和神经系统两组症状。患者反应迟钝、烦躁或淡漠、嗜睡，逐渐陷入昏迷、抽搐，晚期尿少甚至尿闭。

通常患者的血浆渗透压>320 mOsm/L时，即可以出现精神症状，如淡漠、嗜睡等。

当血浆渗透压>350 mOsm/L时，可出现定向力障碍、幻觉、上肢粗震颤、癫痫样发作、偏瘫、偏盲、失语、视觉障碍、昏迷等。

HHS诊断：

HHS由于患者神经、精神症状比较多，往往误诊为神经科的疾病，耽误治疗。它的诊断主要依靠化验检查，其诊断标准为：

（1）血糖≥33.3 mmol/L。

（2）有效血浆渗透压≥320 mOsm/L；有效血浆渗透压(mOsm/L)= 2×(Na＋＋K＋)＋血糖（均以mmol/L计算）。

（4）尿糖呈强阳性，而血清酮体及尿酮体阴性或为弱阳性。

（5）阴离子间隙<12 mmol/L。

由于HHS常发生于老年人，并存多种疾病，且容易在应激情况下发生，故特别容易误诊！该病病情危重、并发症多，病死率远高于糖尿病酮症酸中毒，是老年糖尿病患者的克星。

抢救成功的关键仍然是早期诊断和早期治疗。临床上凡遇原因不明的脱水、休克、意识障碍及昏迷均应想到本病的可能性，尤其是血压低而尿量多者，不论有无糖尿病史，均应进行有关检查以肯定或排除本病。

3.糖尿病并发乳酸酸中毒

01. 诱因：过量使用双胍类药物、伴有急慢性肝肾功能不全、心力衰竭、感染、酗酒、高龄及一氧化碳中毒。

02. 临床表现：急性起病，主要为代谢性酸中毒的表现，可有恶心、呕吐、腹泻、腹痛等消化道症状，缺氧表现（口唇发绀），血压下降等脱水表现，疲乏无力、深大呼吸（无烂苹果昧）、意识障碍、四肢肌张力下降、反射减弱、瞳孔散大甚至昏迷休克，轻症患者表现可不明显。

03. 化验检查：血糖可正常或升高；血清乳酸 ≥ 5 mmol/L（严重时可达 20 - 40 mmol/L）；动脉血气分析 pH < 7.35；碳酸氢根明显降低，常 < 10 mmol/L；阴离子间隙＞ 18 mmol/L；尿酮体呈阴性或弱阳性。

治疗：

(1). 去除诱因；

(2). 补液扩容和纠正休克：提高心输出量，恢复血流动力学稳定，改善组织灌注，减少乳酸浓度，一般选择生理盐水；

(3). 纠正酸中毒：采用分次小剂量碳酸氢钠持续滴注的方式补碱方式，HCO3-上升 4 - 6 mmol/L，维持在 14 - 16 mmol/L，动脉血 PH 高于 7.2。避免大剂量碳酸氢钠引起的高血钠、高渗透压、氧离曲线左移致组织氧供减少及容量负荷过重。

(4). 胰岛素治疗：糖尿病乳酸酸中毒的患者一般血糖升高不明显，如果血糖升高，应避免口服降糖药。可予以小剂量的胰岛素持续静脉泵泵入或静脉输注胰岛素控制血糖。

(5). 肾脏替代治疗：对于服用过量双胍类药物、伴有严重肾功能不全或严重心衰患者，及时给予 CRRT。

糖尿病乳酸酸中毒预防：

乳酸性酸中毒预后差，病死率高。因此预防乳酸性酸中毒的发生尤为关键。预防乳酸性酸中毒，首先要避免易感因素。（1）严格掌握双胍类药物的适应证，有肝肾功能不全、缺氧性疾病及一般情况差者忌用双胍类。二甲双胍引起乳酸性酸中毒的发生率低于苯乙双胍，因此建议尽可能选用二甲双胍（目前临床已基本不使用，但在中小型城市糖尿病患者中含有该成分的药物仍在使用）；（2）使用双胍类者在遇到危重症时应暂停用药，改用胰岛素治疗。

此外，临床医生应加强患者及其家属的教育，告知各种降糖药物的作用及副作用，加强血糖监测。避免患者活动量过大，产生乳酸过多。帮助患者及其家属认识低血糖、乳酸性酸中毒和糖尿病酮症酸中毒的区别，定期复查各项指标。

4.低血糖症

低血糖症是一组由多种病因引起的血浆（或血清）葡萄糖水平降低，并足以引起相应症状和体征的临床综合征，而当血浆葡萄糖浓度升高后，症状和体征也随之消退。病人常以交感兴奋和（或）神经精神及行为异常为主要特点，血糖浓度更低时可以出现癫痫样发作、昏迷和死亡。一般引起低血糖症状的血浆葡萄糖阈值为2.8---3.9mmol/L，然而，对于反复发作的低血糖病人，这一阈值则会向更低的血糖浓度偏移。

化验检查：血糖水平 ≤ 3.9 mmol/L。

治疗：解除神经供糖不足的症状和纠正导致低血糖症的潜在原因。以预防为主。

如何预防低血糖？

1.制定个体化的血糖控制目标，根据病情合理调整药物

血糖控制目标：

● 空腹血糖：4.4-7.0mmol/L

● 非空腹血糖：10.0mmol/L

● HbA1C：＜7%

● 有严重低血糖史、预期寿命短、有严重并发症者，适当放宽血糖控制目标，如 HbA1C＜8%

2.掌握低血糖相关知识，定期就诊

（1）接受正规的糖尿病教育，掌握低血糖相关知识。

（2）定期看医生，根据病情变化及时调整治疗方案。

（3）常备快速血糖监测仪。

3.保持均衡的饮食和运动，不宜波动太大

（1）定时定量进餐。

（2）限制饮酒，尤其不能空腹饮酒。

（3）规律运动，量力而行。

（4）运动中注意心率，变化及身体感受。

（5）运动时间超过1小时要及时加餐。

4.外出时的预防措施

（1）外出或运动时随身携带含糖食品和救助卡。

（2）外出或运动时随身携带糖果、饼干等，救助卡要放在容易看到的地方。

（3）开车的糖友把含糖食物放在伸手可及的地方。

（4）携带的食品必须含糖，不能是木糖醇等甜味剂食品。

高血糖的症状有哪些？

高血糖是否为糖尿病？答案是否定的，高血糖包括糖尿病前期和糖尿病，所以说高血糖不单单是糖尿病，高血糖实际上是指在没有达到糖尿病诊断的标准，而血糖已经超出了正常的范围，因此，归属于糖尿病前期的诊断。那么高血糖的症状都有哪些呢？高血糖的时候应该都进行什么相关干预才能避免发生糖尿病呢？这是广大糖尿病前期的患者最为关心的问题，今天我就为大家解读一下高血糖的症状有哪些？

第一，会出现"三多一少"的症状：

口渴多饮

尿频量多

多食易饥

身体逐渐的消瘦

另外还会出现一些其他相关的症状：

心悸气短

心慌乏力

双下肢麻凉疼痛

双目视物不清

大便次数改变

小便尿中泡沫增多

女性月经发生紊乱

男性出现阳痿早泄等等

第二，舌苔变厚：

舌头是反映人体病理变化最明确的窗口，通过舌头可以看明身体是否有病理转变，糖尿病的患者舌头表面有时候会像涂了一层蜡一样，并且有看不清原来纤细绒毛结构，这也就是厚腻苔的表现，提示血糖可能已经升高了。

第三，会出现经常的恶心，干呕，身体不适，呕吐不断，腹部偶尔出现胀痛，消化不良的症状，并且会有厌食，食欲大减，体重明显减轻，虚弱无力，做事情上用不上力气等等。

总结，高血糖虽然没达到糖尿病的诊断，但是也应该和糖尿病一样来饮食运动严格的控制，避免发展为糖尿病，一旦发现上述症状马上进行血糖的监测，切勿耽误病情！

高血糖与糖尿病的区别是什么？

在临床上高血糖和糖尿病是有一定区别的，糖尿病的患者一定存在高血糖，而高血糖的患者不一定诊断为糖尿病，两者在临床上是有本质区别的，而具体的区别有以下几点分析。

第一，糖尿病指的是糖尿病的症状伴有血糖值升高，临床上患者出现口渴多饮、尿频量多、多食易饥以及身体逐渐的消瘦并且多次测空腹血糖大于等于 7.0 毫摩尔每升，随机血糖大于等于 11.1 毫摩尔每升或者葡萄糖耐量试验两个小时的血糖大于等于 11.1 毫摩尔每升，就可以诊断为糖尿病。如果患者症状不明显隔日复查血糖仍然超过以上值，同样可以诊断为糖尿病。

第二，高血糖指的是血糖值高于正常的范围，但却没达到糖尿病的诊断标准，有的存在空腹血糖受损，有的存在糖耐量异常，总的来说是糖调节异常的一个情况，也可以称之为糖尿病前期，实际上是介于正常与糖尿病之间的一种状态，往往空腹血糖大于 6.1 毫摩尔每升却小于 7.0 毫摩每升，随机血糖大于 7.8 毫摩尔每升却小雨 11.1 毫摩尔每升。

第三，糖尿病和高血糖治疗的方式也稍有不同，糖尿病患者需要用药物来进行治疗，而高血糖可以先通过饮食和运动的方式来调理，因为很多高血糖的患者是临时的和暂时性的，比如应激状态下导致的高血糖、药物所导致的高血糖、其他多种因素导致的高血糖，这样的高血糖不能和糖尿病同等看待，去除诱因高血糖会完全的康复，而糖尿病是终身性的疾病，需要用药物来终身的维持而避免并发急慢性并发症。

病例31-2023：一名79岁男性，身体不自主运动，一过性反应迟钝

以下内容来源于新英格兰医学杂志。

Presentation of Case

Dr. Carrie Chui (Neurology): A 79-year-old man was admitted to this hospital because of involuntary movements on the left side and transient unresponsiveness.

The patient had been in his usual state of health until 9 months before admission, when involuntary movements of the left shoulder and left side of the face developed. The movements were described by the patient as twitching, were not associated with a change in the level of consciousness, and resolved after 1 to 2 minutes. During the next 6 months, the patient had similar episodes approximately once per month, but the episodes increased in duration, lasting 5 to 6 minutes.

Three months before admission, the episodes of involuntary movements increased in frequency, and the patient was evaluated by his primary care physician. The physical examination was normal. Results of kidney-function tests were normal, as were blood levels of glucose and electrolytes, except for the sodium level, which was 129 mmol per liter (reference range, 135 to 145). There was a history of inappropriate antidiuretic hormone secretion, and the sodium level was similar to levels obtained during the past 4 years. Magnetic resonance imaging (MRI) of the head (Figure 1A), performed before and after the administration of intravenous contrast material, revealed a focus of enhancement in the right middle frontal gyrus that was thought to be a small vascular anomaly. Electroencephalography (EEG), performed with the patient in awake and drowsy states, revealed rare, brief, focal slowing in the left temporal lobe during drowsiness; no epileptiform abnormalities were present.

Figure 1

MRI of the Head and CT Angiogram of the Head and Neck.

Two months before admission, the patient was evaluated in the epilepsy clinic affiliated with this hospital. He reported that the episodes of involuntary movements had increased in both frequency and duration, occurring once or twice per day and lasting approximately 10 minutes. Episodes began with tingling and numbness in the left leg that prompted the patient to voluntarily stomp the left foot to relieve the uncomfortable sensation. Then, the patient had involuntary movements that he described as an uncontrollable invisible force moving the left leg and arm, with hyperextension of the arm backward and pronation of the wrist. There was associated numbness in the distal portions of the left third, fourth, and fifth fingers and involuntary movement of the left cheek. No prodromal symptoms occurred. The patient had awareness during the episodes, and after the episodes, he felt fatigued but had a normal level of consciousness, without confusion. The examination in the epilepsy clinic was normal. A diagnosis of seizure disorder was considered, and treatment with levetiracetam was started.

Three weeks before admission, the patient was again evaluated in the epilepsy clinic. He reported that the episodes of involuntary movements still occurred on a daily basis but had decreased in duration and involved only the left leg, without abnormal movements of the arm or face. Dizziness, headache, and weakness had developed and were attributed to the use of levetiracetam. The patient’s family had recorded a video of one of the episodes of involuntary movements. After reviewing the video, the patient’s neurologist thought that the episodes were less likely to be caused by seizures and more consistent with choreoathetoid movements. Cross-tapering of medications — with the simultaneous administration of levetiracetam in decreasing doses and clobazam in increasing doses — was initiated, and the patient was referred to the movement disorders clinic affiliated with this hospital.

On the morning of admission, an episode of involuntary movements of the left leg and left shoulder occurred and persisted for 1 hour. Several hours after the symptoms abated, the patient’s wife found the patient to be unresponsive; he was sitting in a chair. Emergency medical services were called, and when they arrived, the patient was responsive. The fingerstick blood glucose level was 180 mg per deciliter (10.0 mmol per liter) and the blood pressure 110/80 mm Hg. The patient was transported to the emergency department of this hospital for further evaluation.

In the emergency department, the patient reported dysuria and increased urinary frequency. The patient’s daughter noted that he had been more anxious during the past 3 years and occasionally had trouble with memory. Other medical history included Barrett’s esophagus, benign prostatic hypertrophy, chronic hepatitis B virus infection, eczema, gastroesophageal reflux disease, hypertension, nonischemic cardiomyopathy, and osteoporosis. There was no history of head trauma or extended loss of consciousness. Medications included aspirin, atorvastatin, doxazosin, finasteride, omeprazole, metoprolol, sacubitril, and valsartan. There were no known drug allergies. The patient was a lifelong nonsmoker and drank alcohol rarely; he did not use illicit drugs. His mother had had gastric cancer, and his sister had had esophageal cancer; there was no family history of seizures.

On examination, the temporal temperature was 36.8°C, the blood pressure 152/97 mm Hg, the pulse 65 beats per minute, the respiratory rate 16 breaths per minute, and the oxygen saturation 96% while the patient was breathing ambient air. The body-mass index (the weight in kilograms divided by the square of the height in meters) was 21.7. The blood pressure decreased to 130/63 mm Hg with standing. The patient was alert and interactive. The lower jaw was held to the left, but the nasolabial folds and smile were symmetric with activation. There were nonrhythmic, nonstereotyped, writhing movements of the left arm. Tone was normal, and strength was assessed as 5 out of 5 in the arms and legs. Results of liver-function and kidney-function tests were normal, as were blood levels of glucose and electrolytes, except for the sodium level, which was 125 mmol per liter. The lactate level was 2.1 mmol per liter (19 mg per deciliter; reference range, 0.5 to 2.0 mmol per liter [5 to 18 mg per deciliter]). The urinalysis was normal. Intravenous fluids were administered. Imaging studies were obtained.

Dr. Rajiv Gupta: Computed tomographic (CT) angiography of the head and neck (Figure 1B) revealed extensively calcified plaque with severe stenosis of the distal right common carotid artery (CCA), extending into the proximal right internal carotid artery (ICA), as well as stenosis of the right and left paraclinoid ICAs and the left vertebral artery at its origin. There was no vascular abnormality on the CT angiogram that corresponded to the abnormality in the right middle frontal gyrus seen on the previous MRI.

Dr. Chui: The patient was admitted to the hospital. On the second hospital day, the sodium level had increased to 130 mmol per liter, and the lactate level was normal. Additional imaging studies were obtained.

Dr. Gupta: MRI of the head showed no evidence of acute infarction. The focus of enhancement in the right frontal lobe that had been noted previously was not seen on the current MRI.

Dr. Chui: Blood levels of thyrotropin, cobalamin, and glycated hemoglobin and results of coagulation tests were normal. Screening tests for Lyme disease, tuberculosis, and syphilis were negative, as were tests for antibodies to cardiolipin and β₂-glycoprotein. A test for antinuclear antibodies was positive, at a titer of 1:160 in a homogeneous pattern. During a physical therapy session, the patient had abnormal movements of the left leg, left arm, and left side of the face. The abnormal movements diminished when the patient used distraction techniques, such as thigh tapping, finger snapping, and walking while holding a glass of water.

The transient unresponsiveness that led to the patient’s admission was attributed to a combination of sedation from clobazam and hypovolemia. Treatment with clobazam was stopped, and hydration was encouraged. A diagnosis of functional neurologic disorder was considered; outpatient physical therapy with continued use of distraction techniques was recommended. The patient was discharged home on the third hospital day.

Episodes of involuntary movements continued to occur on a daily basis at home. Two weeks after discharge, when the patient was doing exercises while sitting in a chair and having a conversation with his wife, he suddenly stopped talking. She found him slumped in the chair with his eyes closed, no longer exercising. When she asked him questions, he repeatedly said “yes.” Emergency medical services were called, and when they arrived, the patient was alert, diaphoretic, and nonverbal. He had a facial droop on the left side and a right gaze preference. The fingerstick blood glucose level was 130 mg per deciliter (7.2 mmol per liter) and the blood pressure 120/60 mm Hg. The patient was transported to the emergency department of this hospital for further evaluation.

In the emergency department, the temporal temperature was 36.6°C, the blood pressure 143/63 mm Hg, the pulse 66 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 98% while the patient was breathing ambient air. He was alert and interactive. There was a facial droop on the left side. There was no effort against gravity in the left arm. The patient was able to lift the left leg off the bed for 1 to 2 seconds. He had a right gaze deviation that could not be overcome and mild dysarthria. The remainder of the examination was normal. A diagnosis of stroke was considered, and emergency CT angiography was performed.

Dr. Gupta: CT angiography showed no evidence of acute territorial infarction and no changes in cerebrovascular disease.

Dr. Chui: On repeat physical examination performed after CT angiography, the gaze deviation and dysarthria had resolved, and strength was normal. Mild facial paralysis was present.

A diagnosis was made.

Differential Diagnosis

Dr. Albert Y. Hung: This 79-year-old man initially presented with involuntary movements of the left shoulder and face without associated loss of consciousness. Diagnosis of an unusual movement disorder, especially one that is present episodically, can be challenging. Videos brought in by the patient can be very useful.¹ Most movement disorders result from abnormal functioning of extrapyramidal circuits involving the basal ganglia, rather than a specific neuroanatomical lesion, and the first step toward diagnosis is to identify the type of abnormal movements.²

Four salient aspects of this patient’s involuntary movements can help in characterizing the movement disorder before generating a differential diagnosis. First, the movements were paroxysmal, lasting for short periods of time with resolution between episodes. Second, the movements were nonstereotyped, appearing randomly and variably. Third, the movements were restricted to the left side of his body throughout the course, localizing the disease process to the right cerebral hemisphere. Finally, the symptoms were progressive, increasing in both duration and frequency.

Movement Disorders

This patient had abnormal involuntary movements, symptoms indicative of a hyperkinetic movement disorder. Tremor, the most common hyperkinetic disorder, is unlikely because the patient did not have rhythmic movements. Dystonia is also unlikely, because he did not have sustained muscle contractions that were causing twisting or abnormal postures of the legs, arms, head, neck, or face. Although the patient initially described the movements as twitching, his later descriptions are not suggestive of myoclonus or tics, which manifest as sudden, rapid, recurrent movements.

This patient’s neurologist described the involuntary movements as “choreoathetoid” after reviewing a video of an episode. Chorea, athetosis, and ballism make up a spectrum of involuntary movements that often occur in combination. Chorea refers to involuntary movements that are “dancelike” — irregular, random, unintended, and flowing from one body part to another. When these movements are slow and writhing (with a lower amplitude) and involve the distal limbs, the term athetosis is used. The presence of both chorea and athetosis in the same patient is referred to as choreoathetosis. When the movements are fast and flinging (with a higher amplitude) and involve the proximal limbs, the term ballism is used. Although the description of this patient’s movements was not clearly suggestive of ballism, hemichorea and hemiballismus often occur together.

The term dyskinesia can refer to any abnormal movements and is often used to describe hyperkinetic disorders that are induced by specific drugs, such as tardive dyskinesia induced by dopamine antagonists or dyskinesia induced by levodopa in patients with Parkinson’s disease. Often, dyskinesia manifests as chorea or choreoathetoid movements, but chorea and dyskinesia are not synonymous. This patient appears to have involuntary dyskinesia with choreoathetosis as the primary phenomenology. Before constructing a differential diagnosis for dyskinesia in this patient, I will consider two conditions that mimic dyskinesia: seizures and functional movement disorder.

Seizures

Various movement disorders may be mistaken for seizures, although these movement disorders are not associated with EEG abnormalities during the episode. Patients with some forms of epilepsy may present with abnormal movements without other features that are typically associated with seizures, such as aura, change in responsiveness, incontinence, or a postictal state.^3,4 Seizures were initially suspected in this patient, and he was referred to the epilepsy clinic. Recurrent focal seizures were probably suspected because of the transient nature of the episodes. Initial MRI had shown a small abnormality in the right middle frontal gyrus, but this finding was not seen on follow-up imaging, which makes it unlikely to be related to the overall presentation. Baseline EEG had shown only brief left temporal slowing, without epileptiform abnormalities. The EEG was an interictal study, so the findings do not rule out seizures. However, the slowing was ipsilateral to the abnormal movements, so it is unlikely to be related to the episodes. In addition, the patient’s involuntary movements were nonstereotyped and nonrhythmic, which makes his presentation unlikely to be due to a seizure disorder.

Functional Movement Disorder

Because this patient’s movements diminished with the use of distraction techniques, a diagnosis of functional movement disorder was considered. Most cases of functional movement disorder begin abruptly after a trigger, such as a mild physical injury or illness; a psychological stressor can be present but is not required for diagnosis. Symptoms are typically most severe around the time of onset and may wax and wane over time. Although distractibility is a finding associated with functional disorders, abnormal movements that occur with nonfunctional syndromes can sometimes be suppressed by action or incorporated into voluntary movements in a manner that may appear distractible. Several clinical features in this patient make a diagnosis of functional disorder unlikely. Functional movement disorder is more common in women than in men, and the average age at onset is 40 years.⁵ In addition, tremor is the most common clinical phenotype seen in patients with functional movement disorder; chorea or choreoathetosis, which was seen in this patient, is very unusual in patients with functional movement disorder. Overall, functional movement disorder is unlikely to explain this patient’s presentation.

Dyskinesia

Primary paroxysmal dyskinesia refers to a group of heterogeneous syndromes characterized by recurrent involuntary movements that occur episodically and abruptly, without loss of consciousness.⁶ These disorders usually begin in childhood or young adulthood. Both the age of this patient and the described phenomenology make a diagnosis of primary paroxysmal dyskinesia unlikely.

The differential diagnosis in this case is therefore focused on causes of secondary dyskinesia, of which there are many.⁷ MRI ruled out the presence of a mass lesion suggestive of cancer. The patient had no history of acute illness suggestive of a viral or other infectious encephalitis, and there was no history of trauma or exposure to drugs or other toxins. Although his daughter mentioned trouble with memory, there was no compelling history suggestive of a neurodegenerative disease.

A common metabolic cause of secondary dyskinesia is diabetic striatopathy, a syndrome involving the acute-to-subacute onset of chorea and ballism in the context of hyperglycemia.⁸ This syndrome can occur as the initial manifestation of type 2 diabetes mellitus or as a complication of poorly controlled diabetes. Diabetic striatopathy is more likely to develop in women than in men, and the average age at onset is 70 years. Most patients present with hemichorea and hemiballismus, rather than bilateral symptoms. CT shows hyperdensity, and T1-weighted MRI shows hyperintensity, in the contralateral basal ganglia. However, this patient had no history of diabetes and had a normal blood glycated hemoglobin level, features that rule out a diagnosis of diabetic striatopathy.

Choreiform movements can also be a manifestation of autoimmune conditions.⁹ This patient’s initial presentation with unilateral shoulder and face movements would have suggested the possibility of faciobrachial dystonic seizures associated with anti–leucine-rich, glioma-inactivated 1 (anti-LGI1) encephalitis.¹⁰ This condition is often associated with hyponatremia, which was present in this patient. However, as the case evolved, leg involvement and sensory changes developed that would be atypical for anti-LGI1 encephalitis.

One key clue in this case is that the patient did not have an isolated movement disorder. In addition to motor symptoms, he had a variety of sensory symptoms involving both the left arm and the left leg. His first hospital admission was precipitated by an episode of unresponsiveness. The clinical event that led to his second presentation to the emergency department was distinctly different: an acute onset of speech difficulty accompanied by left hemiparesis and right gaze deviation that was worrisome for an acute right middle cerebral artery (MCA) syndrome. The symptoms resolved without intervention, which indicates that he may have had an acute transient ischemic attack (TIA). The most relevant imaging finding was severe cerebrovascular disease, including severe stenosis of the distal right CCA and proximal right ICA. Could this patient’s movement disorder be explained by a vascular lesion?

Limb-Shaking TIAs

Limb-shaking TIAs were first described by C. Miller Fisher in 1962.¹¹ In most case reports, these episodes are associated with high-grade stenosis of the ICA, which was seen in this patient.^12,13 The mechanism is thought to be cerebral hypoperfusion, and changes in posture or head position that decrease cerebral blood flow can precipitate these episodes. In this patient, the first episode of unresponsiveness that led to hospital admission occurred when he was sitting. He then had an acute episode involving right gaze preference that was provoked by exercise and was very suggestive of a TIA in the right MCA territory. These findings are highly suggestive of a diagnosis of limb-shaking TIAs, and I would refer this patient for emergency carotid endarterectomy.

Clinical Impression and Initial Management

Dr. Scott B. Silverman: When I evaluated this patient, his transient right gaze preference and left hemiparesis were consistent with a right MCA syndrome due to a TIA from symptomatic severe stenosis of the right ICA. The mechanism of this event was either artery-to-artery embolism or hypoperfusion. His previous, recurrent episodes of transient choreoathetosis on the left side that had occurred mainly while he was sitting, standing, or exercising were consistent with limb-shaking TIAs from hypoperfusion or low flow.

The pathogenesis of a low-flow state related to severe carotid stenosis resulting in limb-shaking TIAs is described in a small case series.¹⁴ In six out of eight patients, the transient, stereotyped, involuntary movements were eliminated with carotid artery revascularization. Positional cerebral ischemia in patients without orthostatic hypotension has been described.¹⁵

Treatment with atorvastatin was continued, the dose of aspirin was increased to 325 mg per day, and an intravenous heparin infusion was started. The strategy of permissive hypertension was used, with high blood pressure allowed to a maximum systolic blood pressure of 180 mm Hg. The patient was admitted to the stroke service, and carotid artery duplex ultrasonography was performed.

Dr. Gupta: Doppler ultrasonography of the carotid arteries (Figure 2) revealed markedly elevated Doppler flow velocities within the proximal right ICA. There was a parvus et tardus waveform in the distal right ICA, a finding indicative of low flow related to the more proximal high-grade stenosis. The Doppler waveform contours had poststenotic turbulence.

Figure 2

Doppler Ultrasound Image.

Dr. Silverman: The vascular surgery service was consulted, and the patient underwent right carotid endarterectomy.

Clinical Diagnosis

Limb-shaking transient ischemic attacks.

Dr. Albert Y. Hung’s Diagnosis

Limb-shaking transient ischemic attacks due to severe carotid stenosis, with secondary paroxysmal dyskinesia.

Pathological Discussion

Dr. Caroline F. Hilburn: The endarterectomy specimen included the carotid bifurcation and was notable for firm arterial walls, a finding consistent with calcification. On gross examination (Figure 3A), a large plaque was centered at the carotid bifurcation and protruded into the lumen, resulting in a maximal luminal stenosis of 80%. The plaque had an irregular and focally friable surface. On microscopic examination (Figure 3B), the plaque was characterized by extensive calcification. Some regions of the plaque had a smooth, healed fibrous cap, whereas other regions had an irregular surface suggestive of ulceration, which indicated potential sites of plaque rupture. Multiple smaller calcified plaques were present, affecting both branches of the artery.

Figure 3

Endarterectomy Specimen.

Pathological Diagnosis

Complex atherosclerotic plaque with portions of attached media.

Additional Management

Dr. Silverman: After the procedure, the patient had an uneventful recovery and was discharged home on the fifth hospital day. He was seen 1 month after discharge in the stroke prevention clinic. There had been no further episodes of involuntary movements or choreoathetosis and no stroke or TIA. The patient continues to take aspirin, atorvastatin, and antihypertensive medications.

Final Diagnosis

Limb-shaking transient ischemic attacks.

病例28-2024：一名75岁女性，患有水肿、关节炎和蛋白尿

以下内容来源于新英格兰医学杂志。

Presentation of Case

Dr. Christine M. Parsons (Medicine): A 75-year-old woman was evaluated at this hospital because of arthritis, abdominal pain, edema, malaise, and fever.

Three weeks before the current admission, the patient noticed waxing and waning “throbbing” pain in the right upper abdomen, which she rated at 9 (on a scale of 0 to 10, with 10 indicating the most severe pain) at its maximal intensity. The pain was associated with nausea and fever with a temperature of up to 39.0°C. Pain worsened after food consumption and was relieved with acetaminophen. During the 3 weeks before the current admission, edema developed in both legs; it had started at the ankles and gradually progressed upward to the hips. When the edema began to affect her ambulation, she presented to the emergency department of this hospital.

A review of systems that was obtained from the patient and her family was notable for intermittent fever, abdominal bloating, anorexia, and fatigue that had progressed during the previous 3 weeks. The patient reported new orthopnea and nonproductive cough. Approximately 4 weeks earlier, she had had diarrhea for several days. During the 6 weeks before the current admission, the patient had lost 9 kg unintentionally; she also had had pain in the wrists and hands, 3 days of burning and dryness of the eyes, and diffuse myalgias. She had not had night sweats, dry mouth, jaw claudication, vision changes, urinary symptoms, or oral, nasal, or genital ulcers.

The patient’s medical history was notable for multiple myeloma (for which treatment with thalidomide and melphalan had been initiated 2 years earlier and was stopped approximately 1 year before the current admission); hypothyroidism; chikungunya virus infection (diagnosed 7 years earlier); seropositive erosive rheumatoid arthritis affecting the hands, wrists, elbows, and shoulders (diagnosed 3 years earlier); vitiligo; and osteoarthritis of the right hip, for which she had undergone arthroplasty. Evidence of gastritis was reportedly seen on endoscopy that had been performed 6 months earlier. Medications included daily treatment with levothyroxine and acetaminophen and pipazethate hydrochloride as needed for cough. The patient consumed chamomile and horsetail herbal teas. She had no known allergies to medications, but she had been advised not to take nonsteroidal antiinflammatory drugs after her diagnosis of multiple myeloma.

Approximately 5 months before the current admission, the patient had emigrated from Central America. She lived with her daughter and grandchildren in an urban area of New England. She had previously worked in health care. She had no history of alcohol, tobacco, or other substance use. There was no family history of cancer or autoimmune, renal, gastrointestinal, pulmonary, or cardiac disease.

On examination, the temporal temperature was 37.1°C, the heart rate 106 beats per minute, the blood pressure 152/67 mm Hg, and the oxygen saturation 100% while the patient was breathing ambient air. She had a frail appearance and bitemporal cachexia. The weight was 41 kg and the body-mass index (the weight in kilograms divided by the square of the height in meters) 15.2. Her dentition was poor; most of the teeth were missing, caries were present in the remaining teeth, and the mucous membranes were dry. She had abdominal tenderness on the right side and mild abdominal distention, without organomegaly or guarding. Bilateral axillary lymphadenopathy was palpable. Infrequent inspiratory wheezing was noted.

The patient had swan-neck deformity, boutonnière deformity, ulnar deviation, and distal hyperextensibility of the thumbs (Fig. 1). Subcutaneous nodules were observed on the proximal interphalangeal joints of the second and third fingers of the right hand and on the proximal interphalangeal joint of the fourth finger of the left hand. Synovial thickening of the metacarpophalangeal joints of the second fingers was noted. There was mild swelling and tenderness of the wrists. She had pain with flexion of the shoulders and right hip, and there was subtle swelling of the shoulders and right knee. Pitting edema (3+) and vitiligo were noted on the legs. No sclerodactyly, digital pitting, telangiectasias, appreciable calcinosis, nodules, nail changes (including pitting), or tophi were present. The remainder of the examination was normal.

Figure 1

Photograph of the Hands.

The blood levels of glucose, alanine aminotransferase, aspartate aminotransferase, bilirubin, globulin, lactate, lipase, magnesium, and phosphorus were normal, as were the prothrombin time and international normalized ratio; other laboratory test results are shown in Table 1. Urinalysis showed 3+ protein and 3+ blood, and microscopic examination of the sediment revealed 5 to 10 red cells per high-power field and granular casts. Urine and blood were obtained for culture. An electrocardiogram met (at a borderline level) the voltage criteria for left ventricular hypertrophy.

Table 1

Laboratory Data.

Dr. Rene Balza Romero: Computed tomography (CT) of the chest, abdomen, and pelvis, performed after the intravenous administration of contrast material, revealed scattered subcentimeter pulmonary nodules (including clusters in the right middle lobe and patchy and ground-glass opacities in the left upper lobe), trace pleural effusion in the left lung, coronary and valvular calcifications, and trace pericardial effusion, ascites, and anasarca. The scans also showed slight enlargement of the axillary lymph nodes (up to 11 mm in the short axis) bilaterally and a chronic-appearing compression fracture involving the T12 vertebral body.

Dr. Parsons: Morphine and lactated Ringer’s solution were administered intravenously. On the second day in the emergency department (also referred to as hospital day 2), the blood levels of haptoglobin, folate, and vitamin B₁₂ were normal; other laboratory test results are shown in Table 1. A rapid antigen test for malaria was positive. Wright–Giemsa staining of thick and thin peripheral-blood smears was negative for parasites; the smears also showed Döhle bodies and basophilic stippling. Antigliadin antibodies and anti–tissue transglutaminase antibodies were not detected. Tests for hepatitis A IgG and hepatitis C antibodies were positive. Tests for hepatitis B core and surface antibodies were negative. A test for human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) was negative.

Findings on abdominal ultrasound imaging performed on the second day (Fig. 2A and 2B) were notable for a small volume of ascites and kidneys with echogenic parenchyma. Ultrasonography of the legs showed no deep venous thrombosis. An echocardiogram showed normal ventricular size and function, aortic sclerosis with mild aortic insufficiency, moderate tricuspid regurgitation, a right ventricular systolic pressure of 39 mm Hg, and a small circumferential pericardial effusion. Intravenous hydromorphone was administered, and the patient was admitted to the hospital.

Figure 2

Imaging Studies of the Abdomen and Hands.

On the third day (also referred to as hospital day 3), nucleic acid testing for cytomegalovirus, Epstein–Barr virus, and hepatitis C virus was negative, and a stool antigen test for Helicobacter pylori was negative. An interferon-γ release assay for Mycobacterium tuberculosis was also negative. Oral acetaminophen and ivermectin and intravenous hydromorphone and furosemide were administered.

Dr. Balza Romero: Radiographs of the hands (Fig. 2C through 2F) showed joint-space narrowing of both radiocarpal joints and proximal interphalangeal erosions involving both hands. Radiographs of the shoulders showed arthritis of the glenohumeral joint and alignment suggestive of a tear of the right rotator cuff. A radiograph of the pelvis showed diffuse joint-space narrowing of the left hip, without osteophytosis, and an intact right hip prosthesis.

Dr. Parsons: Diagnostic tests were performed, and management decisions were made.

Differential Diagnosis

Dr. Beth L. Jonas: This patient is a 75-year-old woman who recently emigrated from Central America. She presented to this hospital with a multisystem disease involving the respiratory, gastrointestinal, renal, and musculoskeletal systems. Her medical history is notable for seropositive erosive rheumatoid arthritis and multiple myeloma, which had been treated with melphalan and thalidomide. Relevant clinical features on presentation include unintended weight loss and cachexia, axillary lymphadenopathy, serositis, cytopenia in two cell lines, hypocomplementemia, and elevated serum free kappa and lambda light-chain levels (with a normal free light-chain ratio) with no monoclonal spike. The white-cell count was elevated, but she had no eosinophilia. CT images of the chest showed scattered subcentimeter pulmonary nodules. With respect to the patient’s anemia, no schistocytes were present, the haptoglobin level was normal, and the iron studies were unremarkable. These findings, in combination with the elevated ferritin level, indicate anemia of chronic inflammation. The renal findings are most salient in the context of the patient’s hypertension, anasarca, elevated cystatin C level, active urinary sediment with proteinuria in the nephrotic range, and small, echogenic kidneys on ultrasonography.

In constructing a differential diagnosis, I will consider medication use, cancer, infectious disease, and autoimmune disease. Medications can be eliminated as the cause of this patient’s illness, since she was taking only levothyroxine, acetaminophen, and the antitussive agent pipazethate.

Cancer

The patient has a history of multiple myeloma, which may manifest with a multisystem disease involving the kidneys, but serum protein electrophoresis showed no monoclonal protein. Given the presence of nephrotic syndrome in the context of multiple myeloma, systemic immunoglobulin light-chain amyloidosis would be highest on the differential diagnosis with respect to cancer; however, the patient’s normal light-chain ratio makes this diagnosis unlikely. The development of myeloid neoplasms, such as acute myeloid leukemia, myelodysplastic syndromes, and myeloproliferative neoplasms, is important to consider in the context of previous treatment with alkylating agents,¹ which this patient had received. However, the peripheral-blood smear showed no findings that would indicate a hematologic cancer, and such a diagnosis would not explain the patient’s acute kidney injury with nephrotic-range proteinuria.

Infectious Disease

Several features of this patient’s case warrant special consideration, including her history of immunosuppression due to rheumatoid arthritis and to previously treated myeloma, along with the fact that she had emigrated from Central America, where certain infections may be prevalent. Infection with hepatitis A virus, hepatitis B virus, hepatitis C virus, HIV-1 and HIV-2, cytomegalovirus, Epstein–Barr virus, H. pylori, and M. tuberculosis can be ruled out on the basis of laboratory studies. A rapid antigen test for plasmodium species was reported to be positive, but this assay has a known cross-reactivity with rheumatoid factor.² Moreover, the thick and thin peripheral-blood smears were negative. Thus, malaria would be an unlikely diagnosis.

The patient has a history of infection with chikungunya virus, an arbovirus transmitted by a mosquito vector that has been responsible for large epidemics in the Americas since 2013.³ Acute symptoms include fever, rash, arthralgia, and myalgia. The development of a chronic arthritis that may meet the classification criteria for rheumatoid arthritis, as defined by the American College of Rheumatology and the European Alliance of Associations for Rheumatology, has been reported in up to 60% of patients infected with chikungunya virus.^4,5 In the context of this discussion, I considered whether chikungunya virus infection could be the cause of this patient’s symptoms, since this infection occurred before the diagnosis of rheumatoid arthritis. However, the degree of erosion and loss of joint space that was visible on radiographs would be most unusual for arthritis associated with chikungunya virus infection and would not explain the renal manifestations.

Strongyloidiasis is a helminth infection (caused by Strongyloides stercoralis) that is widespread in developing countries. Infection usually occurs through contact with soil, and most affected persons are asymptomatic. However, in immunosuppressed persons, strongyloides hyperinfection syndrome or a disseminated infection can develop as a consequence of accelerated autoinfection.⁶ The clinical presentation of strongyloides hyperinfection syndrome can include gastrointestinal symptoms (diarrhea, constipation, nausea, or vomiting), respiratory symptoms (cough, dyspnea, or wheezing), and rash due to migration of larvae through the subcutaneous tissues. Of note, only a minority of patients present with eosinophilia. Several case reports describe the development of nephrotic-range proteinuria, thrombotic microangiopathy, and IgA vasculitis in patients with strongyloides hyperinfection syndrome.^7-9 However, strongyloidiasis would not explain this patient’s cytopenias and hypocomplementemia.

Autoimmune Disease

The patient has a 3-year history of rheumatoid arthritis, although her clinical features of swan-neck deformity, boutonnière deformity, and joint instability suggest a longer duration of disease. We do not know whether she had received previous treatment with disease-modifying antirheumatic drugs or biologic agents, but the possible use of such treatments may be a consideration with respect to her progression of disease and overall degree of immunosuppression. The blood levels of rheumatoid factor and anti–cyclic citrullinated peptide antibodies were elevated, and radiographs of the hands showed erosive disease, although there was a relative paucity of metacarpophalangeal findings. A review of systems was negative for dry mouth, but her physical examination showed poor dentition and dry mouth — findings that make secondary Sjögren’s syndrome a consideration.

Renal disease can occur in patients with Sjögren’s syndrome. The two most typical presentations are tubulointerstitial nephritis and, less commonly, nephritic syndrome (membranoproliferative glomerulonephritis related to cryoglobulinemia). Tubulointerstitial nephritis may manifest with renal disease of varying severity, usually with a bland urinary sediment and often with abnormalities of tubular function such as distal renal tubular acidosis. Membranoproliferative glomerulonephritis caused by cryoglobulinemia is the most common glomerular disease associated with Sjögren’s syndrome. Although nephrotic-range proteinuria can occur with Sjögren’s syndrome, it is relatively uncommon.¹⁰ Renal disease is uncommon in patients with rheumatoid arthritis and is usually related to coexisting cardiovascular conditions. Medications used in the treatment of autoimmune disease — mainly nonsteroidal antiinflammatory drugs — may be associated with renal disease, but I would not expect the presence of an active urinary sediment, as was seen in this patient.

Amyloid A (AA) amyloidosis, a condition that is rare in the era of aggressive management of rheumatoid arthritis, has been described in patients with severe, long-standing seropositive erosive rheumatoid arthritis. Serum amyloid A (SAA) is a protein that is produced in the liver in response to chronic inflammation associated with interleukin-1, interleukin-6, and tumor necrosis factor α (TNF-α) in the context of chronic infections, autoimmune disease (classically rheumatoid arthritis), autoinflammatory disease, and cancers including renal cell carcinoma and non-Hodgkin’s lymphoma.¹¹ Signs and symptoms of AA amyloidosis are related to the deposition of the protein in organs, and patients often present with multisystem signs and symptoms. The kidney is the organ that is most often affected, but deposition can occur in the heart, gastrointestinal tract, nervous system, musculoskeletal system, and lungs. Proteinuria is the first clinical manifestation in almost 95% of patients with AA amyloidosis, and 50% of affected patients present with nephrotic syndrome.¹² The urinary sediment is generally bland, and complement levels in the blood are normal. AA amyloidosis remains on the differential diagnosis in this patient, but it would not completely explain her renal disease.

Hypocomplementemia

The key to this case is understanding the cause of this patient’s hypocomplementemia. Hypocomplementemia can be due to decreased complement production in the context of liver disease, congenital complement deficiency, or increased complement consumption resulting from activation of the innate immune system. This patient has no history of chronic liver disease and her laboratory test results indicated good hepatic synthetic function. Classical complement deficiency (including C4 deficiency) that begins early in life is associated with autoimmune disease, and early C3 deficiency is characterized by severe pyogenic infections. It would be unusual for a patient of this age to be deficient in both C3 and C4 without earlier clinical consequences. I therefore concluded that the hypocomplementemia in this case was related to complement consumption.

Rheumatic diseases that may be associated with prominent renal manifestations include antineutrophil cytoplasmic antibody–associated vasculitis, systemic sclerosis with renal crisis, cryoglobulinemic vasculitis, antiglomerular basement membrane disease, and systemic lupus erythematosus (SLE). Of those conditions, SLE would be the most likely to be manifested by an active urinary sediment and nephrotic-range proteinuria with consumption of both C3 and C4 in the context of fever, thrombocytopenia, and serositis. This patient’s fever, thrombocytopenia, and serositis also fit with this diagnosis.¹³

Because the patient has long-standing seropositive erosive rheumatoid arthritis, a diagnosis of AA amyloidosis is strongly suspected. Moreover, given the presence of thrombocytopenia, hypocomplementemia, and an active urinary sediment, I would recommend a kidney biopsy to evaluate for lupus nephritis and AA amyloidosis.

Dr. Beth L. Jonas’s Diagnosis

Overlap syndrome of rheumatoid arthritis and systemic lupus erythematosus with amyloid A amyloidosis.

Pathological Discussion

Dr. Claire Trivin-Avillach: Testing for autoimmune antibodies was performed. A test for antinuclear antibodies was positive at a titer of 1:5120 with a homogeneous pattern, and a test for anti–double-stranded DNA antibodies was positive at a titer of 1:2560.

The diagnostic procedure in this case was a core-needle biopsy of the kidney. Examination of the specimen with light microscopy revealed 20 glomeruli, 45% of which were globally sclerosed, along with fibrosis involving approximately 60% of the interstitium and tubular atrophy. Diffusely enlarged glomeruli with thickened capillary walls and an expanded mesangium were weakly positive on periodic acid–Schiff staining; the glomeruli stained pale blue on Masson’s trichrome staining. Congo red staining revealed metachromatic salmon-colored deposition involving the glomeruli, the blood-vessel walls, and the interstitium, which was associated with apple-green birefringence when viewed under polarized light (Fig. 3A). In addition, mesangial and endocapillary hypercellularity was identified in approximately 30% of the nonsclerosed glomeruli and was associated with karyorrhexis (Fig. 3B). One cellular crescent was also detected. These features are characteristic of active proliferative glomerulonephritis.

Figure 3

Biopsy Specimen of the Kidney.

Immunofluorescence microscopy revealed prominent granular staining for IgG (4+), IgM (4+), C3 (3+), C1q (3+), IgA (1+), kappa (3+), and lambda (3+) along the glomerular basement membranes and within the mesangium, as well as focal granular deposits of IgG and C3 along the tubular basement membrane (Fig. 3C and 3D). Additional immunofluorescence studies showed strong positivity (4+) for SAA within the glomeruli, the blood-vessel walls, and the interstitium (Fig. 3E), whereas staining for beta₂-microglobulin, transthyretin, and apolipoprotein A1 was faint.

Electron microscopy revealed the presence of subendothelial and mesangial electron-dense deposits (with no substructure identified) adjacent to randomly arranged fibrils (measuring 8.2 to 10.6 nm in diameter) within the glomerular basement membranes and the mesangium (Fig. 3F). Glomerular endothelial cells appeared reactive and contained tubuloreticular inclusions, features that were suggestive of interferon-mediated activation.

The findings on Congo red staining were characteristic of amyloidosis with typical birefringent material. The strong positivity of SAA within the deposits as compared with the faint staining of other reactants identified the type of amyloid as SAA, which is consistent with the patient’s history of rheumatoid arthritis. The biopsy also showed an immune complex–mediated proliferative glomerulonephritis with a “full house” pattern (defined as positivity for the three immunoglobulin classes IgG, IgM, and IgA and the two complement components C3 and C1q, in reference to the “full house” hand in a poker game). Immune complex–mediated proliferative glomerulonephritis has been reported in patients with rheumatoid arthritis who were receiving anti–TNF-α therapy,¹⁴ which was not the case in this patient. The positive test for hepatitis C antibodies prompted consideration of hepatitis C–related membranoproliferative glomerulonephritis. However, taken together, the negative nucleic acid test for hepatitis C virus, the full house pattern on immunofluorescence, the tubular basement membrane deposits, and the positive test for anti–double-stranded DNA antibodies favor a diagnosis of lupus nephritis of at least class III (defined as focal proliferative glomerulonephritis), according to the criteria of the International Society of Nephrology and the Renal Pathology Society, superimposed on AA amyloidosis.

Pathological Diagnosis

Proliferative lupus nephritis of International Society of Nephrology and Renal Pathology Society class III, superimposed on amyloid A amyloidosis.

Discussion of Management

Dr. Pui W. Cheung: On the basis of the finding of echogenic kidneys on ultrasonography and the findings of extensive interstitial fibrosis and tubular atrophy on kidney biopsy, we know that this patient has advanced chronic kidney disease that is unlikely to be reversible. The patient is also noted to have a markedly lower glomerular filtration rate (GFR) than that predicted by the blood creatinine level owing to the presence of cachexia, and this is substantiated by the cystatin C–based GFR and a 24-hour creatinine clearance of 22 ml per minute per 1.73 m² of body-surface area. The typical induction therapy for stage III or IV lupus nephritis consists of high-dose glucocorticoids and either mycophenolate mofetil or cyclophosphamide. Other reasonable alternatives for initial therapy include mycophenolate mofetil in combination with either a calcineurin inhibitor or belimumab, or cyclophosphamide in combination with belimumab.¹⁵ Hydroxychloroquine is also recommended as part of the therapy, since it has shown benefits in improving the response to treatment and reducing disease flare.¹⁶ Mycophenolate mofetil and cyclophosphamide have similar efficacy with respect to clinical response, which includes a reduction in proteinuria and either an improvement in renal function or stabilization of renal function; the risks of infections and adverse events associated with these medications are also similar.^17,18

Given the severity of the lupus nephritis with overlying AA amyloidosis from active rheumatoid arthritis, the treatment options proposed were high-dose glucocorticoids and rituximab with either mycophenolate mofetil or cyclophosphamide.¹⁹ After discussions with multidisciplinary consultants from rheumatology, infectious diseases, and nephrology, lingering concerns were raised about infection and patient frailty; ultimately, the decision was made to initiate high-dose glucocorticoid therapy in combination with mycophenolate mofetil, rituximab, and hydroxychloroquine.

The patient’s mycophenolate mofetil dose regimen was inconsistent owing to gastrointestinal side effects, and the treatment was eventually withheld because of pancytopenia and fever. Unfortunately, her kidney function worsened, and renal replacement therapy was initiated within 3 weeks after the start of the induction therapy. The cause of her renal failure was thought to be disease progression, compounded by hemodynamically mediated tubular injury in the context of infection. While the administration of mycophenolate mofetil was stopped, treatment with rituximab was continued, with slow tapering of the glucocorticoid dose at the direction of the rheumatologist. She remained dependent on dialysis and was deemed to have end-stage kidney disease after 3 months of dialysis.

Dr. Lisa G. Criscione-Schreiber: The patient has SLE with nephritis, seropositive erosive rheumatoid arthritis, and systemic AA amyloidosis. AA amyloidosis is rare owing to the availability of effective therapies for rheumatoid arthritis and is managed through aggressive treatment of inflammation due to rheumatoid arthritis. Reports addressing the management of rheumatoid arthritis–induced AA amyloidosis generally cite stability of end-organ damage caused by AA amyloid as evidence of effective management of the condition (through treatment of the inflammation of rheumatoid arthritis). Methotrexate, the cornerstone of treatment for rheumatoid arthritis, is contraindicated in this case owing to the presence of kidney disease. The alkylating agent cyclophosphamide has been reported to be effective for the treatment of AA amyloidosis from rheumatoid arthritis²⁰ and has known efficacy in patients with lupus nephritis, both of which make it a viable treatment option. Rituximab has also been reported to be effective for managing rheumatoid arthritis–induced AA amyloidosis,²¹ is approved for the treatment of rheumatoid arthritis, and is used for manifestations of SLE, including thrombocytopenia and nephritis. Although anti–TNF-α agents, abatacept, and Janus kinase inhibitors are reported to be effective for the treatment of AA amyloidosis in patients with rheumatoid arthritis,²² recent publications have coalesced on the ability of anti–interleukin-6 therapy to block interleukin-6–induced hepatic production of SAA.^23-25

The overlap of seropositive erosive rheumatoid arthritis and SLE (sometimes termed “rhupus”) usually resembles rheumatoid arthritis more than SLE; manifestations include thrombocytosis, leukocytosis, an elevated erythrocyte sedimentation rate, an elevated blood level of C-reactive protein, and the presence of marginal erosions on radiographs.²⁶ In contrast, SLE without seropositive erosive rheumatoid arthritis characteristically manifests with thrombocytopenia, leukopenia, and an elevated erythrocyte sedimentation rate but usually not an elevated C-reactive protein level; in addition, nonerosive inflammatory arthritis with reversible deformities is commonly observed. This patient had a mixed laboratory profile, on the basis of the results of antinuclear antibody and anti–double-stranded DNA antibody tests. The challenge of treating an overlap syndrome of rheumatoid arthritis and SLE is choosing disease-modifying antirheumatic drugs that are effective and safe in both conditions. This patient’s most severe disease manifestation is lupus nephritis; therefore, the treatment regimen must target nephritis along with the AA amyloidosis and inflammatory arthritis.

As noted earlier, current induction therapy for lupus nephritis includes either mycophenolate mofetil or cyclophosphamide. Mycophenolate mofetil may provide inadequate treatment of the rheumatoid arthritis and amyloidosis, whereas cyclophosphamide would treat the lupus nephritis, has possible efficacy for treatment of the AA amyloidosis, and would treat the rheumatoid arthritis. Rituximab could be added to cyclophosphamide or mycophenolate mofetil to treat the rheumatoid arthritis and resultant AA amyloidosis and could also possibly help treat the lupus nephritis. The addition of anti–interleukin-6 therapy to mycophenolate mofetil or cyclophosphamide is an intriguing option that may effectively treat the rheumatoid arthritis and subsequent AA amyloidosis. The addition of belimumab to mycophenolate mofetil or cyclophosphamide has been reported to improve renal response in patients with lupus nephritis,²⁷ as has the addition of voclosporin to mycophenolate mofetil.²⁸ However, belimumab is ineffective for the treatment of rheumatoid arthritis, and voclosporin has not been studied in patients with rheumatoid arthritis or in those with a GFR of 45 milliliters per minute or less. The high-dose glucocorticoids that are used in induction therapy for lupus nephritis will effectively manage this patient’s inflammatory arthritis and probably also the subsequent AA amyloidosis. Finally, it is important that every patient with lupus nephritis receive hydroxychloroquine, which improves the treatment response to induction therapy.²⁹

Follow-up

Dr. Parsons: The patient’s hospital course was further complicated by suspected immune-mediated thrombocytopenia, for which she received intravenous immune globulin. Her pancytopenia and arthritis ultimately abated. Unfortunately, she did not have renal recovery and continues to receive hemodialysis. After a prolonged hospital course, she was discharged home.

Final Diagnosis

Overlap syndrome of rheumatoid arthritis and systemic lupus erythematosus complicated by proliferative lupus nephritis, superimposed on amyloid A amyloidosis.

戈沙妥珠单抗（SG）用于HR+/HER2−转移性乳腺癌：3期试验EVER-132-002结果

以下内容来源于PubMed。

Abstract

Sacituzumab govitecan (SG) significantly improved progression-free survival (PFS) and overall survival (OS) versus chemotherapy in hormone receptor-positive human epidermal growth factor receptor 2-negative (HR⁺HER2^-) metastatic breast cancer (mBC) in the global TROPiCS-02 study. TROPiCS-02 enrolled few Asian patients. Here we report results of SG in Asian patients with HR⁺HER2^- mBC from the EVER-132-002 study. Patients were randomized to SG (n = 166) or chemotherapy (n = 165). The primary endpoint was met: PFS was improved with SG versus chemotherapy (hazard ratio of 0.67, 95% confidence interval 0.52-0.87; P = 0.0028; median 4.3 versus 4.2 months). OS also improved with SG versus chemotherapy (hazard ratio of 0.64, 95% confidence interval 0.47-0.88; P = 0.0061; median 21.0 versus 15.3 months). The most common grade ≥3 treatment-emergent adverse events were neutropenia, leukopenia and anemia. SG demonstrated significant and clinically meaningful improvement in PFS and OS versus chemotherapy, with a manageable safety profile consistent with prior studies. SG represents a promising treatment option for Asian patients with HR⁺HER2^- mBC (ClinicalTrials.gov identifier no. NCT04639986 ).

压力导致亚精胺增多并抑制树突状细胞中1型干扰素（IFN-α）诱发腹泻型肠易激综合征

以下内容来源于PubMed。

Abstract

Irritable bowel syndrome with diarrhea (IBS-D) is a common and chronic gastrointestinal disorder that is characterized by abdominal discomfort and occasional diarrhea. The pathogenesis of IBS-D is thought to be related to a combination of factors, including psychological stress, abnormal muscle contractions, and inflammation and disorder of the gut microbiome. However, there is still a lack of comprehensive analysis of the logical regulatory correlation among these factors. In this study, we found that stress induced hyperproduction of xanthine and altered the abundance and metabolic characteristics of Lactobacillus murinus in the gut. Lactobacillus murinus-derived spermidine suppressed the basal expression of type I interferon (IFN)-α in plasmacytoid dendritic cells by inhibiting the K63-linked polyubiquitination of TRAF3. The reduction in IFN-α unrestricted the contractile function of colonic smooth muscle cells, resulting in an increase in bowel movement. Our findings provided a theoretical basis for the pathological mechanism of, and new drug targets for, stress-exposed IBS-D.

Keywords: AdorA2B; Lactobacillus murinus; irritable bowel syndrome with diarrhea; spermidine; stress; type I interferon; xanthine.

婴儿重症细支气管炎的鼻咽部宏基因组与哮喘遗传风险亚型联合分析及其与儿童哮喘风险的相关性

以下内容来源于PubMed。

Abstract

The severe bronchiolitis endotype characterized by a high abundance of H. influenzae, high proportion of RV-A and RV-C infections, and high asthma genetic risk had a significantly higher risk for developing asthma.

Background: Infants with bronchiolitis are at increased risk for developing asthma. Growing evidence suggests bronchiolitis is a heterogeneous condition. However, little is known about its biologically distinct subgroups based on the integrated metagenome and asthma genetic risk signature and their longitudinal relationships with asthma development.

Methods: In a multi-center prospective cohort study of infants with severe bronchiolitis (i.e., bronchiolitis requiring hospitalization), we profiled nasopharyngeal airway metagenome and virus at hospitalization, and calculated the polygenic risk score of asthma. Using similarity network fusion clustering approach, we identified integrated metagenome-asthma genetic risk endotypes. We also examined their longitudinal association with the risk of developing asthma by age six years.

Results: Of 450 infants with bronchiolitis (median age, 3 months), we identified five distinct endotypes-characterized by their nasopharyngeal metagenome, virus, and asthma genetic risk profiles. Compared with endotype A infants (who clinically resembled "classic" bronchiolitis), endotype E infants (characterized by a high abundance of H. influenzae, high proportion of RV-A and RV-C infections, and high asthma genetic risk) had a significantly higher risk for developing asthma (35.9% versus 16.7%; OR_adj, 2.24; 95%CI, 1.02-4.97; p=0.046). The pathway analysis showed that endotype E had enriched microbial pathways (e.g., glycolysis, L-lysine, arginine metabolism) and host pathways (e.g., IFNs, IL-6/JAK/STAT3, fatty acids, MHC, and immunoglobin-related) (FDR<0.05). Additionally, endotype E had a significantly higher proportion of neutrophils (FDR<0.05).

Conclusion: In this multi-center prospective cohort study of infant bronchiolitis, the clustering analysis of integrated-omics data identified biologically distinct endotypes with differential risks for developing asthma.

术前CT肿瘤轮廓不规则性预测肾细胞癌预后

以下内容来源于PubMed。

Summary

Background

Radiology-based prognostic biomarkers play a crucial role in patient counseling, enhancing surveillance, and designing clinical trials effectively. This study aims to assess the predictive significance of preoperative CT-based tumor contour irregularity in determining clinical outcomes among patients with renal cell carcinoma (RCC).

Methods

We conducted a retrospective multi-institutional review involving 2218 patients pathologically diagnosed with RCC. The training and internal validation sets included patients at Zhongshan Hospital between January 2009 and August 2019. The external test set comprised patients from the First Affiliated Hospital, Zhejiang University School of Medicine (January 2016 to January 2018), the Xiamen Branch of Zhongshan Hospital (November 2017 to June 2023), and the Cancer Imaging Archive. The contour irregularity degree (CID), quantified as the ratio of irregular cross-sections to the total tumor cross-sections, was analyzed for its prognostic relevance across different subgroups of RCC patients. A novel CID-based scoring system was developed, and its predictive efficacy was evaluated and compared with existing prognostic models.

Findings

The CID exhibited significant discriminatory power in predicting overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS) among patients with RCC tumors measuring 3 cm or larger (all p < 0.001). Multivariate analyses confirmed the CID as an independent prognostic indicator. Notably, the CID augmented prognostic stratification among RCC patients within distinct risk subgroups delineated by SSIGN models and ISUP grades. The CID-based nomogram (C-Model) demonstrated robust predictive performance, with C-index values of 0.88 (95%CI: 0.84–0.92) in the training set, 0.92 (95%CI: 0.88–0.98) in the internal validation set, and 0.86 (95%CI: 0.81–0.90) in the external test set, surpassing existing prognostic models.

Interpretation

Routine imaging-based assessment of the CID serves as an independent prognostic factor, offering incremental prognostic value to existing models in RCC patients with tumors measuring 3 cm or larger.

Funding

This study was funded by grants from National Natural Science Foundation of China; Shanghai Municipal Health Commission; China National Key R&D Program and Science and Technology Commission of Shanghai Municipality.