目的:短肠综合征是一种吸收障碍,通常由部分肠道的物理损失引起,身体无法充分吸收营养,流体,和电解质。许多短肠综合征患者依赖于通过隧道或外周插入中心导管的家庭肠胃外营养,以确保足够的水合和营养。中心静脉导管是细菌的巢穴,和患者有感染的风险与高水平的发病率和死亡率。乳杆菌是一种普遍存在的微生物,其最经常定植于粘膜表面如胃肠道。乳酸杆菌菌血症是罕见的,在当前医学文献中的发生率有限。
方法:我们的患者是一名60岁的女性,有多次腹部手术导致短肠综合征的既往病史,随后依赖通过外周插入中心导管进行家庭肠外营养。她患有III型慢性肠衰竭,D2类和1期中度营养不良。她最初因推测为肺栓塞而入院,并在外周插入的中央导管的设置中发现深静脉血栓形成。入院时她的腹部检查平淡无奇,她否认腹痛,她唯一的胃肠道主诉是慢性稳定型腹泻.在住院期间,她出现了严重的左下腹疼痛,并注意到她的排便频率降低。她腹部的计算机断层扫描显示慢性稳定的肠扩张,并考虑阻塞。临床上,她没有急性梗阻或肠梗阻的症状。在入院期间,她变得发热,从她的外周插入中心导管和外周静脉生长出革兰氏阴性棒的血培养物被确定为乳酸杆菌菌血症。传染病小组建议移除她的外周插入中心导管,因为他们担心线路感染。
结果:患者接受广谱抗生素治疗,临床上做得很好,并在阴性重复血液培养后重新插入她的外周中心导管后最终出院。尽管她最初在门诊工作表现不错,十个月后,她因感染性休克再次住院,最终去世,继发于肠缺血和怀疑她的外周插入中心导管的真菌血症。
结论:在本案例报告中,我们描述了一例不寻常的慢性肠外营养治疗短肠综合征患者发生导管相关性乳酸杆菌菌血症的病例,这是首次报道的成人肠外营养治疗患者.
Short bowel syndrome is a malabsorption disorder typically caused by the physical loss of a portion of the intestine, whereafter the body is unable to adequately absorb nutrients, fluids, and electrolytes. Many patients with short bowel syndrome are reliant on home parenteral nutrition through a tunneled or peripherally inserted central catheter to ensure sufficient hydration and nutrition. Central venous catheters are a nidus for bacteria, and patients are at risk for infections associated with high levels of morbidity and mortality. Lactobacillus is a ubiquitous microorganism that most frequently colonizes mucosal surfaces such as the gastrointestinal tract. Lactobacillus bacteremia is rare, with limited occurrence in current medical literature.
Our patient is a 60-year-old female with a past medical history significant for multiple abdominal surgeries resulting in short bowel syndrome, with subsequent dependence on home parenteral nutrition via peripherally inserted central catheter. She had type III chronic intestinal failure, category D2, and stage 1 moderate malnutrition. She was originally admitted to the hospital for a presumed pulmonary embolism and was found to have a deep vein thrombosis in the setting of her peripherally inserted central catheter. On admission her abdominal exam was unremarkable, she denied abdominal pain, and her only gastrointestinal complaint was chronic stable diarrhea. During the hospitalization she developed severe left lower quadrant abdominal pain and noted decreased frequency of her bowel movements. A computed tomography scan of her abdomen revealed chronic stable intestinal distension and was concerning for obstruction. Clinically she remained without symptoms of acute obstruction or ileus. During the admission she became febrile, with blood cultures from her peripherally inserted central catheter and peripheral IV growing out gram negative rods determined to be lactobacillus bacteremia. The infectious disease team recommended removal of her peripherally inserted central catheter given their concern for a line infection.
The patient was treated with broad-spectrum antibiotics, did well clinically, and was ultimately discharged following reinsertion of her peripherally inserted central catheter after negative repeat blood cultures. Though she initially did well in the outpatient setting, she ultimately passed away ten months later after re-presenting to the hospital in septic shock, secondary to bowel ischemia and suspected fungemia of her peripherally inserted central catheter.
In this
case report, we describe an unusual
case of a patient with short bowel syndrome on chronic parenteral nutrition who developed catheter-associated lactobacillus bacteremia - the first reported
case in an adult patient on parenteral nutrition.