類風濕性關節炎合併下顎骨急性化膿性骨髓炎導致敗血性休克－病例報告

Septic Shock due to Acute Diffused Purulent Osteomyelitis of Mandible Combined with Rheumatoid Arthitis-Case Report

郭進賢(Chin-Shan Kuo) ； 施嘉霖(Chia-Lin Shih) ； 陳元武(Yuan-Wu Chen) ； 方致元(Chin-Yuang Fang) ； 夏毅然(Yi-Jan Hsia)

《中華民國口腔顎面外科學會雜誌》 13卷2期 (2002/09) Pp. 163-170

https://doi.org/10.7104/CJOMS.200209.0163

摘要

類風濕性關節炎為一慢性發炎性之疾病，可造成關節漸進性功能喪失。目前治療類風濕性關節炎的方法是患者長期服用皮質性類固醇，因此會進而導致免疫低落之狀況。在類風濕性關節炎患者中，合併齒源性感染，進而導致下顎骨髓炎再產生全身性敗血性休克者，殊為少見。
本病例為一位六十五歲女性，因長期下顎骨疼痛，並有膿液滲出，而至本院求診。經初步清創手術（debridement）並括除化膿部份再給予藥物治療後，病況未見改善，故住院做進一步處理。在全身麻醉之下接受廣泛性清創手術與死骨去除術（debridement and sequestrectomy），發現其下顎骨骨髓腔已呈蜂窩狀，並內含有大量的增生內芽組織與膿液蓄積，細菌培養確定由Streptococcus viridanse感染；患者手術後，症狀明顯緩解，傷口癒合良好。兩星期之後，患者臉部紅腫，而再度入院，後因感染擴散，形成敗血性休克，而轉入加護中心。經積極性的先腎及藥物治療，合併多次清創手術及腐骨切除手術後，感染狀況始受到控制，患者意識由昏迷（coma）而轉變為清醒，並於住院後54日出院。
回顧本病例，由於長期服用類固醇類製劑，導致患者之免疫力降低再加上齒源性感染之後，而肇生敗血性休克等全身性反應。故於口腔外科門診中，對長期服用類固醇的患者應特別注意。

關鍵字

骨髓炎 ； 類風濕性關節炎 ； 類固醇 ； 下顎骨

並列摘要

Rheumatoid arthritis is a kind of chronic inflammatory disease. It affects multiple joints and causes progressively disability of the joints. At present, the treatment of patient with rheumatoid arthritis is long-term medication by corticosteroids. Because of this kind of medication, the patient frequently develops the status of immunosupression. This paper reported a case of rheumatoid arthritis who had taken corticosteroid for more than 35 years sustained diffused purulent osteomyelitis of the mandible and then suffered from septic shock. A 65-year-old female complained of a painful sensation combined with pus discharge at her lower jaw for a long time. After initial debridement, curettage and medication, her condition was not improved and she was admitted for further treatments. Further debridement and sequestrectomy were performed under general anesthesia, the mandible lesion showed honeycomb appearance and filled with abundant granulation tissue and pus. Through the bacteria culture from the pus, the. Streptococcus varidanse was verified. After treatments, the symptom and sign got improved and the wound healing was undergoing. Two weeks later, unfortunely, this patient developed reddish swelling at her right face and was admitted again under the diagnosis of cellulites. Because the infection was spread out, the patient gradually showed the symptoms of septic shock and was transferred to the intensive care unit. After aggressively medication care, dialysis and a series of debridement and sequestectomy, the infectious condition was. Gradually controlled and patient consciousness was getting back to clear. She was discharged at the 54th days after admission. The patients with rheumatoid arthritis under the long term corticosteroid treatment usually develop immunosupression. When they are combined with the odontogenic infections, they have , highly potential risk to develop systemic reactions such as septic shock. In the clinic point of view, we have to pay great attention to these patients in order to prevent , severe complications.

並列關鍵字

osteomyelitis ； rheumatoid arthritis ； steroids ； mandible