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sydenham

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[交流] 病例讨论兼翻译:A 35-Year-Old Man with Headache, Deviation of the Tongue

病例讨论兼翻译
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病例如下（摘自The New England Journal of Medicine ）：
A 35-year-old right-handed man was admitted to the hospital because of a persistent headache and deviation of the tongue.

The patient had been in excellent health until about one month earlier, when a left-sided headache developed, with occasional bright spots in the left visual field, subjective fever, chilliness, and anorexia; he lost 5 kg of body weight at this time. The headache became severe and was not affected by nonsteroidal antiinflammatory agents, the patient's position, straining, or coughing. During this period, his tongue deviated to the left and caused drooling, although he had no dysphasia or dysphagia.

One week before admission, the patient was seen at a community health center affiliated with this hospital, where he reported a transient sore throat. Ibuprofen and amoxicillin were prescribed, but his condition did not improve. A throat culture was negative for beta-hemolytic streptococci. He was admitted to this hospital.

The patient was a native of Morocco and had immigrated to the United States one year before admission. He worked as a cook. He had smoked one pack of cigarettes daily for 10 years and used marijuana occasionally; he did not drink alcohol. There was no history of arthralgia, vision loss, rash, motor or sensory deficits, neck stiffness, nausea, vomiting, chest or abdominal pain, cough, head injury or other trauma, exposure to tuberculosis, or other illnesses in recent months.

The temperature was 37.1°C, the pulse was 53, and the respirations were 20. The blood pressure was 125/70 mm Hg.

On physical examination, the patient appeared well. No rash or definite lymphadenopathy was found, although some examiners palpated left cervical fullness; the neck was supple. One senior examiner noted slight temporal-artery tenderness, without thickening.

On neurologic examination, the patient was alert and oriented, with intact speech and comprehension. His cranial-nerve functions were also intact, except for questionable left-sided facial weakness, definite leftward deviation of the tongue, and questionably decreased elevation of the palate on the left side; the gag reflex was preserved. Motor power was 5/5 throughout, without drift, and sensation of a light touch and a pinprick was normal. Coordination was also normal. The deep-tendon reflexes were ++ throughout, and the plantar responses were flexor.

The urine was normal. The hematocrit was 39.5 percent; the white-cell count was 12,000 per cubic millimeter, with 67 percent neutrophils, 25 percent lymphocytes, 5 percent monocytes, 2 percent eosinophils, and 1 percent basophils; the platelet count was 545,000 per cubic millimeter; the mean corpuscular volume was 86 µm3; and the erythrocyte sedimentation rate was 99 mm per hour. The prothrombin and partial-thromboplastin times were normal. The uric acid level was 1.7 mg per deciliter (101 µmol per liter), and the total protein level was 7.9 g per deciliter (albumin, 3.5 g per deciliter; globulin, 4.4 g per deciliter). The sodium level was 142 mmol per liter, the potassium level 4.6 mmol per liter, the chloride level 101 mmol per liter, and the carbon dioxide level 21.6 mmol per liter. The creatine kinase level was low, at 36 U per liter. The levels of urea nitrogen, creatinine, glucose, conjugated and total bilirubin, calcium, phosphorus, magnesium, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, vitamin B12, and folic acid were normal.

A lumbar puncture yielded clear, colorless cerebrospinal fluid that contained 1 mononuclear cell per cubic millimeter; the glucose level was 59 mg per deciliter (3.3 mmol per liter), and the total protein level was 29 mg per deciliter. No fungi, acid-fast bacilli, or other microorganisms were seen. A serologic test for syphilis was negative, and the results of a blood culture were pending. An electrocardiogram revealed a normal rhythm and a heart rate of 60 beats per minute.

Chest radiographs were unremarkable, and a computed tomographic (CT) scan of the brain showed no abnormalities. A magnetic resonance imaging (MRI) study of the brain showed minimally increased T2-weighted signal in the posterior limbs of the internal capsules, with slight extension into the cerebral peduncles; the finding was nonspecific but raised the unlikely possibility of a very early demyelinative process. Slightly increased T2-weighted signal in the right maxillary sinus was suspected to represent retention polyps. There was no evidence of infarction or abnormal contrast enhancement that would suggest metastatic disease.

Thoracic CT scanning (Figure 1 and Figure 2), performed after the oral and intravenous administration of contrast material, revealed circumferential soft-tissue thickening around a 2-cm segment of the proximal portion of the left common carotid artery, with associated luminal narrowing. The other great vessels, the aortic arch, and the proximal descending thoracic aorta were unremarkable except for their bovine-arch anatomical structure, a common variant in which the left common carotid artery arises from the brachiocephalic trunk rather than directly from the aorta. Eccentric soft-tissue density extended along the descending thoracic aorta, from the midportion to the distal region. The findings suggested dissection with intramural hematoma, eccentric mural thickening, or vessel encasement. The remaining mediastinal structures were unremarkable, and there was no lymphadenopathy. The lungs were normal except for mild paraseptal emphysematous change. An abdominopelvic CT scan revealed no abnormalities.
The headache persisted. The patient was afebrile at all times after admission; the blood pressure ranged from 100/70 to 125/80 mm Hg. The results of additional laboratory tests were pending.

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