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【检验临床面对面】隐形的”宝?!薄目?雷登结晶

时间:2019-03-06       作者:检验视界网      浏览量:3650 次

作者:赵肖琴,晋城市人民医院检验科


“哎呀,快来看,快来看!”听到同事的这一声呼唤,我知道我们又发现”好东西”了。处理完手边的工作,我接过同事递过来的大便标本的涂片,放在显微镜下一看,好漂亮的“宝?!薄目?雷登结晶?。ㄈ缤?-4)


a.gif

图1


b.gif

图2


c.gif

图3


d.gif

图4


夏科-雷登结晶为无色或浅黄色两端尖而透明具有折光性的菱形结晶,大小不一。常见于肠道溃疡,尤以阿米巴感染粪便中最易检出。过敏性腹泻及钩虫病患者粪便中亦常见到。[1]


寄生虫感染?肠道溃疡?过敏性肠炎?阿米巴痢疾?这些疾病名称瞬间涌入我的脑海中。查看患者信息:患者男,8岁,因腹痛腹泻就诊于儿科门诊,无发热症状,在家用药情况不明。就诊时首诊医生考虑可能为肠炎,于是进行大便常规的检查。该患者大便标本为黄色稀便(见图5),粘液阳性,镜下未见白细胞及红细胞,可见夏科-雷登结晶,除此以外,并未做其他检查。


5.jpg

图5


为排除寄生虫感染,我们取多处标本涂片镜检,并未发现虫卵,若该患者加做血常规,查看其嗜酸性粒细胞及血红蛋白,对排除钩虫病将会有更大的帮助;鉴于该患者粪便并非粘液脓血便,镜下也未见白细胞、红细胞,且查找虫卵时亦未见阿米巴原虫,基本可排除阿米巴痢疾;之后我们又取大便标本涂片做了革兰氏染色,观察到有真菌孢子存在(见图6),由于患者就诊前的用药情况不明确,不排除抗生素滥用导致的菌群失调。


6.jpg

图6


与同事一番讨论之后,我们和临床大夫进行了联系,告知我们的检查过程以及对检查结果的一些想法。临床医生随即与患者家属取得联系,给患者增加了血常规检查(见图7)。血常规的结果提示白细胞轻度增高,中性粒细胞增高,嗜酸性粒细胞比例正常,无贫血现象,结合镜下并未找到虫卵,基本排除了寄生虫感染。之后临床医生给患者制定了针对性的用药方案,并嘱咐定期复查。一周后患者复查,患者已经没有腹痛腹泻的症状,大便正常呈棕黄色软便,镜下未见夏科-雷登结晶,涂片染色亦未见到真菌孢子。


7.jpg

图7


心得体会:


夏科-雷登结晶是嗜酸性粒细胞裂解后嗜酸性颗粒相互融合,形成两端尖长、大小不等、无色或淡黄色透明的菱形折光性强的蛋白质结晶。属于病理性结晶,过敏性肠炎、肠道溃疡、寄生虫感染、阿米巴痢疾等粪便中可查见,同时还可见到嗜酸性粒细胞。夏科-雷登结晶在实际工作当中很少见到,本案例中,患者大便标本中未见白细胞,血液中嗜酸性粒细胞也不增高。为了弄清该患者出现夏科-雷登结晶的原因,笔者查阅了相关文献,文献报道较少,且均为个案报道,目前尚没有对夏科-雷登结晶形成机制有一个具体明确的解释。我又回顾了检验过程,发现当时没有做瑞氏染色的镜检,或许是嗜酸性粒细胞在粪便那样的环境中破坏了,湿片镜检时并未看到完整的细胞?这也提示我,今后再遇到特殊标本的时候要多想一点,多做一点。


大便常规检查是常用的临床检查方法,包括理学检查、化学检查和有形成分分析等。在工作中,我们每天会面对很多的大便标本,但是我们应该时刻保持认真、严谨地态度对待每一份标本,遇到异?;蚝奔谋瓯?,应积极思考同时和临床及时沟通,才能更好地提高检验能力为临床服务。


参考资料

[1].尚红,王毓三,申子瑜.全国临床检验操作规程 (第四版) [M].北京:人民卫生出版社,2017:177.







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