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患者,女,35岁,因腹胀,乏力,尿黄1月于1998年5月30日入院。患者结婚10年,无子女,月经正常,怀孕5次,均于3～5个妊娠月内自然流产。查体:神志清楚,精神不振,全身皮肤及巩膜均深度黄染,心肺所诊未见异常,腹软,剑下触痛,肝剑下2cm,肋下未触及,脾不大,肝区叩击痛,肝功能:ALT 1375U/L,ALP 128U/L,γ-GT 177U/L,TBil 140.2μmol/L,甲肝抗体、HAV-RNA均为阳性;乙肝病毒血清标志物、HBV-DNA、HCV-RNA、HEV-RNA均为阴性。血沉61mm/h,检测小便常规可见蛋白及管型,心电图示T波低平,抗核抗体(+),狼疮细胞(+)。入院诊断:①急性黄疸型肝炎,甲型,中度。②系统性红斑狼疮。治疗上以茵栀黄注射液30ml加入5％GS 250ml静滴,每日1次;胸腺肽60mg加入5％GS 250ml静滴,每日1次;口服复方益肝灵保肝治疗半个月。病人黄疸不退,转氨酶不降,并拒绝应用激素继续治疗,转请中医治疗。
Patient, female, 35 years old, admitted to hospital on May 30, 1998 due to abdominal distension, weakness, urinary yellow. Patients married 10 years, no children, normal menstruation, pregnancy 5 times, are in 3 to 5 months of pregnancy spontaneous abortion. Physical examination: conscious, lack of energy, the body skin and sclera are deep yellow dye, no abnormal cardiopulmonary diagnosis, abdominal soft, swords tenderness under the liver sword 2cm, the ribs did not touch the spleen, liver knock Pain, liver function: ALT 1375U / L, ALP 128U / L, γ-GT 177U / L, TBil 140.2μmol / L, hepatitis A antibody and HAV-RNA were positive; hepatitis B virus serum markers, -RNA, HEV-RNA were negative. Erythrocyte sedimentation rate 61mm / h, routine examination of urinalysis protein and tube, electrocardiogram T wave low flat, anti-nuclear antibody (+), lupus cells (+). Admission diagnosis: ① acute jaundice hepatitis, A, moderate. ② systemic lupus erythematosus. Treatment of Yinzhihuang injection 30ml added 5% GS 250ml intravenous infusion once daily; Thymosin 60mg added 5% GS 250ml intravenous infusion once daily; oral compound Yiganling liver treatment for half a month. Patient jaundice, aminotransferase does not fall, and refused to continue the treatment of hormones, transfer to Chinese medicine.