Biopsies in patients with symptoms of pulmonary hemorrhage are a high-risk medical decision. This risk is enormous, especially when there is a suspicion that the patient has a tendency to bleed spontaneously – biopsies can cause damage to organs, and biopsies in patients who do not have a tendency to bleed spontaneously require strict bed rest and elastic bands tied outside the body to curb bleeding. Biopsies on people who are already bleeding can lead to more severe bleeding – which can be fatal.

But it was imperative to puncture Wang Lin's lungs. If the cause of his illness could not be diagnosed, it was obvious that the suspension of red blood cells alone would not last long. Even if he could rely on suspended red blood cells to hang his life, after his kidneys completely struck, Wang Lin still had to die - a patient with severe anemia of unknown origin did not even have a chance to survive on dialysis.

"Of course there are risks. Sun Lien said to Xu Yourong, who was about to stop him, "But if we don't do a biopsy, we won't even know what his problem is." His clotting time was normal, indicating that the bleeding was not spontaneous. There are certainly risks associated with having a biopsy in a lung that is already bleeding, but the risk is acceptable compared to the results of doing nothing. ”

Xu Yourong frowned and asked, "Maybe you can use other means, such as PCR or mNGS......"

Sun Lien sighed, "There is not enough time. And we also don't have relatively few suspected targets. The PCR test takes six or seven hours, and the mNGS takes even longer...... Moreover, patients may not be able to accept tens of thousands of examination items, especially if this kind of examination may not be able to detect the problem. ”

"What do you mean...... It doesn't have to be an infection?" Yuan Ping'an asked his own question, "I thought you had locked down the root cause of the problem. ”

"The patient definitely has an infection in his lungs. However, it is uncertain whether there is a direct link between the infection and proteinuria, and whether the infection is related to severe anemia. Sun Lien rubbed his forehead with some pain. "Biopsies are the only way we can determine if there is a connection between the three. ”

"Let's do a lung biopsy first. After thinking about it, Zhou Ce put forward his own suggestion, "Continue to monitor the blood routine, at least rule out renal anemia." Renal puncture is too much of a lesion and may not be able to reach the injured site in one sitting. For a lung biopsy, we can at least go to the lesion first. ”

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"Speaking of which, have you seen the patient's family?" Sun Lien went out with Dr. Pascal. He was going to go out for a bite to eat, and Dr. Pascal had to go out of the clinic for the day. The two happened to be on the same road, and as they were walking on the road, Dr. Pascal suddenly said to Sun Lien, "I heard that this patient is the first patient to be treated?"

Sun Lien nodded, "Dr. Xu didn't agree with Director Zhou's diagnosis of tuberculosis at first, and then let me go and see it. ”

"So, you haven't been to see the patient's family yet?" Dr. Pascal touched the top of his head, "and after you've finished your breakfast, it's better to meet you." At the very least, explain to the patient that you are the attending doctor. ”

For the attending doctor, it is a ritual to meet patients and their families in person, and to identify themselves to each other, and it is also an important part of interaction. Many experienced doctors have emphasized that only after meeting patients and their families can a patient become a living person from a simple "case". And this kind of meeting is also a kind of respect for the other party. You are my doctor, and we need you to heal. Such a meeting can also make the patient's family psychologically calmer.

"I'll go now. "Dr. Pascal doesn't have much advice for Sun, but it's important every time. After Sun Lien groaned for a while, he made a decision directly - he was not very hungry now anyway.

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"Wang Lin's family, is Wang Lin's family there?" the voice of the radio sounded in the emergency hall.

"Yes, yes, yes. A very young girl hurriedly jumped up from her seat with a bag and ran all the way to the door of the rescue room.

"Hello. Sun Lien nodded at the little girl, "I am Wang Lin's attending doctor." ”

"Doctor, how is my dad?" the little girl still had time to be polite to Sun Lien, and she grabbed the bag on her shoulder, as if trying to keep it from falling. He ...... Is he okay?"

Sun Lien stood at the door of the emergency room, and he gave way to the side slightly, "It's not appropriate to discuss the patient's condition in public, you can come with me." He walked ahead and led the way, bringing Wang Lin's daughter into the conference room.

"You may be seated. Sun Lien sat down by himself, "Don't be too anxious first. Your dad's condition is not great, but not to the worst yet. ”

The little girl is not very old, and the status bar shows that she is also 21 years old, named Wang Xinrui.

And he has Hashimoto's thyroiditis.

Sun Lien looked at Wang Xinrui with some confusion, then tried to take his eyes off her head, and began to ask about Wang Lin's illness.

"He's had a fever and cough for a month, isn't he?" Sun Lien looked at the case, ready to verify the case record again.

"Yes. Wang Xinrui nodded. Although the young doctor asked the same questions as the previous doctors, he could give the impression that he was "verifying some kind of speculation". This feeling of no reason made Wang Xinrui feel some hope in her heart.

"During this time, did he have any symptoms of blood in his stool or vomiting blood?" Sun Lien planned to solve the rapid anemia shown by Wang Lin first. If a patient has certain conditions that cause occult internal bleeding, that may explain why his hemoglobin drops so much in eight hours.

"No ......" Wang Xinrui shook her head, her mother died early, and she has been living with her father. "Since my mom passed away, my dad has quit smoking and drinking. Life is very regular. ”

Sun Lien frowned and asked tentatively, "Did your mother die of any disease?"

"No, it's a car accident. Wang Xinrui was a little surprised by Sun Lien's question. This doesn't sound like a direct connection to Wang Lin's illness.

"Are there any special diseases among your father's relatives, such as being particularly allergic to any substances, or having lupus erythematosus?" Sun Lien quietly squeezed the pen in his hand. He vaguely felt that the answer to this question was important.

"Yes. Wang Xinrui nodded, "I have Hashimoto's thyroiditis, and my eldest and second aunts also have it." My aunt said a few days ago that she was diagnosed with something...... Sjogren's disease?"

"Sjogren's syndrome?" Sun Lien put down the pen in his hand. He had a very bold guess.

Hashimoto's thyroiditis is an autoimmune disease, while secondary Sjögren's syndrome is the result of a highly developed systemic autoimmune disease. Both of Wang's sisters have autoimmune diseases, and his daughter has too. Considering the familial nature of autoimmune diseases, Sun believes that Wang Lin may also have some kind of autoimmune disease. And it was this disease that triggered his bleeding in the lungs and suspected glomerulonephritis.

Sun Lien currently has a suspected target - "pulmonary hemorrhage-nephritic syndrome".

Judging from the name alone, it is also the most suspicious.

The exact cause of this disorder, known as Good-pasture syndrome, is unknown. However, it is thought that the patient first suffered lung injury, and then caused the antigenic changes of the alveolar basement membrane of the patient, resulting in the development of anti-basement membrane antibodies. This anti-basement membrane antibody also acts on the glomerular basement membrane, so patients will have symptoms of pulmonary hemorrhage and nephritis at the same time.

If the symptoms are correct, the cause may be Staphylococcus aureus infection. Sun Lien took out his mobile phone and started to call, completely ignoring Wang Xinrui, who was sitting opposite, was still at a loss, not knowing what was going on.

"Dr. Pascal, please come to the emergency room immediately. Sun Lien didn't say a word, and first slipped Lao Pa back. Pulmonary hemorrhage-nephritic syndrome remains an autoimmune disease in nature. Dr. Pascal of the Department of Rheumatology and Immunology came to see that it was the right specialty. After the phone call, Sun Lien called Xu Yourong again and immediately stopped the lung biopsy, "The patient may have pulmonary hemorrhage-nephritic syndrome, don't do a lung biopsy, draw blood for GBM (anti-glomerular basement membrane antibody) examination, and then do a renal biopsy." ”

GBM (anti-glomerular basement membrane antibody) is the definitive evidence for diagnosing this syndrome, and a renal biopsy is done to determine how severe the syndrome has caused to Wang Lin's kidneys.

The syndrome itself is extremely difficult to diagnose and can cause severe damage to the kidneys. If the results of renal puncture are okay, then the disease can be controlled with blood exchange plus immune system suppression therapy, and some patients who are lucky can even recover on their own. But for those who are less lucky, they may have to face the result of having both kidneys removed, on dialysis for more than two years, and then confirming that the GBM (Kang Glomerular Basement Membrane Antibody) is gone before they are ready for a kidney transplant.

After a series of phone calls, Sun Lien explained his actions to Wang Xinrui, and emphasized, "We are still not sure how far your father's illness has reached. Only by a blood test for specific antibodies can we confirm the diagnosis, and only by needle biopsy can we determine what treatment will be better for him later. ”

"This disease...... Is it serious?" Wang Xinrui had some difficulty accepting Sun Lien's statement about "what step of the illness has reached". "I have Hashimoto myself, can't I control my antibodies by taking medication?"

"It is possible to control the antibodies and no longer cause damage to the body, but the original damage is still there. "It's like if you drive a lot of nails into a piece of wood, taking medicine to control antibodies, it's like stopping or even pulling out the nails, but there will still be a lot of holes in the board." If the holes weren't too many, and not too deep, maybe the plank would have been able to continue to be used. But if it's all nailed, the plank won't be able to function properly — if it doesn't be replaced, it will only pose more threat to the bucket. ”

Wang Xinrui pondered for a while, and then sighed, "Listen to you." ”