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VIRALMENINGITIS&ENCEPHALITISCause最常见柯萨奇病毒ECHO病毒肠道病毒其次流行性腮腺炎单纯疱疹病毒腺病毒PathologyViralinfectionscanaffectthecentralnervoussysteminthreeways血源性播散:hematogenousdisseminationofasystemicviralinfection(eg,arthropod-borneviruses虫媒性病毒);轴突传播:neuronalspreadofthevirusbyaxonaltransport(eg,herpessimplex,rabies狂犬病病毒);自身免疫性感染后脱髓鞘:autoimmunepostinfections
demyelination脱髓鞘
(eg,varicella水痘病毒,influenza).Pathologicchangesinviralmeningitisconsistofaninflammatorymeningealreactionmediatedbylymphocytes.
病毒性脑膜炎的病理改变是由淋巴细胞介导的炎性脑膜反应。Clinicalfindings---symptomsandsignsClinicalmanifestationsincludefever,headache,neckstiffness,photophobia畏光,painwitheyemovement,andmildimpairmentofconsciousness.Patientsusuallydonotappearasillasthosewithbacterialmeningitis.Systemicviralinfectionmaycauseskinrash,pharyngitis咽炎,lymphadenopathy淋巴结病,pleuritis胸膜炎,carditis心肌炎,jaundice黄疸,organomegaly器官肿大,diarrhea腹泻,ororchitis睾丸炎,andthesefindingsmaysuggestaparticularetiologicagent病原体.Becauseviralencephalitisinvolvesthebraindirectly,markedalterationsofconsciousness,seizures,andfocalneurologicsignscanoccur.Whensignsofmeningealirritation脑膜刺激征andbraindysfunctioncoexist共存,theconditionistermedmeningoencephalitis脑膜脑炎.Proteinisnormalorslightlyincreased(usually80~120mg/dL).Glucoseisusuallynormal,butmaybedecreasedinmumps腮腺炎,herpeszoster带状疱疹,orherpessimplexencephalitis.Gram’sstainandbacterial,fungal,andacid-fastbacillius(AFB)culturesarenegative.Oligoclonalbands寡克隆区带andCSFproteinelectrophoresis电泳abnormalitiesmaybepresent.Anetiologicdiagnosiscanoftenbemadebyvirusisolation,polymerasechainreaction,oracute-andconvalescentphase恢复期CSFantibodytiters抗体滴度.Bloodcountsmayshowanormalwhitecellcount,leukopenia白血球减少症,ormildleukocytosis白细胞增多.Serumamylase血清淀粉酶isfrequentlyelevatedinmumps
腮腺炎;abnormalliverfunctiontestsareassociatedwithbothhepatitisviruses肝炎病毒andinfectiousmononucleosis单核细胞增多症.TheEEGisdiffuselyslow,especiallyifthereisdirectcerebralinvolvement.DifferentialdiagnosisThedifferentialdiagnosisofmeningitiswithmononuclearcellpleocytosisincludespartiallytreatedbacterialmeningitis治疗不彻底的细菌性脑膜炎aswellassyphilitic梅毒的,tuberculous结核性的,fungal,parasitic寄生物的,neoplastic肿瘤的,andothermeningitides脑(脊)膜炎.EvidenceofsystemicviralinfectionandCSFwetmounts,stainedsmears,cultures,andcytologicexamination细胞学检查candistinguishamongthesepossibilities.Whenpresumedearlyviralmeningitisisassociatedwithapolymorphonuclear多形核白细胞pleocytosisoflessthan1000whitebloodcells/mLandnormalCSFglucose,oneoftwostrategiescanbeused.ThepaitentcanbetreatedforbacterialmeningitisuntiltheresultsofCSFculturesareknown;Treatmentcanbewithheldandlumbarpuncture腰椎穿刺术
repeatedin6~12hours.Ifthemeningitisisviralinorigin,thesecondsampleshouldshowamononuclearcellpleocytosis.Neurologicabnormalitiesresultfromperivenous静脉周围的demyelination脱髓鞘,withoftenseverelyaffectsthebrainstem.TheCSFshowsalymphocyticpleocytosis脑脊液细胞数增多,usuallywithcellcountsof50~150/mL,andmildproteinelevation.TreatmentExceptforherpessimplexencephalitis,whichisdiscussedseparatelynospecifictherapyforviralmeningitisandencephalitisisavailable.Corticosteroidsareofnoprovenbenefitexceptinimmune-mediatedpostinfectioussyndromes.Headacheandfevercanbetreatedwithacetaminophen醋氨酚,butaspirinshouldbeavoided,especiallyinchildrenandyoungadults,becauseofitsassociationwithReye’ssyndrome.Seizuresusuallyrespondtophenytoin苯妥英钠orphenobarbital苯巴比妥.Supportivemeasuresincomatose昏睡的patientsincludemechanicalventilationandintravenousornasogastricfeeding鼻饲.Herpessimplexvirus(HSV)encephalitisHSVisthemostcommoncauseofsporadic散发的fatalencephalitisintheUnitedStates.Abouttwo-thirdsofcasespatientsover40yearsofage.Primaryherpesinfectionsmostoftenpresentasstomatitis口炎(HSVtype1)oravenereally
性交的transmittedgenital生殖器eruption出疹(HSVtpye2).PathologyHSVtpye1encephalitisisanacute,necrotizing引坏死的,asymmetric不对称的hemorrhagic出血性的processwithlymphocyticandplasmacell浆细胞reaction.Usuallyinvolvesthemedialtemporalandinferiorfrontallobes.Intranuclearinclusions核内包涵体maybeseeninneurons神经元andglia神经胶质.Patientswhorecover康复期mayshowcystic囊的necrosis坏死oftheinvolvedregions.嗜酸性CowdryA型包涵体ClinicalFinding---ASymptomsandSignsTheclinicalsyndromemayincludeheadache,stiffneck,vomiting,behavioraldisorders,memoryloss,anosmia嗅觉丧失,aphasia,hemiparesis轻偏瘫,andfocalorgeneralizedseizures.Activeherpeslabialis唇疱疹isseenoccasionally,butdoesnotreliablyimplicateHSVasthecauseofencephalitis.HSVencephalitisisuauallyrapidlyprogressiveoverseveraldaysandmayresultincomaordeath.Themostcommonsequelae后遗症inpatientswhosurvivearememoryandbehaviordisturbances,reflectingthepredilection
嗜好,偏爱ofHSVforlimbicstructures.LaboratoryFindingsLaboratoryFindings---CSFTheCSFinHSVtpye1encephalitismostoftenshowsincreasedpressurelymphocyticormixedlymphocyticandpolymorphonuclear多形核白细胞pleocytosis(50~100whitebloodcells/mL)mildproteinelevation,andnormalglucose.Redbloodcells,xanthochromia黄变,anddecreasedglucoseareseeninsomecases.LaboratoryFindings---VIRUSThevirusgenerallycannotbeisolatedfromtheCSF,butviralDNAhasbeendetectedbythepolymerasechainreaction聚合酶链反应insomecases.HSV抗体检定ELASA是现今国际上通用的HSV抗体检测方法。本方法采用双份血清和双份脑脊液作HSV-1抗体的动态检测。诊断标准:双份CSF抗体有增高趋势,滴度1:8以上;双份CSF抗体4倍以上升高;血与CSF的抗体比值<40。LaboratoryFindings---EEGTheEEGmayshowperiodic周期的slow-wavecomplexesarisingfromoneorbothtemporallobesLaboratoryFindings---CTMRICTscansandMRImayshowabnormalitiesinoneorbothtemporallobes.Thesecanextendtofrontalorparietalregions顶区andaresometimesenhancedwiththeinfusion注入ofcontrastmaterial造影剂.However,imagingstudiesmayalsobenormal.DiagnosisDifferentialDiagnosisThesymptomsandsignsarenotspecificforherpesvirusinfection.ThegreatestdiagnosticdifficultyisdistinguishingbetweenHSVencephalitisandbrainabscess脑脓肿,andthetowdisordersoftencannotbedifferentiatedonclinicalgroundsalone.brainabscessbrainabscessOtherCNSinfectionsandvasculitis血管炎canalsomimicHSVencephalitis.Deginitivediagnosiscanbemadebybiopsyofaffectedbrainareas,withthechoiceofbiopsysiteguidedbytheEEG,CT,orMRIfindings.However,becausetreatmentismosteffectivewhenbegunearlyandiscomparativelysafe,themostcommonapproachistotreatpatientswithpossibleHSVencephalitisasdescribedbelowandtoreservebiopsyforthose
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