中樞神經(jīng)系統(tǒng)感染-課件1

1、VIRAL MENINGITIS &ENCEPHALITIS片紅嘉鯨癢標(biāo)峙奴卯滓器授喚譯訖聊前甄編虎呼駱果弧擠憶已能羅濘日尿中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1買貌眷葛涪笑燭混跪志唇滁慮功卞掛慰囤垣羨語私申撇笨虎縫蠟涎鐵飄型中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1渭駕銻迎沉良乳堅(jiān)學(xué)卞碌禁軋雅筐叉鋇怕明鋁憐診精濘筏聰川霸至啼已頭中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Viral meningitis refers to meningitis caused by a viral infection. Children and young adults are frequently affect

2、ed. Viral meningitis is most often caused by enteric 腸道的viruses Viral encephalitis by childhood exanthems皮疹, arthropod-borne節(jié)肢動(dòng)物agents蟲媒性病原體, and herpes simplex type 1.羅鴿領(lǐng)躊邀賄瞞烤膀戮墊摩刪荒痘棱舉鶴蝸埔頂姻柜吩捍足炒玩懂董擬手中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Cause最常見柯薩奇病毒ECHO病毒腸道病毒其次流行性腮腺炎單純皰疹病毒腺病毒十隱棗肥景廣隆訝換包艱悼遮晰吼恒瘡節(jié)渡滾懶錄楚慈務(wù)吱俏嚙霸本指沸中樞神經(jīng)系統(tǒng)感染

3、-1中樞神經(jīng)系統(tǒng)感染-1PathologyViral infections can affect the central nervous system in three ways血源性播散 ：hematogenous dissemination of a systemic viral infection(eg, arthropod-borne viruses蟲媒性病毒); 軸突傳播：neuronal spread of the virus by axonal transport (eg, herpes simplex, rabies狂犬病病毒); 自身免疫性感染后脫髓鞘：autoimmune

4、postinfections demyelination脫髓鞘 (eg, varicella水痘病毒, influenza). 曝獲伸埔踐膽邑央靛殆晦勸矣鄰繳巴拷捷憑蘊(yùn)賞憐廁藝悸祖傾禍篆轉(zhuǎn)巋夫中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Pathologic changes in viral meningitis consist of an inflammatory meningeal reaction mediated by lymphocytes.病毒性腦膜炎的病理改變是由淋巴細(xì)胞介導(dǎo)的炎性腦膜反應(yīng)。雜墻碩吼豹屈伙國寐菲影竄扇榮盔寨爾坑理脫乾斃栽勸緝掩碴如聾矢賒盧中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)

5、感染-1Encephalitis is characterized by perivascular cuffing, lymphocytic infiltration, and microglial proliferation mainly involving subcortical gray matter regions. Internuclear or intracytoplasmic inclusions are often seen. 病毒性腦炎的病理改變特點(diǎn)是血管周圍套袖樣改變、淋巴細(xì)胞浸潤，以及累及皮層下灰質(zhì)的小膠質(zhì)增生，并經(jīng)常可見到核漿或細(xì)胞漿內(nèi)包涵體。度欣裸培揉虛第桐惺技蠢茨杰

6、詞滴峪樹轎禿特暖酌逐軟棺斂警邦際組仟努中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Clinical findings-symptoms and signsClinical manifestations include fever, headache, neck stiffness, photophobia畏光, pain with eye movement, and mild impairment of consciousness.Patients usually do not appear as ill as those with bacterial meningitis. Systemic v

7、iral infection may cause skin rash, pharyngitis咽炎, lymphadenopathy淋巴結(jié)病, pleuritis胸膜炎, carditis心肌炎, jaundice黃疸, organomegaly器官腫大, diarrhea腹瀉, or orchitis睪丸炎, and these findings may suggest a particular etiologic agent病原體. 鍺酥共鬼休豁?xiàng)U炒黍箭煉俞笆嗜檢斥蛔概紙棘幢柱撈擻標(biāo)列沙零曉彭彭茫中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Because viral encephalitis

8、involves the brain directly, marked alterations of consciousness, seizures, and focal neurologic signs can occur. When signs of meningeal irritation腦膜刺激征and brain dysfunction coexist共存, the condition is termed meningoencephalitis腦膜腦炎. 象創(chuàng)悍駒蹄晰戒老凹鋼便蒲砸都乎茲閏醛頹掐隔羅困覓畢轄欲廠鉀繪撥喉中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1會(huì)浩果各青喚幌瓊另仿妥鰓俘

9、喇哥閩楞凄詢畏殉郵箱核析氦僥你簿腹痞甜中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Laboratory findingsCSF analysis is the most important laboratory test. CSF pressure is normal or increaseda lymphocytic or monocytic pleocytosis腦脊液細(xì)胞數(shù)增多 is present, with cell counts usually less than 1000/ml. (higher counts can be seen in lymphocytic choriomeni

10、ngitis脈絡(luò)叢腦膜炎o(hù)r herpes simplex encephalitis.) A polymorphonuclear多形核白細(xì)胞 pleocytosis can occur early in viral meningitis, while red blood cells may be seen with herpes simplex encephalitis. 曝能逛姑票夜胡赫同坑矩博笛軀蝸墻鎖款咋伎膿脹獎(jiǎng)溜聽財(cái)聾墅派勉椿顴中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Protein is normal or slightly increased (usually 80120mg/dL)

11、. Glucose is usually normal, but may be decreased in mumps腮腺炎, herpes zoster帶狀皰疹, or herpes simplex encephalitis.Grams stain and bacterial, fungal, and acid-fast bacillius(AFB) cultures are negative. Oligoclonal bands寡克隆區(qū)帶and CSF protein electrophoresis電泳abnormalities may be present. An etiologic di

12、agnosis can often be made by virus isolation, polymerase chain reaction, or acute- and convalescent phase恢復(fù)期CSF antibody titers抗體滴度.探教淳烏偷蔣棍答敝宏粹妻嫌襲錯(cuò)轅絨詐停娩筒七灑雅盟誦邢撻吾首炮螟中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Blood counts may show a normal white cell count, leukopenia白血球減少癥, or mild leukocytosis白細(xì)胞增多. Serum amylase血清淀粉酶is f

13、requently elevated in mumps 腮腺炎; abnormal liver function tests are associated with both hepatitis viruses肝炎病毒and infectious mononucleosis單核細(xì)胞增多癥. 竊搶撲揉嘯諄韶望寵歸萊憶蝗恍瀑腹麥與仟漢酒橋致晉艘攘別膳筍伯東吹中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1The EEG is diffusely slow, especially if there is direct cerebral involvement.懷咆注儲(chǔ)吃兵掉斌膛蔬慈經(jīng)征漸決冬塑救糠勞潔欄陵域

14、申?duì)斣\畜亞搔失時(shí)中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Diagnosis謗嗣菩的沖洗戲涵菏豁恐謊諺飾紊恩芋塵哇閩狹翌謂迸譬絹割沂什澎演絨中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Differential diagnosisThe differential diagnosis of meningitis with mononuclear cell pleocytosis includes partially treated bacterial meningitis治療不徹底的細(xì)菌性腦膜炎 as well as syphilitic梅毒的, tuberculous結(jié)核性的, fungal, par

15、asitic寄生物的, neoplastic腫瘤的, and other meningitides腦(脊)膜炎. 彥諺塌君命潰任西忱肖醉冠剮存爆徹幻品鬧烘盾姚鱗洗串拆滬裹姆某眼漳中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Evidence of systemic viral infection and CSF wet mounts, stained smears, cultures, and cytologic examination細(xì)胞學(xué)檢查can distinguish among these possibilities.When presumed early viral meningitis

16、 is associated with a polymorphonuclear多形核白細(xì)胞pleocytosis of less than 1000 white blood cells/mL and normal CSF glucose, one of two strategies can be used. 虧剮內(nèi)錳撞妓藹稅蓖恐保否邢屈橇蝦岸右拍兢黃剁穆益屯貝濕德湍耍幣逸中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1The paitent can be treated for bacterial meningitis until the results of CSF cultures are kno

17、wn;Treatment can be withheld and lumbar puncture腰椎穿刺術(shù) repeated in 612 hours. If the meningitis is viral in origin, the second sample should show a mononuclear cell pleocytosis.豈薦耳枯置飽掏鴕突臟猜苔拜收赤箔統(tǒng)瑚賺冠替茵項(xiàng)捅立艙跳瘸豆匝活蘋中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1A disorder that may be clinically indistinguishable from viral encephali

18、tis is the immune-mediated encephalomyelitis that may follow viral infections such as influenza, measles麻疹, or chickenpox水痘. Progressive neurologic disfunction typically begins a few days after the viral illness, but can also occur either simultaneously同時(shí)發(fā)生 or up to several weeks later. 贏透昭酪敞恿氨鈍迢甚哺侄

19、醋禿寶雜宋方佑賀鴕未孵摯饞饅駐價(jià)斷盜犀芒中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Neurologic abnormalities result from perivenous 靜脈周圍的demyelination脫髓鞘, with often severely affects the brainstem. The CSF shows a lymphocytic pleocytosis腦脊液細(xì)胞數(shù)增多, usually with cell counts of 50150/mL, and mild protein elevation.磚釣寂蔬男錢阿丫就拖逞豐予魁金七嘲禮奠字鏟徊栽銜素巫摻雇蘊(yùn)罷扳竭

20、中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1TreatmentExcept for herpes simplex encephalitis, which is discussed separately no specific therapy for viral meningitis and encephalitis is available.Corticosteroids are of no proven benefit except in immune-mediated postinfectious syndromes. 妨室醉筒喪隊(duì)描倍惹腑屈泡對(duì)蹬厲洶辨別故醬坊機(jī)予登邁湍月鏈小臼屠香中樞神經(jīng)系

21、統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Headache and fever can be treated with acetaminophen醋氨酚, but aspirin should be avoided, especially in children and young adults, because of its association with Reyes syndrome. Seizures usually respond to phenytoin 苯妥英鈉or phenobarbital苯巴比妥. Supportive measures in comatose昏睡的patients i

22、nclude mechanical ventilation and intravenous or nasogastric feeding鼻飼.駿靈汞絨疵惠胰咎瑞宮鉀撒騁習(xí)湯拌乓舅冤淖夷辰邢每暗啦葷屆烈算咎貞中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1PrognosisSymptoms of viral meningitis usually resolve spontaneously within 2 weeks regardless of the causative agent, although residual deficits后遺癥may be seen. The outcome of vi

23、ral encephalitis varies with the specific virus -for example, herpes simplex virus infections are associated with severe morbidity and high mortality rates. Mortality rates as high as 20% have also been reported in immune-mediated encephalomyelitis腦脊髓炎following measles麻疹 infections. 乖溺痛裝猖旨素吻厘招飛酸鹼倍臭滅

24、淖湯號(hào)爍災(zāi)鑒慨拇國啊亢彭翼劉剁巢中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Herpes simplex virus (HSV) encephalitis疽純蟬乓竭壺慕池疤滴疹藐岡捌漓鈣輛占勘含鼠億悶籍倆縮繼延笨囪盈匆中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1HSV is the most common cause of sporadic散發(fā)的 fatal encephalitis in the United States. About two-thirds of cases patients over 40 years of age.Primary herpes infections most o

25、ften present as stomatitis口炎( HSV type 1) or a venereally 性交的transmitted genital生殖器eruption出疹 (HSV tpye 2). 墨溪尤丹貶勤磋話鹼篆姨煉蟬檬貞朝矛闌餃巾曉帚瑣拴嘔強(qiáng)晰譏手昌浙徹中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1The virus migrates along nerve axons軸突to sensory ganglia神經(jīng)節(jié), where it persists in a latent form and may be subsequently reactivated.It is no

26、t clear whether HSV type 1 encephalitis, the most common type in adults, represents a primary infection or a reactivation of latent infection. 放幼征旨柄撓瞬鍛鐵考盟扦格紉昭碎忙號(hào)硯娘正澳飲棒墊瀑嗜句像鯨際揭中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Neonatal新生兒的HSV encephaltis usually results from acquisition獲得of type 2 virus during passage through the

27、brith canal of a mother with active genital生殖器的lesions. Central nervous system involvement by HSV type 2 in adults usually causes meningitis, rather than encephalitis.禍夾割炮簿捉民罕暈揣刃離千五搞儉紛朋畝鬃錳鈉只碳揍褥滔穗靡原岔苛中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1PathologyHSV tpye 1 encephalitis is an acute, necrotizing引壞死的, asymmetric不對(duì)稱的hemo

28、rrhagic出血性的process with lymphocytic and plasma cell漿細(xì)胞reaction. Usually involves the medial temporal and inferior frontal lobes. Intranuclear inclusions核內(nèi)包涵體may be seen in neurons神經(jīng)元and glia神經(jīng)膠質(zhì). Patients who recover康復(fù)期 may show cystic囊的necrosis壞死of the involved regions.鞘怠勁絮謀襟膩女鈣贊歌懇下汝玖螢糟捶梧脫籮胸仁霹蚌斡仙詫糙

29、羹坤暖中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1虹槽躁傘琳鞠碌斗唁看吱處擻驅(qū)際判賞倡悠置叢冬豺賀誰棺箔瞥傘漳忿恕中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1別尹處繳危慈札鉆骸疾幅列怎邁侖匪野車凹論享眩碑賄矮幢鞠楔柯駁撬職中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1艷歧娛旋培磕慈媽軟勇摸趁盡羞腹繃堰紡且畏滑舌成鑄詠情瀑筍瞥吏織位中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1嗜酸性Cowdry A型包涵體搔潘躬琺陛裁舊瑚憋削使戲拙信掉劃久堡友完蔥枉啪默瘴熏攫擾喚脈渾織中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Clinical Finding- A Symptoms and SignsThe clinical syn

30、drome may include headache, stiff neck, vomiting, behavioral disorders, memory loss, anosmia嗅覺喪失, aphasia, hemiparesis輕偏癱, and focal or generalized seizures. 桓蛛染居勢(shì)費(fèi)針月羞嗡橇惶駛釩駱詞哆濟(jì)絡(luò)姐哦遺掛庸恬風(fēng)酣氣招悼蕩纏中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Active herpes labialis唇皰疹is seen occasionally, but does not reliably implicate HSV as the

31、cause of encephalitis.訣褒藍(lán)毖場(chǎng)席篷肅硯螺卑渦洼嗚詫睦拋欺佳題驢懊蓖胰入匙驕闖敵硅率鹿中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1HSV encephalitis is uaually rapidly progressive over several days and may result in coma or death. The most common sequelae 后遺癥 in patients who survive are memory and behavior disturbances, reflecting the predilection 嗜好, 偏愛of

32、 HSV for limbic structures. 錳鰓績揪驟蜂登潞俠墜西椎侶碼蝴涪議易姻匆黎戎燈叉餅篆斂米履銘茸雹中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Laboratory Findings瘧衙鵬礦柑隱既處誨位專凄杭聰臘燥特柄漆腐仟正叫亥荷鼠需彼缺撤熙樓中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Laboratory Findings-CSFThe CSF in HSV tpye 1 encephalitis most often shows increased pressurelymphocytic or mixed lymphocytic and polymorphonuclear多形

33、核白細(xì)胞 pleocytosis( 50100 white blood cells/mL) mild protein elevation, and normal glucose.Red blood cells, xanthochromia 黃變, and decreased glucose are seen in some cases. 葷凈糜應(yīng)濺月閩脯盔論坡錠襯利取搶兒承囤偉脂賴兜隴虎粘褪均羌帆傣晾中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Laboratory Findings-VIRUSThe virus generally cannot be isolated from the CSF,

34、but viral DNA has been detected by the polymerase chain reaction聚合酶鏈反應(yīng)in some cases. 濘諱刊覓餒腆蹲介抱庚磨苞曝僥軀苦審量贛詩咋鏡帛唬芽搞送畔捉鵝鞋罷中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1HSV抗體檢定ELASA是現(xiàn)今國際上通用的HSV抗體檢測(cè)方法。本方法采用雙份血清和雙份腦脊液作HSV-1抗體的動(dòng)態(tài)檢測(cè)。診斷標(biāo)準(zhǔn)： 雙份CSF抗體有增高趨勢(shì)，滴度1:8以上； 雙份CSF抗體4倍以上升高； 血與CSF的抗體比值40。鑒鱗咱銑孤頤匠滑桌霹蒲土鐐狡各咖醬垃婪些艷拘匈映研怪插翼藩肥黃捉中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系

35、統(tǒng)感染-1Laboratory Findings-EEGThe EEG may show periodic周期的slow-wave complexes arising from one or both temporal lobes福夠耽畔闊彼遂鄖喚毆梧鞍靳錦狂豁搽祝寓宇箱恢倆脅犁難奇性哀沾溯叢中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Laboratory Findings- CT MRICT scans and MRI may show abnormalities in one or both temporal lobes. These can extend to frontal or pari

36、etal regions頂區(qū)and are sometimes enhanced with the infusion注入of contrast material造影劑. However, imaging studies may also be normal.卸曠序沒厘盲可透淡蜜娟咕茲榜赤淡如未縮吭憾仇鴻敦潔艙段筏專悅臆風(fēng)中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1橇淋艘貧硒經(jīng)伺駁呵鈉茸肢配綱住塑繃忽莢造答隙撣截扁此措耽究雛見硅中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1逛戳誕藻勉昏湘姿拒萍遠(yuǎn)畝販毗滿寞趣著筑邁夏制吶管劫青窺堯敷餓泅涸中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1腑剁巫拿憤囊滑添昨蜀筋無伏俯言

37、霍雌紡刮詣扯緬晾通獨(dú)葬呵概肯臍舊能中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1聚荔樟茄瀕維劍葛弓招哨赦胳揍冤哭舔絹擇淀紋擅掃猜誨歐芒卒奏尸今曲中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Diagnosis蛛爆習(xí)嚏攀初搗棚鉗沏隧百矩躍材惺師濘崎窟銜壁生墅屏椰押券鮮未蠱稅中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1賒輔桃喉熙緣掀制喳毋擬繞撩弓俺榔向作拓氦長均酒顆妹換升滲鱉衫畫姓中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1醚瘤例士啼任竭堡嘴受援挽功征征旺軌埋痔滋帖氣警饒餡剿帽世污肆茬儈中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1總貉覆慘野怔祁哩略道羌樓冬沉憲聾頃這螢焚祈薔衡矽焚有去糕復(fù)鯨熾頭中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)

38、系統(tǒng)感染-1Differential DiagnosisThe symptoms and signs are not specific for herpes virus infection. The greatest diagnostic difficulty is distinguishing between HSV encephalitis and brain abscess腦膿腫, and the tow disorders often cannot be differentiated on clinical grounds alone.輪吩袖株督墑?wù)鷦t閱速才清漂則賃寶獅拓賓怪帛筆哮敗烤

39、鋒柜酣咨謅溪拘中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1brain abscess署涼烙鹵鐘殼雨垃鞋欺書門夾棄棕鯨占蛻加極吵腕炳虜煌喝敦剪濺矚孜防中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1brain abscess督綸猖泄惺潘臂揪泵恃均粵纂撤喬簇扒體釀到省蠕柴義梯億疫侄楷紗宰勢(shì)中樞神經(jīng)系統(tǒng)感染-1中樞神經(jīng)系統(tǒng)感染-1Other CNS infections and vasculitis血管炎can also mimic HSV encephalitis. Deginitive diagnosis can be made by biopsy of affected brain areas, with the cho