中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座培訓(xùn)課件

1、中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座第一節(jié) 概述 Term：Infections of CNS All kinds of pathogen (bacteia,viruses,spirochete ,parasites,fungi,rickettsia and prion prottein) invade cerebral parenchyma, meninges and blood vessel lead to acute and subacute infections.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座2第一節(jié) 概述 Term：Infections of CNS第一節(jié) 概述分類(lèi)

2、： 感染的部位 ；發(fā)病情況及病程 ；特異性致病因子 CNS感染途徑(pathway of infection)hematogenous spread；direct infection ；Peripheral nerves pathwayCNS病毒感染性疾病新的認(rèn)識(shí) 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座3第一節(jié) 概述分類(lèi)： 感染的部位 ；發(fā)病情況及病程 ；特異性第二節(jié) 病毒感染性疾病 Viral infections of CNS單純皰疹病毒性腦炎Herpes Simplex Encephalitis Creutzfeldt-Jakob Disease中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座4第二節(jié) 病毒感染性疾病

3、 Viral infectioHerpes Simplex Encephalitis 病因及發(fā)病機(jī)制( Causes and Mechanisms)病理（pathology) 臨床表現(xiàn) (Clinical features)輔助檢查 (laboratory finding)診斷及鑒別診斷 (Diagnosis and Differential Diagnosis)治療（treatment) 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座5Herpes Simplex Encephalitis 病因HSE-Causes and MechanismsHSV-嗜神經(jīng)(neurotropic )DNA病毒 90%的人類(lèi)

4、HSE是由I型引起 70%HSE起因于內(nèi)源性病毒的活化 (復(fù)發(fā)性皰疹感染 )25%的病例是原發(fā)感染 (口腔和呼吸道 )6%15%系由II型所致 (產(chǎn)婦生殖道HSV-II原發(fā)感染 )絕大多數(shù)新生兒的HSE系HSV-II引起 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座6HSE-Causes and MechanismsHSV-HSE- Pathology顳葉、額葉等部位出血性壞死 |、滲出急性期后可見(jiàn)小膠質(zhì)細(xì)胞增生 Intense hemorrhagic necrosis of the inferior and medial parts of the temporal lobes and the medial-

5、orbital parts of the frontal lobes.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座7HSE- Pathology顳葉、額葉等部位出血性壞死 |HSE-PathologyCowdry A型包涵體 (A type inclusion body)存在于病灶邊緣的部分神經(jīng)細(xì)胞核內(nèi) 及星型細(xì)胞和少突膠質(zhì)細(xì)胞核內(nèi)。 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座8HSE-PathologyCowdry A型包涵體 (A tHSE- Clinical feature1任何年齡、季節(jié)均可發(fā)病原發(fā)感染的潛伏期為221天，平均6天；前驅(qū)期癥狀2病程 多急性起病 ，口唇皰疹史 （1/4），高熱，首發(fā)癥狀 ：頭痛、輕微

6、的意識(shí)和人格改變 或全身性或部分性運(yùn)動(dòng)性發(fā)作 ；病情緩慢進(jìn)展精神癥狀表現(xiàn)突出智能障礙也較明顯 3 神經(jīng)癥狀 局灶性腦損害 ；腦膜刺激征 ；意識(shí)障礙 ；全身性或部分性癲癇 。重癥腦疝形成而死亡 （死亡率高達(dá)40%70% ）。中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座9HSE- Clinical feature1任何年齡、季HSE-Clinical feature1.It occurs sporadically throughout the year and in patients of all ages. During prodromal stage:fever,headache,muscular ache

7、etc.2.The onset is acute,patients may had herpes labialis(1/4) and fever.The early manifestations:headach,personality change,slight concious disorder and seizures .Psychotic behavior, memory loss become evident later.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座10HSE-Clinical feature1.It occurHSE-Clinical feature3.Neurologic symp

8、tom and sign hemiparesis,aphasia,meningeal rritatioin,disorder of conciousness,focal or generalized seizures.It may result in coma or death in some cases.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座11HSE-Clinical feature3.NeurologHSE- Laboratory Diagnosis1腦電圖 彌漫性高波幅慢波 2頭顱CT可正常，也可見(jiàn)一側(cè)或雙側(cè)顳葉、海馬及邊緣系統(tǒng)局灶性低密度區(qū) 3腦脊液檢查壓力及細(xì)胞數(shù)正?；蜉p度增高，重癥者可明顯

9、增高。4腦脊液病原學(xué)檢查對(duì)診斷頗有意義 檢測(cè)HSV抗原 檢測(cè)HSV特異性lgM、lgG抗體 CSF中HSV-DNA（PCR快速診斷）腦組織病理學(xué)及病原學(xué)檢查 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座12HSE- Laboratory Diagnosis1腦電HSE-Laboratory DiagnosisEEG:lateralized high-voltage slow-waves.CT scans show hypodensity of the affected areas. MRI shows signal changes in almost all. 圖1 圖2 圖3CSF:increased pr

10、essure, lymphocytic pleocytosis, mild protein elevation and normal glucose.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座13HSE-Laboratory DiagnosisEEG:lHSE-Laboratory DiagnosisTests for the detection of HSV antigen in the CSF by the application of PCR are useful.The absolute way for dianosis:fluorecent antibody study and viral cul

11、true of cerebral tissue obtained by brain biopsy. 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座14HSE-Laboratory DiagnosisTestsHSE-diagnosis1臨床診斷依據(jù)：口唇或生殖道皰疹史；高熱、腦炎、精神癥狀三主征及局灶性神經(jīng)系統(tǒng)損害體征；腦脊液紅、白細(xì)胞數(shù)增多，糖和氯化物正常；腦電圖以顳、額區(qū)損害為主的腦彌漫性異常；頭顱CT或MRI發(fā)現(xiàn)顳葉局灶性出血性腦軟化灶；特異性抗病毒藥物治療有效。2. 實(shí)驗(yàn)室檢查 ：CSF病原體檢查及病理檢查中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座15HSE-diagnosis1臨床診斷依據(jù)：口唇或生殖道HSEDif

12、ferential diagnosis急性播散性腦脊髓炎：多在感染或疫苗接種后急性發(fā)病 結(jié)核性腦膜腦炎：結(jié)核病病史或接觸史，慢性過(guò)程，腦膜刺激征是TBM早期表現(xiàn) ，可有腦神經(jīng)損害，CSF檢查提示診斷 。 腸道病毒性腦炎：也是病毒性腦炎的常見(jiàn)病因之一，多見(jiàn)于夏秋季，可為流行性或散發(fā)性 帶狀皰疹病毒性腦炎 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座16HSEDifferential diagnosis急性播散HSE -treatmentAntiviral agentsThere was no specific treatment for HVE untill the late 1970s acyclovir w

13、as introduced.Acyclovir and ganciclovir are most effective drugs.They significantly reduce both the mortality and morbidity.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座17HSE -treatmentAntiviral agentsHSE- treatment1抗病毒化學(xué)藥物治療 (1) 無(wú)環(huán)鳥(niǎo)苷 (阿昔洛韋, acyclovir) (2) 更昔洛韋(ganciclovir) 2免疫治療干擾素及其誘生劑 轉(zhuǎn)移因子 腎上腺皮質(zhì)激素3全身支持治療 4對(duì)癥治療 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座18

14、HSE- treatment1抗病毒化學(xué)藥物治療 中樞神Creutzfeldt-Jakob Disease Creutzfeldt-Jakob病 (CJD)是最常見(jiàn)的人類(lèi)朊蛋白病 （具傳染性的朊蛋白所致的散發(fā)性中樞神經(jīng)系統(tǒng)變性疾?。?CJD is also called Subacute Spongiform Encephalopathy. (SSE)It belongs to the category called the transmissible spongiform encephalopathies (prion diseases)中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座19Creutzfeldt

15、-Jakob Disease CreuPrP and prion Protein dease朊蛋白(prion protein, PrP)一種既具有傳染性又缺乏核酸的非病毒性致病因子 Prion is neither a virus nor a viroid(nucleic acid alone,without a capsid structure)but the conversion of a normal cellular protein.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座20PrP and prion Protein dease朊蛋白PrP and prion Protein dease人類(lèi)朊

16、蛋白病還有 Kuru病、Gerstmann-Straussler綜合征(GSS)、致死性家族性失眠癥(FFI)、缺乏特征性病理改變的朊蛋白癡呆和伴痙攣性截癱的朊蛋白癡呆 。中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座21PrP and prion Protein dease人類(lèi)朊What is CJD?Refer to a distinctive cerebral disease in which a rapidly progressive and profound dementia associated with cerebellar ataxia,diffuse myoclonic jerks and a

17、 variety of other visual and neurologic abnormalities. The outstanding features of the neuropathologic changes are widespread neuronal loss and gliosis accompanied by a striking vacuolation or spongy state of the affected regions中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座22What is CJD?Refer to a distincCJD- Pathogenesis and Typ

18、e1型和2型存在于散發(fā)性CJD(sporadicula CJD ) 3型為醫(yī)源性CJD-通過(guò)角膜、硬腦膜移植，腦源性生物制品和埋藏未充分消毒的腦電極而傳播 Type-3:iatrogenic CJD by transplantation of corneas and implantation of infected depth electrdes etc.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座23CJD- Pathogenesis and Type1型和2CJD- Pathogenesis4型是新變異型-與瘋牛病(MCD)具有相似的種系特異性 PrP基因突變形成遺傳性家族型CJD 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知

19、識(shí)講座24CJD- Pathogenesis4型是新變異型-與瘋牛病(CJD- Pathology大體-腦呈海綿狀改變，皮質(zhì)、基底節(jié)和脊髓萎縮變性。Spongy appearance shows in cerebral and cerebellar cortex.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座25CJD- Pathology大體-腦呈海綿狀改變，皮質(zhì)、基 CJD -Pathology顯微鏡下-神經(jīng)元丟失、星形細(xì)胞增生、細(xì)胞胞漿中空泡形成，可發(fā)現(xiàn)感染組織內(nèi)異常PrP淀粉樣斑塊。 Widespread neuronal loss and gliosis accompanied by a striki

20、ng vacuolation and PrPsc in the affected regions.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座26 CJD -Pathology顯微鏡下-神經(jīng)元丟失、星形細(xì)CJD-臨床表現(xiàn) 1發(fā)病年齡2578歲，平均58歲，男女均可罹患，新變異型平均26歲 2隱襲起病，緩慢進(jìn)行性發(fā)展初期：表現(xiàn)頗似神經(jīng)癥，可有頭痛、眩暈、共濟(jì)失調(diào)及視覺(jué)障 礙等 中期：進(jìn)行性癡呆為主要表現(xiàn)，伴人格改變 ，有失語(yǔ)、偏癱、錐體束征 或肌肉萎縮 及2/3病人出現(xiàn)肌陣攣，最具特征性 晚期：出現(xiàn)尿失禁、無(wú)動(dòng)性緘默、昏迷 等3變異型CJD臨床表現(xiàn)共濟(jì)失調(diào)和行為改變 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座27CJD-臨床

21、表現(xiàn) 1發(fā)病年齡2578歲，平均58歲，男女CJD-clinical feature1. It occurs mostly in the late middle age, although can occur in young adult.2. Progressive development.The early stage: AtypicalThe mid stage: gradual dementia with personality change. Myoclonus occurs in 2/3 of patients.The late stage : Coma, akinetic mut

22、ism.3. Variant CJD中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座28CJD-clinical feature1. It occuCJD- Laboratory Finding1免疫熒光檢測(cè)CSF中14-3-3蛋白可呈陽(yáng)性 -可疑CJD病人重要指標(biāo)。血清S100蛋白（隨病情進(jìn)展呈持續(xù)性增高）。2腦電圖：疾病中晚期可出現(xiàn)間隔0.52秒周期性棘-慢復(fù)合波。 3晚期CT和MRI：可見(jiàn)腦萎縮；MRI顯示雙側(cè)尾狀核、殼核T2呈對(duì)稱(chēng)性均質(zhì)高信號(hào) ，T1可完全正常 。中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座29CJD- Laboratory Finding1免疫熒光檢CJD-Laboratory FindingTest

23、of CSF by immunoassay, the finding of 14-3-3 protein is very useful in separating SSE. Also is the serum P-100.EEG :High voltage slow and sharp-wave complexes(0.5-2Hz).MRI subtle hyperintensity of the lenticular nuclei on T2 weighted images when the disease is fully established.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座30CJD-L

24、aboratory FindingTest of CJD- Diagnosis(診斷標(biāo)準(zhǔn))很可能(probable) CJD在2年內(nèi)發(fā)生的進(jìn)行性癡呆；肌陣攣、視力障礙、小腦癥狀、無(wú)動(dòng)性緘默等四項(xiàng)中具有其中兩項(xiàng)；腦電圖周期性同步放電的特征性改變。如病人腦活檢發(fā)現(xiàn)海綿狀態(tài)和PrPSC者，則為確診的CJD?？捎媚X蛋白檢測(cè)代替腦電圖特異性改變。中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座31CJD- Diagnosis(診斷標(biāo)準(zhǔn))很可能(probabCJD-DiagnosisProbable SSE1)Progressive dementia in 2 years2)Two of myoclonus, visual

25、disterbance, ataxia and akinetic mutism.3)EEG: synchronous discharge.Definite diagnosisSpongy or PRPsc is found by brain tissue biopsy.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座32CJD-DiagnosisProbable SSE中樞神經(jīng)系CJD-鑒別診斷 Alzheimer病進(jìn)行性核上性麻痹橄欖腦橋小腦萎縮腦囊蟲(chóng)病肌陣攣性癲等鑒別中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座33CJD-鑒別診斷 Alzheimer病中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座培訓(xùn)課件腦囊蟲(chóng)病Cere

26、bral Cysticercosis中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座35腦囊蟲(chóng)病Cerebral Cysticercosis中樞神經(jīng)Cerebral Cysticercosis由豬帶絳蟲(chóng)蚴蟲(chóng)(囊尾蚴)寄生腦組織形成包囊所致。Cysticercosis is the larval stage (cysticercus) of infection with the pork tapeworm.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座36Cerebral Cysticercosis由豬帶絳蟲(chóng)蚴蟲(chóng)Cerebral Cysticercosis是一種最常見(jiàn)的CNS寄生蟲(chóng)感染，也是我國(guó)北方癥狀性癲常見(jiàn)的病因之一。Cysti

27、cercosis is a leading cause of epilepsy and other neurologic disturbances.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座37Cerebral Cysticercosis是一種最常見(jiàn)的C腦囊蟲(chóng)病-病因及發(fā)病機(jī)制 最常見(jiàn)的傳播途徑是攝入帶有蟲(chóng)卵污染的食物 少見(jiàn)原因?yàn)楦亻T(mén)-口腔轉(zhuǎn)移而形成的自身感染或者是絳蟲(chóng)的節(jié)片逆行入胃 蟲(chóng)卵進(jìn)入十二指腸內(nèi)孵化逸出六鉤蚴，蚴蟲(chóng)經(jīng)血液循環(huán)分布全身并發(fā)育成囊尾蚴，有不少囊尾蚴寄生在腦內(nèi)。 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座38腦囊蟲(chóng)病-病因及發(fā)病機(jī)制 最常見(jiàn)的傳播途徑是攝入帶有蟲(chóng)卵污染腦囊蟲(chóng)病- Pathology典型的

28、包囊大小為510mm，可有薄壁包膜，或呈多個(gè)囊腔 The cysts may be 5-10mm.Thelesions are most often multiple but may be solitary.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座39腦囊蟲(chóng)病- Pathology典型的包囊大小為510mm，Cysticercosis -Pathology腦實(shí)質(zhì)中包囊內(nèi)存活的蚴蟲(chóng)很少引起炎癥，通常在感染后數(shù)年蚴蟲(chóng)死亡后才出現(xiàn)明顯的炎癥反應(yīng) Only when the cyst degenerated many months or years after the initial infestation, a

29、n inflammatory and granulomatous reaction is elicited and focal symptoms arise.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座40Cysticercosis -Pathology腦實(shí)質(zhì)中包囊腦囊蟲(chóng)病- Clinical Feature1腦實(shí)質(zhì)型 臨床癥狀與包囊的位置有關(guān) 。2蛛網(wǎng)膜型 頭痛、腦積水和虛性腦膜炎等。3腦室型 阻塞性腦積水；布龍(Brun)征發(fā)作（移動(dòng)的包囊，可突然阻塞第四腦室正中孔，導(dǎo)致腦壓突然增高，引起眩暈、嘔吐、意識(shí)障礙和跌倒 ） 。4脊髓型 非常罕見(jiàn) 中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座41腦囊蟲(chóng)病- Clinical F

30、eature1腦實(shí)質(zhì)型 Clinical FeatureThe cerebral manifestations of cysticercosis are diverse, related to the encystment and subsequent calcification of the larvae in cerebral parenchyma, subarachnoid space and ventricle.The flow of CSF may be obstructed by large subarachnoid or intraventricular cyst and leads to obstructive hydrocephalus.中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座42Clinical FeatureThe cerebral m腦囊蟲(chóng)病- Laboratory Diagnosis1血常規(guī)檢查嗜酸性粒細(xì)胞增多。 2用ELISA和Western 印跡法檢測(cè)血清囊蟲(chóng)抗體常為陽(yáng)性。 3頭顱CT和MRI可發(fā)現(xiàn)腦積水及被阻塞的部位，CT可見(jiàn)單個(gè)或多個(gè)鈣化點(diǎn)，CT平掃見(jiàn)包囊為小的透亮區(qū)，增強(qiáng)掃描為彌散性或環(huán)形增強(qiáng)影。中樞神經(jīng)系統(tǒng)感染醫(yī)學(xué)知識(shí)講座43腦囊蟲(chóng)病- Laboratory Diagnosis1血Laboratory Diagno