病毒性腦炎診斷的困惑

1、病毒性腦炎診斷的困惑,腦出血,炎癥,病毒性腦炎,病毒性腦炎引發(fā)的腦出血,Herpes zoster encephalitis presenting as multiple cerebral hemorrhages – a rare presentation:a case report.Journal of Medical Case Reports 2013, 7:155,,Herpes simplex 1 encephalitis pr

2、esenting as a brain haemorrhage with normal cerebrospinal fluid analysis: a case report. Journal of Medical Case Reports 2008, 2:387,,單純皰疹病毒性腦炎合并出血性腦卒中1例報告.新醫(yī)學(xué),2007,11(38)752-753.,病毒感染破壞腦組織的同時波及病灶中的血管，一般只表現(xiàn)為出血壞死性炎癥反應(yīng)，如損害

3、較大動脈，則會發(fā)生蛛網(wǎng)膜下隙出血和腦實質(zhì)血腫。,Neuropathology of viral infections. Handbook of Clinical Neurology, Vol. 123 (3rd series),2014.,診斷的困惑,病毒性腦炎的診斷依據(jù),,,感染性腦炎,自身免疫性腦炎,感染性腦炎,自身免疫性腦炎,自身免疫性腦炎的臨床分類,《自身免疫性腦炎中國專家共識 2017》,自身免疫性腦炎的診斷條件,,

4、4 合理地排除其他病因,,,,,確診,鑒別,病原學(xué)檢測,病毒一覽,Epidemiology of viral encephalitis in 2011. Médecine et maladies infectieuses 41 (2011) 453–464,,,診斷思路,病毒性腦炎患者病毒學(xué)診斷需要首先考慮以下因素:,A Guide to Utilization of the Microbiology Laboratory

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9、and MRI findings in the diagnosis of Japanese encephalitis. J Neurol Sci,2010, 174: 3–8.,日本腦炎,,Multiple reversible MR signal changes caused by Epstein-Barr virus encephalitis. AJNR Am J Neuroradiol ,2006,27: 1447–1449.,

10、EB病毒腦炎,Congenital cytomegalovirus infectionand disease. Adv Pediatr Infect Dis ,1996,11: 135–162.,巨細胞病毒腦炎,Prospective casecontrol study of encephalopathy in children with dengue hemorrhagic fever. Am J Trop Med Hyg ,2001

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13、 viii.,Nipah病毒腦炎,實驗室診斷手段,Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clin Infect Dis. 2013;57:1114-1128.,,腦脊液PCR 的敏感性及特異性均超過9

14、5%，有研究建議在治療2周后，再次進行腦脊液PCR檢查，如果結(jié)果仍為陽性，則需要繼續(xù)抗病毒治療。研究顯示，PCR在神經(jīng)系統(tǒng)癥狀出現(xiàn)3-7日后的陽性率最高，第二周病毒DNA減少至30–50%，15天后減少至25%。,Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the internation

15、al encephalitis consortium. Clin Infect Dis.2013;57:1114-1128.Diagnosis of herpes simplex encephalitis: application of PCR to CSF from brain-biopsied patients and correlation with disease. J Infect Dis 1995;171:857-863.

16、,,RT-PCR以敏感性高、特異性高、污染少、可定量等優(yōu)點著稱。PCR在部分確診的腦炎患者中呈陰性結(jié)果，因此對于具有典型腦炎臨床及影像學(xué)特征的患者，不要因為此陰性結(jié)果而排除病毒性腦炎診斷。,European consensus on viral encephalitis. Lancet ,1997,349: 299–300.Development and Field Testing of a Real

17、-Time PCR Assay for Caprine Arthritis-Encephalitis-Virus (CAEV).Open Virol J. 2012;6:82-90.,,腦脊液白細胞計數(shù)少于10/mm3時，PCR檢測陽性率明顯下降。研究證實，單純皰疹病毒腦炎的病毒負荷在102-107單純皰疹病毒基因組/mL腦脊液，經(jīng)治療后，其數(shù)量級將下降，否則標(biāo)志預(yù)后不佳。,Monitoring of herpes simplex

18、virus DNA types 1 and 2 viral load in cerebrospinal fluid by real-time PCR in patients with herpes simplex encephalitis. J Med Viro,2009,l 81: 1432–1437.Prognostic value of intrathecal antibody production and DNA viral

19、load in cerebrospinal fluid of patients with herpes simplex encephalitis. J Neurol 256: 1243–1251.,,體征,影像,電生理,病原學(xué)檢測,癥狀,排他,,Backman et al.The development of an intervention to promote adherence to national guidelines for