病毒性脑炎诊断的困惑课件.ppt

病毒性脑炎诊断的困惑,脑出血,炎症,病毒性脑炎,病毒性脑炎引发的脑出血,Herpeszosterencephalitispresentingasmultiplecerebralhemorrhagesararepresentation:acasereport.JournalofMedicalCaseReports2013,7:155,Herpessimplex1encephalitispresentingasabrainhaemorrhagewithnormalcerebrospinalfluidanalysis:acasereport.JournalofMedicalCaseReports2008,2:387,单纯疱疹病毒性脑炎合并出血性脑卒中1例报告.新医学,2007,11(38)752-753.,病毒感染破坏脑组织的同时波及病灶中的血管，一般只表现为出血坏死性炎症反应，如损害较大动脉，则会发生蛛网膜下隙出血和脑实质血肿。,Neuropathologyofviralinfections.HandbookofClinicalNeurology,Vol.123(3rdseries),2014.,诊断的困惑,病毒性脑炎的诊断依据,感染性脑炎,自身免疫性脑炎,感染性脑炎,自身免疫性脑炎,自身免疫性脑炎的临床分类,自身免疫性脑炎中国专家共识2017,自身免疫性脑炎的诊断条件,4合理地排除其他病因,确诊,鉴别,病原学检测,病毒一览,Epidemiologyofviralencephalitisin2011.Mdecineetmaladiesinfectieuses41(2011)453464,诊断思路,病毒性脑炎患者病毒学诊断需要首先考虑以下因素:,AGuidetoUtilizationoftheMicrobiologyLaboratoryforDiagnosisofInfectiousDiseases:2013RecommendationsbytheInfectiousDiseasesSocietyofAmerica(IDSA)andtheAmericanSocietyforMicrobiology(ASM).ClinInfectDis.2013;57:e22-e121.Casedefinitions,diagnosticalgorithms,andprioritiesinencephalitis:consensusstatementoftheinternationalencephalitisconsortium.ClinInfectDis.2013;57:1114-1128.,Brainregionsaffectedbyvirusesthatcausemeningitisandencephalitis,Viraldiseasesofthecentralnervoussystem.CurrentOpinioninVirology2015,11:4454,影像学的帮助,单纯疱疹病毒脑炎,Centralnervoussysteminfectionsincancerpatients.SeminNeurol,2010,30:296310.,水痘-带状疱疹病毒脑炎,Postvaricellabasalgangliainfarctioninchildren.AJNRAmJNeuroradiol,1995,16:449452.,St.Louisencephalitisandthesubstantianigra:MRimagingevaluation.AJNRAmJNeuroradiol,1999,20:12811283.,圣路易斯脑炎,ComparisonofCTscanandMRIfindingsinthediagnosisofJapaneseencephalitis.JNeurolSci,2010,174:38.,日本脑炎,MultiplereversibleMRsignalchangescausedbyEpstein-Barrvirusencephalitis.AJNRAmJNeuroradiol,2006,27:14471449.,EB病毒脑炎,Congenitalcytomegalovirusinfectionanddisease.AdvPediatrInfectDis,1996,11:135162.,巨细胞病毒脑炎,Prospectivecasecontrolstudyofencephalopathyinchildrenwithdenguehemorrhagicfever.AmJTropMedHyg,2001,65:848851.,登革热,Chikungunyafever:CNSinfectionandpathologiesofare-emergingarbovirus.ProgNeurobiol,2010,91:121129.,切昆贡亚热,LaCrosseviralencephalitismimicsherpessimplexviralencephalitis.PediatrNeurol25:413415.,LaCrosse病毒脑炎,Fatalencephalitisduetonovelparamyxovirustransmittedfromhorses.Lancet,1997,349:9395.,Hendra病毒性脑炎,ImagingoftopographicviralCNSinfections.NeuroimagingClinNAm,2008,18:8592,viii.,Nipah病毒脑炎,实验室诊断手段,Casedefinitions,diagnosticalgorithms,andprioritiesinencephalitis:consensusstatementoftheinternationalencephalitisconsortium.ClinInfectDis.2013;57:1114-1128.,脑脊液PCR的敏感性及特异性均超过95%，有研究建议在治疗2周后，再次进行脑脊液PCR检查，如果结果仍为阳性，则需要继续抗病毒治疗。研究显示，PCR在神经系统症状出现3-7日后的阳性率最高，第二周病毒DNA减少至3050%，15天后减少至25%。,Casedefinitions,diagnosticalgorithms,andprioritiesinencephalitis:consensusstatementoftheinternationalencephalitisconsortium.ClinInfectDis.2013;57:1114-1128.Diagnosisofherpessimplexencephalitis:applicationofPCRtoCSFfrombrain-biopsiedpatientsandcorrelationwithdisease.JInfectDis1995;171:857-863.,RT-PCR以敏感性高、特异性高、污染少、可定量等优点著称。PCR在部分确诊的脑炎患者中呈阴性结果，因此对于具有典型脑炎临床及影像学特征的患者，不要因为此阴性结果而排除病毒性脑炎诊断。,Europeanconsensusonviralencephalitis.Lancet,1997,349:299300.DevelopmentandFieldTestingofaReal-TimePCRAssayforCaprineArthritis-Encephalitis-Virus(CAEV).OpenVirolJ.2012;6:82-90.,脑脊液白细胞计数少于10/mm3时，PCR检测阳性率明显下降。研究证实，单纯疱疹病毒脑炎的病毒负荷在102-107单纯疱疹病毒基因组/mL脑脊液，经治疗后，其数量级将下降，否则标志预后不佳。,MonitoringofherpessimplexvirusDNAtypes1and2viralloadincerebrospinalfluidbyreal-timePCRinpatientswithherpessimplexencephalitis.JMedViro,2009,l81:14321437.PrognosticvalueofintrathecalantibodyproductionandDNAviralloadincerebrospinalfluidofpatientswithherpessimplexencephalitis.JNeurol256:12431251.,体征,影像,电生理