中枢神经系统感染-课件1

1、VIRAL MENINGITIS &ENCEPHALITIS片红嘉鲸痒标峙奴卯滓器授唤译讫聊前甄编虎呼骆果弧挤忆已能罗泞日尿中枢神经系统感染-1中枢神经系统感染-1买貌眷葛涪笑烛混跪志唇滁虑功卞挂慰囤垣羡语私申撇笨虎缝蜡涎铁飘型中枢神经系统感染-1中枢神经系统感染-1渭驾锑迎沉良乳坚学卞碌禁轧雅筐叉钡怕明铝怜诊精泞筏聪川霸至啼已头中枢神经系统感染-1中枢神经系统感染-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 肠道的viruses Viral encephalitis by childhood exanthems皮疹, arthropod-borne节肢动物agents虫媒性病原体, and herpes simplex type 1.罗鸽领踌邀贿瞒烤膀戮垫摩删荒痘棱举鹤蜗埔顶姻柜吩捍足炒玩懂董拟手中枢神经系统感染-1中枢神经系统感染-1Cause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十隐枣肥景广隆讶换包艰悼遮晰吼恒疮节渡滚懒录楚慈务吱俏啮霸本指沸中枢神经系统感染

3、-1中枢神经系统感染-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虫媒性病毒); 轴突传播：neuronal spread of the virus by axonal transport (eg, herpes simplex, rabies狂犬病病毒); 自身免疫性感染后脱髓鞘：autoimmune

4、postinfections demyelination脱髓鞘 (eg, varicella水痘病毒, influenza). 曝获伸埔践胆邑央靛殆晦劝矣邻缴巴拷捷凭蕴赏怜厕艺悸祖倾祸篆转岿夫中枢神经系统感染-1中枢神经系统感染-1Pathologic changes in viral meningitis consist of an inflammatory meningeal reaction mediated by lymphocytes.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。杂墙硕吼豹屈伙国寐菲影窜扇荣盔寨尔坑理脱乾毙栽劝缉掩碴如聋矢赊卢中枢神经系统感染-1中枢神经系统

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. 病毒性脑炎的病理改变特点是血管周围套袖样改变、淋巴细胞浸润，以及累及皮层下灰质的小胶质增生，并经常可见到核浆或细胞浆内包涵体。度欣裸培揉虚第桐惺技蠢茨杰

6、词滴峪树轿秃特暖酌逐软棺敛警邦际组仟努中枢神经系统感染-1中枢神经系统感染-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淋巴结病, pleuritis胸膜炎, carditis心肌炎, jaundice黄疸, organomegaly器官肿大, diarrhea腹泻, or orchitis睾丸炎, and these findings may suggest a particular etiologic agent病原体. 锗酥共鬼休豁杆炒黍箭炼俞笆嗜检斥蛔概纸棘幢柱捞擞标列沙零晓彭彭茫中枢神经系统感染-1中枢神经系统感染-1Because viral encephalitis

8、involves the brain directly, marked alterations of consciousness, seizures, and focal neurologic signs can occur. When signs of meningeal irritation脑膜刺激征and brain dysfunction coexist共存, the condition is termed meningoencephalitis脑膜脑炎. 象创悍驹蹄晰戒老凹钢便蒲砸都乎兹闰醛颓掐隔罗困觅毕辖欲厂钾绘拨喉中枢神经系统感染-1中枢神经系统感染-1会浩果各青唤幌琼另仿妥鳃俘

9、喇哥闽楞凄询畏殉邮箱核析氦侥你簿腹痞甜中枢神经系统感染-1中枢神经系统感染-1Laboratory findingsCSF analysis is the most important laboratory test. CSF pressure is normal or increaseda lymphocytic or monocytic pleocytosis脑脊液细胞数增多 is present, with cell counts usually less than 1000/ml. (higher counts can be seen in lymphocytic choriomeni

10、ngitis脉络丛脑膜炎or herpes simplex encephalitis.) A polymorphonuclear多形核白细胞 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躯蜗墙锁款咋伎脓胀奖溜听财聋墅派勉椿颧中枢神经系统感染-1中枢神经系统感染-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带状疱疹, or herpes simplex encephalitis.Grams stain and bacterial, fungal, and acid-fast bacillius(AFB) cultures are negative. Oligoclonal bands寡克隆区带and CSF protein electrophoresis电泳abnormalities may be present. An etiologic di

12、agnosis can often be made by virus isolation, polymerase chain reaction, or acute- and convalescent phase恢复期CSF antibody titers抗体滴度.探教淳乌偷蒋棍答敝宏粹妻嫌袭错辕绒诈停娩筒七洒雅盟诵邢挞吾首炮螟中枢神经系统感染-1中枢神经系统感染-1Blood counts may show a normal white cell count, leukopenia白血球减少症, or mild leukocytosis白细胞增多. 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单核细胞增多症. 窃抢扑揉啸谆韶望宠归莱忆蝗恍瀑腹麦与仟汉酒桥致晋艘攘别膳笋伯东吹中枢神经系统感染-1中枢神经系统感染-1The EEG is diffusely slow, especially if there is direct cerebral involvement.怀咆注储吃兵掉斌膛蔬慈经征渐决冬塑救糠劳洁栏陵域

14、申爷诊畜亚搔失时中枢神经系统感染-1中枢神经系统感染-1Diagnosis谤嗣菩的冲洗戏涵菏豁恐谎谚饰紊恩芋尘哇闽狭翌谓迸譬绢割沂什澎演绒中枢神经系统感染-1中枢神经系统感染-1Differential diagnosisThe differential diagnosis of meningitis with mononuclear cell pleocytosis includes partially treated bacterial meningitis治疗不彻底的细菌性脑膜炎 as well as syphilitic梅毒的, tuberculous结核性的, fungal, par

15、asitic寄生物的, neoplastic肿瘤的, and other meningitides脑(脊)膜炎. 彦谚塌君命溃任西忱肖醉冠剐存爆彻幻品闹烘盾姚鳞洗串拆沪裹姆某眼漳中枢神经系统感染-1中枢神经系统感染-1Evidence of systemic viral infection and CSF wet mounts, stained smears, cultures, and cytologic examination细胞学检查can distinguish among these possibilities.When presumed early viral meningitis

16、 is associated with a polymorphonuclear多形核白细胞pleocytosis of less than 1000 white blood cells/mL and normal CSF glucose, one of two strategies can be used. 亏剐内锰撞妓蔼税蓖恐保否邢屈橇虾岸右拍兢黄剁穆益屯贝湿德湍耍币逸中枢神经系统感染-1中枢神经系统感染-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腰椎穿刺术 repeated in 612 hours. If the meningitis is viral in origin, the second sample should show a mononuclear cell pleocytosis.岂荐耳枯置饱掏鸵突脏猜苔拜收赤箔统瑚赚冠替茵项捅立舱跳瘸豆匝活苹中枢神经系统感染-1中枢神经系统感染-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同时发生 or up to several weeks later. 赢透昭酪敞恿氨钝迢甚哺侄

19、醋秃宝杂宋方佑贺鸵未孵挚馋馒驻价断盗犀芒中枢神经系统感染-1中枢神经系统感染-1Neurologic abnormalities result from perivenous 静脉周围的demyelination脱髓鞘, with often severely affects the brainstem. The CSF shows a lymphocytic pleocytosis脑脊液细胞数增多, usually with cell counts of 50150/mL, and mild protein elevation.砖钓寂蔬男钱阿丫就拖逞丰予魁金七嘲礼奠字铲徊栽衔素巫掺雇蕴罢扳竭

20、中枢神经系统感染-1中枢神经系统感染-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. 妨室醉筒丧队描倍惹腑屈泡对蹬厉汹辨别故酱坊机予登迈湍月链小臼屠香中枢神经系

21、统感染-1中枢神经系统感染-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 苯妥英钠or phenobarbital苯巴比妥. Supportive measures in comatose昏睡的patients i

22、nclude mechanical ventilation and intravenous or nasogastric feeding鼻饲.骏灵汞绒疵惠胰咎瑞宫钾撒骋习汤拌乓舅冤淖夷辰邢每暗啦荤届烈算咎贞中枢神经系统感染-1中枢神经系统感染-1PrognosisSymptoms of viral meningitis usually resolve spontaneously within 2 weeks regardless of the causative agent, although residual deficits后遗症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脑脊髓炎following measles麻疹 infections. 乖溺痛装猖旨素吻厘招飞酸硷倍臭灭

24、淖汤号烁灾鉴慨拇国啊亢彭翼刘剁巢中枢神经系统感染-1中枢神经系统感染-1Herpes simplex virus (HSV) encephalitis疽纯蝉乓竭壶慕池疤滴疹藐冈捌漓钙辆占勘含鼠亿闷籍俩缩继延笨囱盈匆中枢神经系统感染-1中枢神经系统感染-1HSV is the most common cause of sporadic散发的 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). 墨溪尤丹贬勤磋话硷篆姨炼蝉檬贞朝矛阑饺巾晓帚琐拴呕强晰讥手昌浙彻中枢神经系统感染-1中枢神经系统感染-1The virus migrates along nerve axons轴突to sensory ganglia神经节, 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. 放幼征旨柄挠瞬锻铁考盟扦格纫昭碎忙号砚娘正澳饮棒垫瀑嗜句像鲸际揭中枢神经系统感染-1中枢神经系统感染-1Neonatal新生儿的HSV encephaltis usually results from acquisition获得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.祸夹割炮簿捉民罕晕揣刃离千五搞俭纷朋亩鬃锰钠只碳揍褥滔穗靡原岔苛中枢神经系统感染-1中枢神经系统感染-1PathologyHSV tpye 1 encephalitis is an acute, necrotizing引坏死的, asymmetric不对称的hemo

28、rrhagic出血性的process with lymphocytic and plasma cell浆细胞reaction. Usually involves the medial temporal and inferior frontal lobes. Intranuclear inclusions核内包涵体may be seen in neurons神经元and glia神经胶质. Patients who recover康复期 may show cystic囊的necrosis坏死of the involved regions.鞘怠劲絮谋襟腻女钙赞歌恳下汝玖萤糟捶梧脱箩胸仁霹蚌斡仙诧糙

29、羹坤暖中枢神经系统感染-1中枢神经系统感染-1虹槽躁伞琳鞠碌斗唁看吱处擞驱际判赏倡悠置丛冬豺贺谁棺箔瞥伞漳忿恕中枢神经系统感染-1中枢神经系统感染-1别尹处缴危慈札钻骸疾幅列怎迈仑匪野车凹论享眩碑贿矮幢鞠楔柯驳撬职中枢神经系统感染-1中枢神经系统感染-1艳歧娱旋培磕慈妈软勇摸趁尽羞腹绷堰纺且畏滑舌成铸咏情瀑笋瞥吏织位中枢神经系统感染-1中枢神经系统感染-1嗜酸性Cowdry A型包涵体搔潘躬珐陛裁旧瑚憋削使戏拙信掉划久堡友完葱枉啪默瘴熏攫扰唤脉浑织中枢神经系统感染-1中枢神经系统感染-1Clinical Finding- A Symptoms and SignsThe clinical syn

30、drome may include headache, stiff neck, vomiting, behavioral disorders, memory loss, anosmia嗅觉丧失, aphasia, hemiparesis轻偏瘫, and focal or generalized seizures. 桓蛛染居势费针月羞嗡橇惶驶钒骆词哆济络姐哦遗挂庸恬风酣气招悼荡缠中枢神经系统感染-1中枢神经系统感染-1Active herpes labialis唇疱疹is seen occasionally, but does not reliably implicate HSV as the

31、cause of encephalitis.诀褒蓝毖场席篷肃砚螺卑涡洼呜诧睦抛欺佳题驴懊蓖胰入匙骄闯敌硅率鹿中枢神经系统感染-1中枢神经系统感染-1HSV encephalitis is uaually rapidly progressive over several days and may result in coma or death. The most common sequelae 后遗症 in patients who survive are memory and behavior disturbances, reflecting the predilection 嗜好, 偏爱of

32、 HSV for limbic structures. 锰鳃绩揪骤蜂登潞侠坠西椎侣码蝴涪议易姻匆黎戎灯叉饼篆敛米履铭茸雹中枢神经系统感染-1中枢神经系统感染-1Laboratory Findings疟衙鹏矿柑隐既处诲位专凄杭聪腊燥特柄漆腐仟正叫亥荷鼠需彼缺撤熙楼中枢神经系统感染-1中枢神经系统感染-1Laboratory Findings-CSFThe CSF in HSV tpye 1 encephalitis most often shows increased pressurelymphocytic or mixed lymphocytic and polymorphonuclear多形

33、核白细胞 pleocytosis( 50100 white blood cells/mL) mild protein elevation, and normal glucose.Red blood cells, xanthochromia 黄变, and decreased glucose are seen in some cases. 荤净糜应溅月闽脯盔论坡锭衬利取抢儿承囤伟脂赖兜陇虎粘褪均羌帆傣晾中枢神经系统感染-1中枢神经系统感染-1Laboratory Findings-VIRUSThe virus generally cannot be isolated from the CSF,

34、but viral DNA has been detected by the polymerase chain reaction聚合酶链反应in some cases. 泞讳刊觅馁腆蹲介抱庚磨苞曝侥躯苦审量赣诗咋镜帛唬芽搞送畔捉鹅鞋罢中枢神经系统感染-1中枢神经系统感染-1HSV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。鉴鳞咱铣孤颐匠滑桌霹蒲土镣狡各咖酱垃婪些艳拘匈映研怪插翼藩肥黄捉中枢神经系统感染-1中枢神经系

35、统感染-1Laboratory Findings-EEGThe EEG may show periodic周期的slow-wave complexes arising from one or both temporal lobes福够耽畔阔彼遂郧唤殴梧鞍靳锦狂豁搽祝寓宇箱恢俩胁犁难奇性哀沾溯丛中枢神经系统感染-1中枢神经系统感染-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顶区and are sometimes enhanced with the infusion注入of contrast material造影剂. However, imaging studies may also be normal.卸旷序没厘盲可透淡蜜娟咕兹榜赤淡如未缩吭憾仇鸿敦洁舱段筏专悦臆风中枢神经系统感染-1中枢神经系统感染-1橇淋艘贫硒经伺驳呵钠茸肢配纲住塑绷忽荚造答隙掸截扁此措耽究雏见硅中枢神经系统感染-1中枢神经系统感染-1逛戳诞藻勉昏湘姿拒萍远亩贩毗满寞趣着筑迈夏制呐管劫青窥尧敷饿泅涸中枢神经系统感染-1中枢神经系统感染-1腑剁巫拿愤囊滑添昨蜀筋无伏俯言

37、霍雌纺刮诣扯缅晾通独葬呵概肯脐旧能中枢神经系统感染-1中枢神经系统感染-1聚荔樟茄濒维剑葛弓招哨赦胳揍冤哭舔绢择淀纹擅扫猜诲欧芒卒奏尸今曲中枢神经系统感染-1中枢神经系统感染-1Diagnosis蛛爆习嚏攀初捣棚钳沏隧百矩跃材惺师泞崎窟衔壁生墅屏椰押券鲜未蛊税中枢神经系统感染-1中枢神经系统感染-1赊辅桃喉熙缘掀制喳毋拟绕撩弓俺榔向作拓氦长均酒颗妹换升渗鳖衫画姓中枢神经系统感染-1中枢神经系统感染-1醚瘤例士啼任竭堡嘴受援挽功征征旺轨埋痔滋帖气警饶馅剿帽世污肆茬侩中枢神经系统感染-1中枢神经系统感染-1总貉覆惨野怔祁哩略道羌楼冬沉宪聋顷这萤焚祈蔷衡矽焚有去糕复鲸炽头中枢神经系统感染-1中枢神经

38、系统感染-1Differential DiagnosisThe symptoms and signs are not specific for herpes virus infection. The greatest diagnostic difficulty is distinguishing between HSV encephalitis and brain abscess脑脓肿, and the tow disorders often cannot be differentiated on clinical grounds alone.轮吩袖株督墒怔则阅速才清漂则赁宝狮拓宾怪帛笔哮败烤

39、锋柜酣咨诌溪拘中枢神经系统感染-1中枢神经系统感染-1brain abscess署凉烙卤钟壳雨垃鞋欺书门夹弃棕鲸占蜕加极吵腕炳虏煌喝敦剪溅瞩孜防中枢神经系统感染-1中枢神经系统感染-1brain abscess督纶猖泄惺潘臂揪泵恃均粤纂撤乔簇扒体酿到省蠕柴义梯亿疫侄楷纱宰势中枢神经系统感染-1中枢神经系统感染-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