中枢神经系统感染-课件1.ppt
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1、VIRAL MENINGITIS&ENCEPHALITIS Viral meningitis refers to meningitis caused by a viral infection.Children and young adults are frequently affected.Viral meningitis is most often caused by enteric 肠道的肠道的viruses Viral encephalitis by childhood exanthems皮疹皮疹,arthropod-borne节肢节肢动物动物agents虫媒性病原体虫媒性病原体,and
2、 herpes simplex type 1.Cause最常见最常见 柯萨奇病毒柯萨奇病毒 ECHO病毒病毒 肠道病毒肠道病毒其次其次流行性腮腺炎流行性腮腺炎单纯疱疹病毒单纯疱疹病毒腺病毒腺病毒PathologyViral infections can affect the central nervous system in three ways1.血源性播散血源性播散:hematogenous dissemination of a systemic viral infection(eg,arthropod-borne viruses虫媒性病毒虫媒性病毒);2.轴突传播轴突传播:neurona
3、l spread of the virus by axonal transport(eg,herpes simplex,rabies狂犬病病毒狂犬病病毒);3.自身免疫性感染后脱髓鞘自身免疫性感染后脱髓鞘:autoimmune postinfections demyelination脱髓鞘脱髓鞘(eg,varicella水痘病毒水痘病毒,influenza).Pathologic changes in viral meningitis consist of an inflammatory meningeal reaction mediated by lymphocytes.病毒性脑膜炎的病理改
4、变是由淋巴细胞介导的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。炎性脑膜反应。Encephalitis 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病毒性脑炎的病理改变特点是血管周围套袖样
5、改变、淋巴细胞浸润,以及累及皮层下灰质的改变、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小胶质增生,并经常可见到核浆或细胞浆内包涵体。涵体。Clinical findings-symptoms and signs Clinical manifestations include fever,headache,neck stiffness,photophobia畏光畏光,pain with eye movement,and mild impairment of consciousness.Patients usually do not appear as ill a
6、s those with bacterial meningitis.Systemic viral infection may cause skin rash,pharyngitis咽炎咽炎,lymphadenopathy淋巴结病淋巴结病,pleuritis胸胸膜炎膜炎,carditis心肌炎心肌炎,jaundice黄疸黄疸,organomegaly器官肿大器官肿大,diarrhea腹泻腹泻,or orchitis睾丸炎睾丸炎,and these findings may suggest a particular etiologic agent病原体病原体.Because viral encep
7、halitis involves the brain directly,marked alterations of consciousness,seizures,and focal neurologic signs can occur.When signs of meningeal irritation脑膜刺激征脑膜刺激征and brain dysfunction coexist共存共存,the condition is termed meningoencephalitis脑膜脑炎脑膜脑炎.Laboratory findingsCSF analysis is the most importan
8、t laboratory test.CSF pressure is normal or increaseda lymphocytic or monocytic pleocytosis脑脊液细胞数增多脑脊液细胞数增多 is present,with cell counts usually less than 1000/ml.(higher counts can be seen in lymphocytic choriomeningitis脉络丛脑膜炎脉络丛脑膜炎or herpes simplex encephalitis.)A polymorphonuclear多形核白细胞多形核白细胞 pleo
9、cytosis can occur early in viral meningitis,while red blood cells may be seen with herpes simplex encephalitis.Protein is normal or slightly increased(usually 80120mg/dL).Glucose is usually normal,but may be decreased in mumps腮腺炎腮腺炎,herpes zoster带状疱疹带状疱疹,or herpes simplex encephalitis.Grams stain an
10、d bacterial,fungal,and acid-fast bacillius(AFB)cultures are negative.Oligoclonal bands寡克隆区带寡克隆区带and CSF protein electrophoresis电泳电泳abnormalities may be present.An etiologic diagnosis can often be made by virus isolation,polymerase chain reaction,or acute-and convalescent phase恢复期恢复期CSF antibody tite
11、rs抗体滴度抗体滴度.Blood counts may show a normal white cell count,leukopenia白血球减少白血球减少症症,or mild leukocytosis白细胞增多白细胞增多.Serum amylase血清淀粉酶血清淀粉酶is frequently elevated in mumps 腮腺炎腮腺炎;abnormal liver function tests are associated with both hepatitis viruses肝炎病毒肝炎病毒and infectious mononucleosis单核细胞增多症单核细胞增多症.Th
12、e EEG is diffusely slow,especially if there is direct cerebral involvement.DiagnosisDifferential diagnosis The differential diagnosis of meningitis with mononuclear cell pleocytosis includes partially treated bacterial meningitis治疗不彻治疗不彻底的细菌性脑膜炎底的细菌性脑膜炎 as well as syphilitic梅毒梅毒的的,tuberculous结核性的结核性
13、的,fungal,parasitic寄生物的寄生物的,neoplastic肿瘤的肿瘤的,and other meningitides脑脑(脊脊)膜炎膜炎.Evidence of systemic viral infection and CSF wet mounts,stained smears,cultures,and cytologic examination细胞学检查细胞学检查can distinguish among these possibilities.When presumed early viral meningitis is associated with a polymorp
14、honuclear多形核白细胞多形核白细胞pleocytosis of less than 1000 white blood cells/mL and normal CSF glucose,one of two strategies can be used.1.The paitent can be treated for bacterial meningitis until the results of CSF cultures are known;2.Treatment can be withheld and lumbar puncture腰椎穿刺术腰椎穿刺术 repeated in 612
15、 hours.If the meningitis is viral in origin,the second sample should show a mononuclear cell pleocytosis.A disorder that may be clinically indistinguishable from viral encephalitis is the immune-mediated encephalomyelitis that may follow viral infections such as influenza,measles麻疹麻疹,or chickenpox水痘
16、水痘.Progressive neurologic disfunction typically begins a few days after the viral illness,but can also occur either simultaneously同时发生同时发生 or up to several weeks later.Neurologic abnormalities result from perivenous 静脉周围的静脉周围的demyelination脱髓鞘脱髓鞘,with often severely affects the brainstem.The CSF show
17、s a lymphocytic pleocytosis脑脊液细胞数增多脑脊液细胞数增多,usually with cell counts of 50150/mL,and mild protein elevation.Treatment Except for herpes simplex encephalitis,which is discussed separately no specific therapy for viral meningitis and encephalitis is available.Corticosteroids are of no proven benefit e
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