本文選題：流行性乙型腦炎 + 腦脊液�。� 參考：《河北醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的：流行性乙型腦炎（Japanese encephalitis，JE）簡稱乙腦，是由乙腦病毒感染，流行在亞洲和太平洋地區(qū)重要的病毒腦炎。大多數(shù)乙腦感染是無癥狀的，但有癥狀的乙腦可從非特異性的發(fā)熱到嚴(yán)重腦炎不同。臨床上以高熱、意識障礙、抽搐、局灶神經(jīng)功能障礙、腦膜刺激征等為特征，病死率高、后遺癥嚴(yán)重，并且在流行區(qū)主要侵犯兒童。隨著乙腦疫苗的應(yīng)用，乙腦的發(fā)病率明顯減少，但部分地區(qū)仍有暴發(fā)，且成人感染乙腦的病例數(shù)增多。因此，盡早確診，盡早評估乙腦病情輕重，對于臨床具有重要的意義。S100B作為中樞神經(jīng)系統(tǒng)(CNS)損傷時體現(xiàn)星形膠質(zhì)細(xì)胞增生的敏感標(biāo)志蛋白，目前在臨床被很多學(xué)者重視。本研究旨在了解乙腦患者的臨床特點(diǎn)，并測定乙腦患者腦脊液中S100B蛋白的含量，探究S100B在乙腦發(fā)病過程中的重要意義。 方法：2013年8月～2013年10月河北醫(yī)科大學(xué)第二醫(yī)院神經(jīng)內(nèi)科收治的診斷為流行性乙型腦炎的患者92例，依據(jù)石家莊市防疫站檢測的乙腦病毒IgM抗體陽性和臨床特征確診，并收集腦脊液共107份。通過腦脊液常規(guī)、生化、細(xì)胞學(xué)，影像學(xué)和腦電圖等輔助檢查，了解乙腦患者的臨床特點(diǎn)。其中將資料完整的45名乙腦患者，共57份腦脊液，依據(jù)病程、病情輕重和影像學(xué)表現(xiàn)，分成若干亞組進(jìn)行相關(guān)比較。對照組：共12例，其中周圍神經(jīng)病變2例，良性顱內(nèi)壓增高癥1例，陳舊腔隙性腦梗死1例，靜脈竇血栓1例，，面神經(jīng)麻痹1例，血管性頭疼1例，門診腰椎穿刺術(shù)排除中樞神經(jīng)系統(tǒng)感染患者5例。 對所有入選患者進(jìn)行腰椎穿刺術(shù)，并行腦脊液常規(guī)、生化、細(xì)胞學(xué)系列檢查，包括MGG染色及阿利新蘭染色，并且資料完整的45名乙腦患者的腦脊液應(yīng)用ELISA法測定S100B蛋白的含量。 結(jié)果:1流行病學(xué)：所有患者男：女=55%：45%，發(fā)病數(shù)八月升高，九月達(dá)到高峰，患者年齡小于15歲的只有4人，15-45歲占50%，45-65歲占43.48%，所有患者中農(nóng)民占79%。 2腦脊液常規(guī)、生化：經(jīng)過統(tǒng)計本實(shí)驗(yàn)所有乙腦患者相關(guān)資料，腦脊液白細(xì)胞數(shù)多輕度升高，葡萄糖和氯化物含量多正常，蛋白質(zhì)含量多升高。將資料完整的45名乙腦患者按各種分類方法分成各亞組（輕型組、中型組、重型組、極期組、恢復(fù)期組），經(jīng)比較各亞組的乙腦患者腦脊液白細(xì)胞數(shù)及蛋白含量明顯高于對照組，且差異有統(tǒng)計學(xué)意義（P＜0.05）。但比較乙腦各亞組和對照組的葡萄糖、氯化物含量，差異無統(tǒng)計學(xué)意義（P0.05）。 3乙腦患者腦脊液細(xì)胞學(xué)早期呈混雜細(xì)胞學(xué)反應(yīng)，隨著病程嗜中性粒細(xì)胞逐漸減少，淋巴細(xì)胞逐漸增多，病程中可見到激活性單核細(xì)胞和漿細(xì)胞，恢復(fù)期多以淋巴細(xì)胞反應(yīng)為主或呈典型淋巴細(xì)胞反應(yīng)。影像學(xué)上以雙側(cè)丘腦受累為主，并且基底節(jié)區(qū)和海馬區(qū)也是常見受累部位為特征。腦電圖多為廣泛中度至重度異常，治療后可恢復(fù)。 4腦脊液S100B蛋白含量測定：乙腦組輕型531.94±166.95pg/m（l極期組627.77±155.93pg/ml，恢復(fù)期組412.15±83.14pg/ml），中型組852.25±309.75pg/ml （極期組822.76±275.99pg/ml，恢復(fù)期組907.03±382.24pg/ml），重型組1045.60±468.93pg/ml （極期組1155.5±559.22pg/ml，恢復(fù)期組923.40±333.21pg/ml）�？倶O期組864.53±409.94pg/ml，總恢復(fù)期組748.22±371.22pg/ml。MRI未顯示病灶組629.38±215.49pg/ml，MRI顯示病灶組950.93±364.52pg/ml。對照組295.29±97.20pg/ml。經(jīng)比較S100B水平在乙腦輕型組、中型組、重型組、總極期組、總恢復(fù)期組、MRI未顯示病灶組及MRI顯示病灶組都高于對照組，并且差異都有統(tǒng)計學(xué)意義（P＜0.05）。輕型組S100B濃度低于中、重型組，差異都有統(tǒng)計學(xué)意義（P＜0.05），重型組S100B濃度比中型組高，但差異無統(tǒng)計學(xué)意義（P0.05）。MRI未顯示病灶組S100B水平比MRI顯示病灶組低，并且之間差異有統(tǒng)計學(xué)意義（P＜0.05）。輕型極期S100B濃度高于輕型恢復(fù)期，并且差異有統(tǒng)計學(xué)意義（P＜0.05），但中型極期與中型恢復(fù)期、重型極期與重型恢復(fù)期之間差異無統(tǒng)計學(xué)意義（P0.05）。 5比較其中12例乙腦患者在病程的不同時期多次測量的腦脊液中S100B蛋白水平。分別在第6~9天及第12~18天測量的9名乙腦患者，在第6~9天S100B平均含量為1126.0±555.78pg/ml，而在第12~18天S100B平均含量為1007.4±366.24pg/ml，經(jīng)比較第12~18天的S100B含量有所降低，但差異無統(tǒng)計學(xué)意義（P0.05）。分別在第6~9天及超過20天測量的8名患者，在第6~9天S100B平均為869.83±413.40pg/ml，在超過20天S100B平均為823.87±218.11pg/ml。病程超過20天的乙腦患者S100B水平比第6~9天的水平低，但比較差異沒有統(tǒng)計學(xué)意義（P0.05）。 結(jié)論：1、乙腦的患者主要是小于15歲的兒童，但成人感染乙腦在局部地區(qū)有暴發(fā)趨勢。 2、乙腦患者腦脊液細(xì)胞學(xué)混雜細(xì)胞學(xué)反應(yīng)持續(xù)時間較一般病毒腦炎長。 3、乙腦患者影像上以丘腦，特別是雙側(cè)丘腦受累為特征，基底節(jié)及海馬也是常見受累部位。在流行地區(qū)、流行季節(jié)，影像學(xué)上雙側(cè)丘腦受累應(yīng)高度懷疑乙腦。 4、乙腦患者腦脊液中的S100B含量升高。 S100B蛋白含量與乙腦病情輕重、病程及影像學(xué)表現(xiàn)有一定相關(guān)，動態(tài)觀察其含量變化，對乙腦患者的病情監(jiān)測及判斷療效均具有重要意義。
[Abstract]:Objective: Japanese encephalitis (JE), abbreviated to the encephalitis B, is an important viral encephalitis epidemic in Asia and the Pacific region. Most of the infection is asymptomatic, but symptomatic encephalitis is different from non specific fever to severe encephalitis. The symptoms of focal nerve dysfunction, meningeal irritation are characterized by high mortality, severe sequelae, and major invasion of children in epidemic areas. With the application of the vaccine, the incidence of the encephalitis is obviously reduced, but there are still outbreaks in some areas, and the number of cases of adult infected with the brain is increasing. Therefore, the early diagnosis and assessment of the seriousness of the state of the encephalitis B as soon as possible, .S100B is a sensitive marker of astrocyte proliferation when it is damaged in the central nervous system (CNS). At present, many scholars pay more attention to the clinical characteristics of the patients in the brain, and determine the content of S100B protein in cerebrospinal fluid of the patients with encephalitis, and explore the process of S100B in the pathogenesis of the brain. The importance of it.
Methods: from August 2013 to October 2013, 92 cases of epidemic encephalitis B were diagnosed in the neurology department of the second hospital of Hebei Medical University. According to the positive and clinical characteristics of IgM antibody and clinical characteristics of the encephalitis B virus detected in Shijiazhuang epidemic prevention station, 107 cerebrospinal fluid were collected. The routine, biochemical, cytology, imaging and brain of the cerebrospinal fluid were used. The clinical characteristics of the patients with encephalitis B were examined by electrogram. Of the 45 patients with complete data, 57 cerebrospinal fluid were divided into several subgroups according to the course of disease, the severity of the disease and the imaging findings. The control group was 12 cases, including 2 cases of peripheral neuropathy, 1 cases of benign intracranial hypertension, and old lacunar infarction. There were 1 cases of death, 1 cases of venous sinus thrombosis, 1 cases of facial nerve paralysis, 1 cases of vascular headache, and 5 cases of central nervous system infection excluded from outpatient lumbar puncture.
All selected patients were treated with lumbar puncture, routine, biochemical, and cytological examination of cerebrospinal fluid, including MGG staining and aliran blue staining. The cerebrospinal fluid of 45 patients with complete data was determined by ELISA method for the determination of S100B protein.
Results: 1 epidemiology: all the patients were male: female =55%:45%, the incidence of the disease increased in August, reached the peak in September, the patient was less than 15 years old only 4, 15-45 year old 50%, 45-65 years old 43.48%, all the patients accounted for 79%..
2 cerebrospinal fluid routine, biochemistry: after statistics, all the data of the patients with encephalitis were collected, the white blood cells in cerebrospinal fluid increased slightly, the content of glucose and chloride was more normal, and the content of protein was increased. The 45 patients with complete data were divided into subgroups according to various classification methods (light group, medium group, heavy group, polar group, stage of recovery, and recovery period. The number of white blood cells and protein content in cerebrospinal fluid of the patients in the comparison group were significantly higher than those in the control group, and the difference was statistically significant (P < 0.05), but there was no significant difference in the content of glucose and chloride in the subgroups of the group B and the control group (P0.05).
In the early stage of the cerebrospinal fluid cytology of 3 patients with encephalitis, there was a mixed cytological reaction. With the gradual decrease in the neutrophil and the increase of the lymphocyte, the activation monocytes and plasma cells were seen in the course of the disease. The recovery period was mainly by lymphocyte reaction or typical lymphocyte reaction. The basal ganglia and hippocampus are also common locations. EEG is mostly generalized to moderate to severe abnormalities, and can be recovered after treatment.
4 S100B protein content in cerebrospinal fluid: light 531.94 + 166.95pg/m in group B group (627.77 + 155.93pg/ml in L polar group, 412.15 + 83.14pg/ml in recovery period), 852.25 + 309.75pg/ml in medium group (822.76 + 275.99pg/ml in polar group, 907.03 + 382.24pg/ml in recovery period) and 1045.60 + 468.93pg/ml in severe group (1155.5 + 559.22pg/ml in polar group), 923 in recovery period. .40 + 333.21pg/ml). The total polar phase group was 864.53 + 409.94pg/ml, the total recovery group was 748.22 + 371.22pg/ml.MRI without 629.38 + 215.49pg/ml, MRI showed that the focus group was 950.93 + 364.52pg/ml. control group 295.29 + 97.20pg/ml. after comparison S100B level in the light group of encephalitis, middle group, heavy type, total polar group, total recovery period, MRI did not show the focus The group and MRI showed that the lesion group was all higher than the control group (P < 0.05). The S100B concentration in the light group was lower than that in the heavy group (P < 0.05), and the concentration of S100B in the heavy group was higher than that in the medium group, but the difference was not statistically significant (P0.05).MRI did not show that the level of S100B in the focus group was lower than that in the MRI group. The difference was statistically significant (P < 0.05). The concentration of S100B in light polar period was higher than that in light recovery period, and the difference was statistically significant (P < 0.05), but there was no significant difference between the medium and medium recovery period, the heavy and heavy recovery period (P0.05).
5 compared the level of S100B protein in the cerebrospinal fluid which was measured repeatedly in 12 patients at different stages of the course of the disease. The average content of S100B was 1126 + 555.78pg/ml on day 6~9 and day 12~18, respectively, on day 6~9 and 12~18. The average content of S100B was 1007.4 + 366.24pg/ml on day 12~18, and the S100B content of day 12~18 days was compared. The amount was reduced, but the difference was not statistically significant (P0.05). 8 patients were measured at day 6~9 and over 20 days respectively, on day 6~9, the average S100B was 869.83 + 413.40pg/ml, and the S100B level of the patients with 823.87 + 218.11pg/ml. in more than 20 days more than 20 days was lower than the level of day 6~9, but the difference was not statistically significant. Meaning (P0.05).
Conclusion: 1, the children of JE are mainly younger than 15 years old, but there is an outbreak trend in adults.
2, the cytological response of cerebrospinal fluid in patients with encephalitis B was longer than that of common viral encephalitis.
3, the brain is characterized by thalamus, especially the involvement of the bilateral thalamus. The basal ganglia and hippocampus are also the common sites of involvement. In epidemic areas, the epidemic season, imaging of bilateral thalamus should be highly suspected of encephalitis.
4, the content of S100B in cerebrospinal fluid of patients with encephalitis is increased. The content of S100B protein is related to the seriousness of the disease, the course of disease and the manifestation of imaging. It is of great significance to observe the changes of the content of the cerebrospinal fluid, and to monitor the patient's condition and judge the curative effect.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R512.32

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