本文選題：抗NMDAR腦炎 + 病毒性腦炎��； 參考：《重慶醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景:自身免疫性腦炎是泛指一組由自身免疫抗體介導(dǎo)的神經(jīng)功能損傷的疾病,是迄今較為新型的腦炎分類。10年前Dalmau等人首先發(fā)現(xiàn)并報(bào)道了卵巢畸胎瘤相關(guān)的副腫瘤性抗N-甲基-D-天冬氨酸受體腦炎,該報(bào)道稱的上是自身免疫腦炎范疇的轉(zhuǎn)折點(diǎn)。隨著這一敲門磚似的研究成果及抗體檢測深入,近年來各種新型的自身免疫性腦炎被陸續(xù)發(fā)現(xiàn)并報(bào)道,主要可分為兩大類:抗神經(jīng)元細(xì)胞內(nèi)抗原抗體、抗神經(jīng)細(xì)胞表面/突觸蛋白抗體。而NMDAR腦炎是自身免疫性腦炎中最常見、最典型的類型,約占自身免疫性腦炎患者的80%,好發(fā)于青年女性和兒童,與畸胎瘤關(guān)系較密切,與其他惡性腫瘤相關(guān)性較小。這種亞型的自身免疫性腦炎是由免疫球蛋白G攻擊神經(jīng)元細(xì)胞表面的N-甲基-D-天冬氨酸受體谷氨酸的N1亞基使神經(jīng)元產(chǎn)生炎癥反應(yīng),導(dǎo)致神經(jīng)細(xì)胞功能紊亂而產(chǎn)生一系列的臨床癥狀,主要可表現(xiàn)為發(fā)熱、頭痛等前驅(qū)癥狀、精神行為異常、不自主運(yùn)動(dòng)、癲癇、近期記憶力下降、自主神經(jīng)功能紊亂等。如果能夠早期治療,這種功能紊亂是可逆的。但是如果沒有的到及時(shí)的治療,長期的炎癥反應(yīng)和N-甲基-D-天冬氨酸介導(dǎo)的谷氨酸興奮性毒性可能造成神經(jīng)元細(xì)胞永久性破壞。對于NMDAR腦炎患者而言,早期的診斷及治療可擁有相對較好的預(yù)后,可以恢復(fù)到患病前基本生活功能狀態(tài),而且后續(xù)復(fù)查影像學(xué)檢查既往異常的病灶也可能會(huì)完全吸收、消失。所以早期的診斷及治療對于抗NMDAR腦炎患者而言極其重要,直接關(guān)系的抗NMDAR腦炎患者的治療效果及預(yù)后。腦炎的主要致病原因可分為兩大類,即自身免疫性和感染性。由于自身免疫性腦炎相關(guān)抗體檢測在國內(nèi)可能比較容易得到,近年來發(fā)現(xiàn)并確診的自身免疫性腦炎的病例量大幅度上升,可能會(huì)給臨床醫(yī)生帶來一種錯(cuò)覺認(rèn)為自身免疫性腦炎比感染性腦炎更多見,這可能是因?yàn)楦腥拘缘牟≡w檢測尤其是病毒PCR檢測的不全面或技術(shù)限制,導(dǎo)致了病毒性腦炎的診斷不足。事實(shí)上自身免疫性腦炎約占腦炎的10%-20%,較病毒性腦炎患病比例低。因此,對于自身免疫性腦炎和病毒性腦炎早期的鑒別診斷就顯得格外重要,直接關(guān)系到治療方案的制定、治療效果及患者遠(yuǎn)期的預(yù)后。目的:抗N-甲基-D-天冬氨酸受體(N-methyl-D-aspartate recep-tor,NMDAR)腦炎是自身免疫性腦炎中最常見的類型,臨床表現(xiàn)多樣化,好發(fā)于青年女性及兒童;病毒腦炎為臨床上常見腦炎類型,臨床特點(diǎn)可與抗NMDAR腦炎相似,本文主要探討NMDAR抗體水平對抗NMDAR抗體腦炎和病毒性腦炎的鑒別診斷及抗NMDAR抗體水平對抗NMDAR腦炎病情評估作用。方法:回顧性分析重慶醫(yī)科大學(xué)附屬第一醫(yī)院2014年3月-2016年3月期間診斷為抗NMDAR腦炎和病毒性腦炎患者。其中抗NMDAR腦炎患者53例為研究組(11例重癥患者和42例普通患者),病毒性腦炎患者22例作為對照組。對兩組患者的一般情況、臨床資料及血清、腦脊液的NMDAR抗體水平進(jìn)行分析。結(jié)果:1、抗NMDAR腦炎患者中男性21例、女性32例,平均(45.12±10.13)歲;22例病毒性腦炎中男性7例、女性15例,平均年齡(47.22±12.49)歲;兩組間在性別與平均年齡差異不具有統(tǒng)計(jì)學(xué)意義。2、抗NMDAR腦炎患者中有前驅(qū)感染史12例(22.6%)、發(fā)熱24例(45.3%),意識障礙27例(50.9%)、癲癇發(fā)作32例(60.4%)、不自主運(yùn)動(dòng)21例(39.6%)、頭痛23例(43.4%)、精神行為異常39例(78.1%)。病毒性腦炎患者中有前驅(qū)感染史14例(63.6%)、發(fā)熱21例(95.5%),意識障礙3例(13.6%)、癲癇發(fā)作1例(4.6%)、不自主運(yùn)動(dòng)2例(9.1%)、頭痛14例(63.6%)、精神行為異常0例(0)�？筃MDAR腦炎相比病毒性腦炎患者在以下臨床表現(xiàn)中存在顯著差異:有前驅(qū)感染史(X2=11.54,P=0.00)、發(fā)熱(X2=16.31,P=0.00)、意識障礙(X2=9.02,P=0.00)、癲癇發(fā)作(X2=19.67,P=0.00)、不自主運(yùn)動(dòng)(X2=6.82,P=0.00)、精神異常(X2=27.44,P=0.00)。3、抗NMDAR腦炎組患者血清中抗NMDAR抗體濃度平均含量為14.03±5.62ng/ml、腦脊液中抗NMDAR抗體濃度平均含量為29.31±4.37ng/ml;病毒性腦炎組患者血清中抗NMDAR抗體濃度平均含量為3.94±2.97ng/ml、腦脊液中抗NMDAR抗體濃度平均含量為12.34±3.19ng/ml。兩組血清(t=7.95,P=0.00)、腦脊液(t=16.46,P=0.00)中NMDAR抗體含量差異顯著,且均腦脊液含量顯著高于血清含量;4、11例抗NMDAR腦炎重癥患者血清中抗NMDAR抗體濃度為高水平者9例、腦脊液中中抗NMDAR抗體濃度為高水平者10例,;42例抗NMDAR腦炎普通組患者血清中抗NMDAR抗體濃度為高水平者2例、腦脊液中抗NMDAR抗體濃度為高水平者2例�？筃MDAR腦炎重癥和普通患者血清(X2=31.47,P=0.00)、腦脊液(X2=36.94,P=0.00)中NMDAR抗體高和低水平構(gòu)成的差異有統(tǒng)計(jì)學(xué)意義。結(jié)論:1、抗NMDAR腦炎和病毒性腦炎患者在臨床表現(xiàn)上存在一定差別,且存在統(tǒng)計(jì)學(xué)意義。前驅(qū)感染史、發(fā)熱、意識障礙、癲癇發(fā)作、不自主運(yùn)動(dòng)、精神異常多見于自身免疫性腦炎患者。2、抗NMDAR腦炎患者的抗NMDAR抗體濃度均高于病毒性腦炎患者;且兩組患者腦脊液的抗NMDAR抗體濃度均較血清中抗NMDAR抗體濃度高。提示抗NMDAR抗體在腦脊液中更為敏感,且血清、腦脊液中NMDAR抗體濃度和具體水平可作為鑒別診斷要點(diǎn)。3、抗NMDAR腦炎重癥患者的血清及腦脊液中抗NMDAR抗體濃度較抗NMDAR腦炎普通患者高,且抗體濃度差異存在統(tǒng)計(jì)學(xué)意義,提示血清、腦脊液中抗NMDAR抗體水平越高,病情可能越嚴(yán)重。
[Abstract]:Background: autoimmune encephalitis is a group of diseases characterized by neurologic impairment mediated by autoantibodies. It is a new type of encephalitis that Dalmau et al..10 years ago first discovered and reported the paraneoplastic anti N- methyl -D- aspartate receptor encephalitis associated with ovarian teratoma. This report is called the autoimmune brain. In recent years, a variety of new autoimmune encephalitis has been discovered and reported in succession, with two major categories: anti neuronal cell antigen antibody, anti nerve cell surface / synaptic protein antibody, and NMDAR encephalitis is the most important of autoimmune encephalitis. The most common, typical type, about 80% of the patients with autoimmune encephalitis, is more likely to occur in young women and children, closely related to teratoma and less associated with other malignant tumors. This subtype of autoimmune encephalitis is the N1 subunit of the immunoglobulin G that attacks the N- methyl -D- aspartic acid receptor of the neuron cell surface. An inflammatory response to a neuron resulting in a disorder of the nerve cell to produce a series of clinical symptoms, such as fever, headache and other precursory symptoms, abnormal mental behavior, involuntary movement, epilepsy, recent memory decline, and autonomic nervous dysfunction. If fruit can be treated early, this disorder is reversible. But such as Chronic treatment, chronic inflammatory response and N- methyl -D- aspartic glutamic acid induced excitotoxicity may cause permanent damage to neuron cells. For patients with NMDAR encephalitis, early diagnosis and treatment can have a relatively good prognosis and can be restored to the basic living condition before the disease. The early diagnosis and treatment are extremely important for the patients with anti NMDAR encephalitis, and the direct relation to the treatment effect and prognosis of anti NMDAR encephalitis patients. The main causes of encephalitis can be divided into two categories: autoimmune and infectious. The detection of autoimmune encephalitis related antibodies may be easier to be obtained in China. In recent years, the number of cases of autoimmune encephalitis found and confirmed has risen substantially. It may bring a illusions to clinicians and think that autoimmune encephalitis is more common than infectious encephalitis, which can be attributed to the detection of infectious pathogens. In fact, autoimmune encephalitis is about 10%-20% of encephalitis, which is lower than viral encephalitis. Therefore, the early differential diagnosis of autoimmune encephalitis and viral encephalitis is particularly important, which is directly related to the system of treatment. Objective: Anti N- methyl -D- aspartic acid receptor (N-methyl-D-aspartate recep-tor, NMDAR) encephalitis is the most common type of autoimmune encephalitis, and its clinical manifestations are diversified in young women and children; viral encephalitis is a common type of clinical encephalitis, and the clinical characteristics can be associated with anti NMDAR encephalitis. Similarly, this paper mainly discusses the differential diagnosis of NMDAR antibody level against NMDAR antibody encephalitis and viral encephalitis and the evaluation of anti NMDAR antibody level against NMDAR encephalitis. Methods: a retrospective analysis of the diagnosis of anti NMDAR encephalitis and viral encephalitis in the First Affiliated Hospital of Chongqing Medical University during the year of -2016 in March 2014. 53 cases of anti NMDAR encephalitis were studied in the study group (11 cases of severe and 42 cases) and 22 cases of viral encephalitis as a control group. The general situation, clinical data and serum and cerebrospinal fluid NMDAR antibody levels in two groups were analyzed. Results: 1, 21 men and 32 women with anti NMDAR encephalitis, average (45.12 + 10.13) years of age; 22 cases. There were 7 male and 15 women in viral encephalitis, with an average age of (47.22 + 12.49) years. The difference between sex and average age was not statistically significant in two groups.2, 12 cases (22.6%), 24 fever (45.3%), 27 cases of consciousness disorder (50.9%), epileptic seizures (60.4%), autonomic movement and headache cases in the patients with anti NMDAR encephalitis. (43.4%) 39 cases of abnormal mental behavior (78.1%). There were 14 cases of predominant infection (63.6%), 21 fever (95.5%), 3 cases of disturbance of consciousness (13.6%), 1 cases of epileptic seizures (13.6%), 1 cases of epileptic seizures, 1 cases (9.1%), headache 14, and abnormality of sperm deity. The following clinical manifestations of anti NMDAR encephalitis were compared with those of viral encephalitis. There were significant differences: X2=11.54 (P=0.00), fever (X2=16.31, P=0.00), X2=9.02 (P=0.00), epileptic seizures (X2=19.67, P=0.00), involuntary movement (X2=6.82, P=0.00), and psychosis (X2=27.44, P=0.00). The average concentration of anti serum antibody in the serum of anti cerebrospinal meningitis group was 14.03 +. The average concentration of MDAR antibody was 29.31 + 4.37ng/ml, the average concentration of anti NMDAR antibody in the serum of the patients with viral encephalitis was 3.94 + 2.97ng/ml, the average concentration of anti NMDAR antibody in the cerebrospinal fluid was 12.34 + 3.19ng/ml. two groups (t=7.95, P=0.00), and the difference of NMDAR antibody in the cerebrospinal fluid (t=16.46, P=0.00) was significant, and the cerebrospinal fluid was all cerebrospinal fluid The content of the serum anti NMDAR antibody in the 4,11 patients with NMDAR encephalitis was high in 9 cases, and in the middle of the cerebrospinal fluid, the concentration of anti NMDAR antibody was high in 10 cases, and in the 42 patients with NMDAR encephalitis, the concentration of anti NMDAR antibody in the serum was high and the anti NMDAR antibody in the cerebrospinal fluid was high. There were 2 cases. There were significant differences in the high and low level of NMDAR antibodies in the serum (X2=31.47, P=0.00) and cerebrospinal fluid (X2=36.94, P=0.00) of the patients with NMDAR encephalitis and common patients. Conclusion: 1, there are some differences in the clinical manifestations of the patients with anti NMDAR encephalitis and viral encephalitis, and there are statistical significance. Obstruction, epileptic seizures, involuntary movement, abnormal psychosis in autoimmune encephalitis patients.2, anti NMDAR encephalitis patients with anti NMDAR antibody concentration is higher than viral encephalitis patients, and the two groups of cerebrospinal fluid anti NMDAR antibody concentration is higher than the serum NMDAR antibody concentration. Suggesting that anti NMDAR antibody in cerebrospinal fluid more sensitive, and blood The concentration and specific level of NMDAR antibody in cerebrospinal fluid can be used as the key point of differential diagnosis.3. The anti NMDAR antibody concentration in serum and cerebrospinal fluid of patients with anti NMDAR encephalitis is higher than that of anti NMDAR encephalitis, and the difference of antibody concentration is statistically significant. It suggests that the higher the level of anti NMDAR antibody in the cerebrospinal fluid, the more serious the disease may be.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R742.9

【參考文獻(xiàn)】

相關(guān)期刊論文 前8條

1 黃小欽;樊春秋;葉靜;;重癥抗N-甲基-D-天冬氨酸受體腦炎的臨床特點(diǎn)及預(yù)后分析[J];臨床神經(jīng)病學(xué)雜志;2016年02期

2 高豐;張雷;閆偉;;抗N-甲基-D-天冬氨酸受體腦炎的研究進(jìn)展[J];中國實(shí)驗(yàn)診斷學(xué);2016年03期

3 李華;崔應(yīng)麟;楊敏華;高峰;;抗N-甲基-D-天冬氨酸受體腦炎三例報(bào)告并文獻(xiàn)復(fù)習(xí)[J];中國神經(jīng)免疫學(xué)和神經(jīng)病學(xué)雜志;2015年04期

4 鄧秋霞;杜鴻雁;林華;高嵐;;7例重癥抗N-甲基-D天冬氨酸受體腦炎患者的護(hù)理[J];中華護(hù)理雜志;2015年05期

5 李瑩;夏振西;劉楠;丁繼朝;黃勇華;;抗NMDA受體腦炎三例誤診原因分析并文獻(xiàn)復(fù)習(xí)[J];臨床誤診誤治;2015年04期

6 劉文鈺;田林郁;郭佳南;陳佳妮;周東;;抗N-甲基-D-天冬氨酸受體腦炎1例報(bào)告[J];中國臨床神經(jīng)科學(xué);2015年02期

7 滕麗華;王仲;;抗NMDA受體腦炎30例誤診分析[J];臨床誤診誤治;2015年01期

8 王華;;兒童抗N-甲基-D-天門冬氨酸受體腦炎的診斷與鑒別診斷[J];中國當(dāng)代兒科雜志;2014年06期

相關(guān)碩士學(xué)位論文 前1條

1 喬娜娜;兒童腦炎中抗NMDAR抗體水平測定及臨床意義探討[D];山東大學(xué);2013年

，

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