基于医院监测的流行性乙型脑炎确诊病例漏诊及其原因分析

Analysis for Characteristics of Laboratory Confirmed Japanese Encephalitis Cases of Hospitalbased Surveillance in Shandong Province

目的分析流行性乙型脑炎(乙脑)临床漏诊情况及漏诊原因,为指导临床诊断提供依据。方法对济南市部分医院乙脑漏诊情况及其原因,以及临床诊断、临床漏诊的乙脑确诊病例的流行病学特征、临床特征、临床检验等进行比较分析。结果在128例实验室确诊病例中,漏诊77例(60.16%),其中53例被诊断为病毒性脑炎、病毒性脑膜炎或病毒性脑膜脑炎。传染病专科医院漏诊率低,不开展乙脑IgM抗体检测的医院漏诊率较高。按照入院诊断时漏诊和入院诊断为乙脑分组分析其流行病学特征显示,在病例来源、性别上,两组病例差异无统计学意义;而在发病时间上,7～9月之外乙脑的非发病高峰期漏诊率较高;在病例年龄分布上,<5岁病例漏诊较高。分析其临床特征发现,两组病例在有发热、头痛、精神萎靡等症状的差异无统计学意义,但在恶心、呕吐、嗜睡、意识障碍、颈项强直、脑膜刺激征等方面,入院诊断乙脑组均显著高于漏诊组。分析两组病例临床常规实验室检验发现,无论是血象还是脑脊液(Cerebrospinal Fluid,CSF)常规,两组病例检测结果差异无统计学意义。结论医疗机构,尤其是非传染病专科医院乙脑病例漏诊严重,漏诊的主要原因是部分病例临床症状不典型,而非传染病专科医院在流行季节不开展乙脑特异性IgM抗体检测,将乙脑病例诊断为其他病毒性感染神经系统疾病。应在医疗机构推广使用血清或CSF特异性乙脑IgM抗体检测,提高医疗机构的诊断水平,减少乙脑危害。

Objective To investigate the status of missed diagnosis of Japanese encephalitis（JE） and to explore the reason in order to provide foundation for clinical diagnosis.Methods Comparision on epidemiological and clinical characteristic and clinical test of clinical diagnosis cases and missed diagnosis cases in hospitals in Jinan was performed.Results 77 cases were missed diagnosed in the 128 laboratory confirmed cases,and the missed diagnosis rate was 60.16%.The rate was relative lower in infectious disease special hospitals,and higher in hospitals that did not perform the anti-JEV IgM examination.The analysis on the epidemiological characters of the two groups of missed diagnosis cases and un-missed diagnosis cases showed no statistical difference on cases origin and gender.However,a relative high number of JE cases were miss diagnosed before July or after September.Children under 5 years old accounted for the majority of the missed diagnosis group.Analysis on the clinical manifestations showed no statistical differences existed in fever,headache,and depressed,while in nausea,vomiting,lethargy,conscious disturbance,stiffneck,and meningeal irritation,the un-missed diagnosis group was obviously high than the missed group.No difference in laboratory test,such as hemogram and cerebrospinal fluid examination was found between the two groups.Conclusions The missed diagnosis was high in medical institution,especially in non infectious disease specific hospital.The main reason for missed diagnosis was slight or atypical symptoms.Besides,anti-JEV IgM examination was not performed in non infectious disease specific hospital,resulting in the missed diagnosis of JE into other viral nervous system infectious disease.The Japanese encephalitis virus specific IgM antibody examination on sera or CSF should be carried out extensively in medical agencies.Moreover,the capability of diagnosis and treatment of JE in hospitals should be improved to reduce the jeopardize of JE.