急性播散性脑脊髓炎与经典多发性硬化的临床对比分析

Comparison of clinical features between acute disseminated encephalomyelitis and classical multiple sclerosis

目的寻找临床上鉴别急性播散性脑脊髓炎（acute disseminated encephalomyelitis, ADEM）与经典多发性硬化（ classical multiple sclerosis, CMS）的方法。方法回顾性分析20例ADEM和24例CMS患者的流行病学特点、临床症状、实验室检查和MRI，对各定性资料进行卡方检验，定量资料进行两独立样本的Wilcoxon秩和检验。结果ADEM患者起病年龄[（27±15）岁]较CMS患者[（37±13）岁，Z=-2．218，P=0．027]小。ADEM患者通常有前驱感染史（75％），发热（65％）、脑膜刺激征（40％）、癫痫（25％），较CMS者常见（X^2=23．652、18．609、9．189、4．514，均P〈0．05），脑病更多见于ADEM患者。ADEM患者血白细胞[（11．9±5．8）×10^9／L，Z=-2．030，P=0．042]、C反应蛋白（2．74mg／L，Z=-3．028，P=0．002）、红细胞沉降率（11．00mm／h，Z=-2．406，P=0．016）、脑脊液白细胞（9×10^6／L，Z=-2．781，P=0．005）较CMS患者[上述指标分别为（8．0±3．2）×10^9／L、0．49mg／L、7．00mm／h、2×10^6／L]高，脑脊液蛋白（ADEM组0．19g／L，CMS组0．17g／L）及寡克隆带（OCB）阳性率（ADEM组4／20，CMS组11／24）在两者问差异无统计学意义。在MRI上，ADEM患者更多见皮质灰质病灶（14／20，x^2=15．213，P=0．000）、基底节区灰质病灶（14／20，x^2=8．910，P=0．003）和脑干病灶（14／20，x^2=5．867，P=0．015），脊髓病灶多近中央分布（83％，x^2=11．542，P=0．001），病灶边界模糊（95％，x^2=21．787，P=0．000）；CMS患者更多见近皮质白质病灶（21／24，x^2=17．628，P=0．000）、侧脑室旁病灶（21／24，x^2=15．213，P=0．000）和胼胝体病灶（14／24，x^2=8．640，P=0．003），脊髓病灶多呈偏心分布（85％），病灶边界清楚（75％）。结论ADEM与CMS无论在流行病学特点、临床症状，还是在脑脊液和MRI检查方面都有一定差异。

Objective To improve differential diagnosis between acute disseminated encephalomyelitis （ADEM） and classical multiple sclerosis （CMS）. Methods All 20 cases of ADEM and 24 cases of CMS were examined. Their epidemiologieal and clinical findings, laboratory features and magnetic resonance imaging （MRI） data were analyzed using X2 test for categorical variables, Wilcoxon Rank-Sum tests for continuous variables. Results ADEM and CMS showed no sex predominance. Patients with ADEM （ （27± 15） years） were younger than CMS （ （37 ±13） years, Z = -2. 218, P =0. 027）. The following findings were more commonly seen in ADEM compared with CMS： predemyelinating infectious disease （75% vs 4%, X^2 =23.652, P=0.000）, fever （65% vs 4%, X^2 = 18.609, P =0.000）, meningeal irritation sign （40% vs 0, X^2 = 9. 189, P = 0. 002） , seizure （25% vs 0, X2 = 4. 514, P = 0. 034 ） , and eneephalopathy. ADEM patients were more likely to present with blood leueocytosis （ （ 11.9 ±5.8）×10^9/L vs （8.0±3.2） ×10^9/L, Z = -2. 030, P =0. 042）, high C-reactive protein （2. 74 mg/L vs 0. 49 rag/L, Z = - 3. 028, P = 0. 002） , increased erythrocyte sedimentation rate （ 11.00 mm/h vs 7.00 mm/h,Z = -2. 406, P =0. 016） , and cerebrospinal fluid leueocytosis （9×10^6/L vs 2 ×10^6/L, Z =-2. 781, P = 0. 005 ）. There were no differences in cerebrospinal fluid protein and oligoclonal band between the two groups. The following MRI lesions were more commonly seen in ADEM patients： cortical gray matter lesions （ 14/20, X^2 = 15. 213, P = 0. 000）, basal ganglia gray matter lesions （ 14/20, X^2 = 8. 910, P = 0. 003） , and brainstem lesions （14/20, X^2 = 5. 867, P = 0. 015）. In contrast, lesions in subcortieal white matter （21/24, X^2 = 17. 628, P = 0. 000） , periventrieular area （21/24, X^2 = 15. 213, P = 0. 000） and corpus eallosum （ 14/24, X^2 = 8. 640, P = 0. 003） were more common in the MRI image of CMS patients. The lesions in spinal cord were usually centrally distributed in ADEM （83%） , while peripherally in CMS （85%, X^2 = 11. 542, P =0. 001）. The lesions had poorly defined margins in ADEM （95%）, but well defined margins in CMS （75%,X^2 = 21. 787, P = 0. 000）. Conclusion There are differences in epidemiologieal and clinical findings, laboratory features and MRI appearances between ADEM and CMS.