肠道病毒71型手足口病并发神经系统损害的临床特征及随访研究

Clinical analysis and follow-up of patients with hand, foot and mouth disease complicated with nervous system damage resulted from enterovirus 71 infection

目的探讨12例肠道病毒71型(EV71)手足口病(HFMD)并发神经系统损害患儿的临床特征和磁共振成像(MRI)特点并进行随访。方法回顾性分析2008年5月～2011年10月海南地区EV71感染流行期间入住本院的12例伴有神经系统损害的HFMD患儿的临床特征及MRI表现,并在患者治疗后4周末以及3～6个月进行随访,其中3例患者随访至1年。结果本组12例患者年龄6～37个月,中位年龄14个月。HFMD合并脑干脑炎者6例,其中3例合并急性弛缓性麻痹(AFP),MRI横断面显示桥脑、延髓、中脑后部T1低信号、T2高信号,以桥脑后部病灶多见;HFMD合并AFP者4例,MRI表现为脊髓前角点状T1稍低信号、T2高信号,常累及多节段,增强扫描部分前角和脊神经前根可明显强化;HFMD合并无菌性脑膜炎者(AM)2例,MRI出现蛛网膜下腔增宽、脑室扩大等征象。随访发现无菌性脑膜炎患者完全康复,单桥脑病灶患者预后优于脑干多部位受损患者,单纯脑干脑炎患者预后优于并发AFP患者。单侧肢体瘫痪者恢复较快,双侧及四肢瘫痪者恢复较慢,合并颈髓病变患者较下胸段至圆锥脊髓损伤患者肌力恢复差。结论 MRI可有效评价EV71感染有手足口病神经系统损害程度,脑干被盖部和脊髓前角是常见受损部位,MRI结果与临床表现具有一致性,MRI可准确地显示病变,对评估病情及预后有重要价值。

Objective To explore the imaging characterization and clinical follow-up of neurological complications associated with the enterovirus 71 （ EV71 ） epidemics in 12 children with hand, foot and mouth disease （HFMD）. Methods Total of 12 HFMD cases with neurological complications during the recent EV71 outbreaks in Hainan, from May 2008 to October 2011 were collected and analyzed, retrospectively. The recovery of their impairment was followed up at the 4th weekend, 3 to 6 months, and 3 cases were followed-up for 1 year. Results In brainstem encephalitis （6 cases ） , all lesions presented as significant hyperintense in the posterior portions of the medulla oblongata, midbrain, and ports as seen in T2-weighted images and hypointense in Tl-weighted images. In sagittal sections, acute flaccid paralysis（AFP） associated with HFMD （4 cases） due to EV71 infection appeared as a linear high signal of the posterior in the spinal cord. Two symmetrical, well-defined hyperintense lesions in the spinal cord were found in T2-weighted transverse images, strong enhancement of the ventral horns and root were found in the contrast-enhanced axial Tl-weighted image. The manifestations of aseptic meningitis （AM） （2 cases） on MRI with widening of the interhemispheric and hydrocephalus could be the indirect signs of AM. MRI and clinics of the 2 cases with AM were normal in the 4 weeks follow-up. The patients with single pons lesions recovered better than those with multi-lesions, also patients with simple brainstem encephalitis recovered better than those complicated with AFP cases. The patients with single extremity recovered faster than those with paralysis of both or four limbs, some lesions in the lower thoracic cord and COMUS recovered faster than those with cervical cord in the follow-up. Conclusions MRI is an effective method to investgate neurological complications associated with EV71 epidemics. Involvements of posterior portions of the medulla oblongata and pons, and bilateral anterior horns of spinal cord are characteristic findings. MRI can directly and completely show the range and degree of changes associated with neurological complications in HFMD due to EV71 infection and provide instructive suggestions for the treatment.