急性单纯疱疹病毒性脑炎及脑膜炎患者临床特征及预后分析

Clinical Features and Prognosis of Acute Herpes Simplex Viral Encephalitis and Meningitis Patients

目的了解成年人急性单纯疱疹病毒(HSV)性脑炎及脑膜炎的临床表现、脑脊液(CSF)及神经影像学检查表现,探讨患者临床不良预后的危险因素。方法选取2009—2015年于南京大学医学院附属鼓楼医院急诊科治疗的HSV性脑炎或脑膜炎患者80例为研究对象,其中脑炎20例,脑膜炎60例。记录患者性别、年龄、临床表现;经腰椎穿刺留取CSF,检测白细胞计数、淋巴细胞分数、粒细胞分数、红细胞计数、蛋白、葡萄糖水平;记录神经影像学及脑电图(EEG)检查结果;出院时采用Glasgow预后评分评价患者临床预后。结果 7例患者颅脑CT有异常改变,其中2例单侧颞叶或颞额区异常密度影,1例左侧岛叶皮质亚急性梗死,1例左侧颞骨内侧高密度影,3例为非特异性改变。14例患者颅脑MRI有异常改变,其中5例单侧颞叶或颞额叶区异常,1例双侧颞额叶区异常,1例左侧岛叶皮质点状出血和亚急性梗死,1例双侧额叶皮质弥散性高密度影,6例为非特异性改变。9例患者EEG有异常改变,其中3例额叶区或颞叶区波形异常,6例为非特异性改变。10例患者出现不良临床预后,其中2例为植物状态,7例为严重功能缺损,1例为中度功能缺损。HSV性脑炎与脑膜炎患者年龄、头痛、意识状态改变、癫痫、局灶性神经缺损、颈强直、CT异常、MRI异常、EEG异常比例,以及住院时间、不良临床预后发生率比较,差异均有统计学意义(P<0.05)。多因素Logistic回归分析显示,合并疾病〔β=2.701,SE=0.804,OR=14.895,95%CI(3.081,72.013)〕、HSV性脑炎〔β=3.766,SE=0.750,OR=43.207,95%CI(9.934,187.917)〕是患者发生不良临床预后的危险因素(P<0.05)。结论 HSV性脑炎和脑膜炎的临床症状、神经影像学检查、EEG及临床预后存在明显差异,合并疾病和HSV性脑炎患者是不良临床预后的危险因素。

Objective To present the clinical manifestations,cerebrospinal fluid（ CSF） characteristics,imaging studies and to investigate the risk factors for adverse clinical outcomes among adults with herpes simplex virus（ HSV） encephalitis or meningitis.Methods The subjects enrolled in this study were 80 patients with HSV encephalitis（ n=20） or meningitis（ n=60） treated in Department of Emergency,Nanjing Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School from 2009 to 2015.We recorded the data of the patients,such as gender,age,clinical manifestations,neural imaging and EEG examination results.The measurement of white blood cell count,lymphocyte percentage,granulocyte percentage,red blood cell count,protein and glucose levels in CSF collected through lumbar puncture was performed in the patients.Glasgow Outcome Scale was used to evaluate the clinical prognosis at discharge.Results Seven patients had abnormal change of cranial CT,among them,2 had abnormal density shadow in the unilateral temporal lobe or temporal frontal area,1 had subacute infarction on the left insular cortex,1 had high- density shadow on the inside of left temporal bone,and 3 had nonspecific changes.Fourteen cases of cranial MRI had abnormal changes,including 5 cases in unilateral temporal lobe or temporal frontal zone,1 case in bilateral temporal frontal zones,1 case with dotted hemorrhage and subacute infarction in the left insular cortex,1 case with diffuse high- density shadows on bilateral frontal cortexes,6 cases with nonspecific changes.Nine patients had abnormal EEG changes, of whom, 3 had unusual waveforms in frontal or temporal lobe areas, and 6 had nonspecific changes.Ten cases had adverse clinical outcomes,including 2 of vegetative state,7 of severe impairments and 1 of moderate function defect.Significant differences were observed between HSV encephalitis and meningitis patients in terms of age,proportions of patients with headache,changes in state of consciousness,seizures and focal neurologic deficits,neck stiffness,abnormal CT,MRI,and EEG,as well as the length of stay,and the incidence of adverse clinical outcome（ P 0.05）.Multivariate Logistic regression revealed that the risk factors for adverse clinical outcomes were comorbidity 〔β=2.701, SE=0.804,OR=14.895,95% CI（ 3.081,72.013） 〕and HSV encephalitis 〔β=3.766,SE=0.750,OR=43.207,95%CI（ 9.934,187.917） 〕（ P〈0.05）.Conclusion HSV encephalitis and meningitis have differences in clinical presentations,imaging and EEG manifestations and clinical outcomes.Adverse clinical outcome are observed more frequently in those patients with comorbidities and an HSV encephalitis presentation.