基层医院以非视神经炎为首发表现的视神经脊髓炎误诊分析

Misdiagnosis of Optical Neuromyelitis with Non-optic Neuritis as Initial Manifestation in Primary Hospital

目的探讨基层医院以非视神经炎为首发表现的视神经脊髓炎的误诊原因及防范措施。方法对基层医院曾误诊的以非视神经炎为首发表现的视神经脊髓炎5例的临床资料进行回顾性分析。结果本组2例以反复性呃逆为首发表现,2例以反复性恶心和呕吐为首发表现,收住消化内科,诊断为胃肠炎,误诊时间1~3个月。1例以肢体乏力为首发表现收住神经内科,予脊髓MRI及脑脊液检查诊断为急性脊髓炎,误诊时间6个月。5例按误诊疾病予相应治疗症状均无明显改善。5例均在疾病首发1~6个月出现视力下降收住神经内科,通过头颅及脊髓MRI、血清及脑脊液AQP4IgG等检查,确诊为视神经脊髓炎,予大剂量糖皮质激素、丙种球蛋白、免疫抑制、营养神经及疏通微循环等治疗。出院后6个月内随访,4例视力明显改善,未再发作呃逆或恶心、呕吐;1例视力及肢体功能恢复不理想。结论以非视神经炎为首发表现的视神经脊髓炎临床极易误诊。加强基层医院医师对视神经脊髓炎相关知识的学习,保持警惕性,是避免其误诊的关键。

Objective To explore the causes of misdiagnosis and preventive measures for optical neuromyelitis in primary hospitals with non-opic neuritis as the initial manifestation. Methods We conducted a retrospective analysis of the clinical data of 5 patients with optical neuromyelitis with non-optic neuritis as the initial manifestation diagnosed in primary hospitals. Results In this group, two patients in this group had recurrent hiccups, and two with recurrent nausea and vomiting as the first manifestations. They were admitted to the Department of Gastroenterology and misdiagnosed as gastroenteritis. The duration of misdiagnosis was 1 to 3 months. One patient was admitted to the Department of Neurology due to limb weakness as initial manifestation, and misdiagnosed as acute myelitis by the spinal MRI and cerebrospinal fluid examination. The duration of misdiagnosis was 6 months. There were 5 cases with no significant improvements in the symptoms after misdiagnosis and corresponding treatment. Visual acuity of 5 cases was all decreased in 1 to 6 months after initial onset, and the patients were admitted to Department of Neurology. Based on relevant examinations, including skull and spinal cord MRI, and detection of AQP4 IgG in serum and cerebrospinal fluid they were diagnosed as optical neuromyelitis, and then treated with high doses of glucocorticoids, gamma globulin, immunosuppressor, neurotrophic drugs, and microcirculation improvement. At 6-month follow-up after discharge, visual acuity of 4 cases was improved significantly, with no recurrence of hiccups, nausea or vomiting; visual and limb function recovery was far from satisfactory in one case. Conclusion Optical neuromyelitis with non-opic neuritis as the initial manifestation is of extremely high probability to be misdiagnosed. Therefore, for physicians, strengthening the knowledge of optical neuromyelitis in primary hospitals and maintaining vigilance is the key point to avoid misdiagnosis.