李斯特菌脑干脑炎三例临床分析

Clinical analysis of three cases of listerial rhombencephalitis

目的探讨李斯特菌脑干脑炎的临床、影像及脑脊液改变特点,以提高临床医生对本病的认识。方法搜集山东大学齐鲁医院2017年4月—8月收治的3例李斯特菌脑干脑炎患者的所有临床资料,进行回顾性分析。结果3例患者均为成年女性,既往体健,均急性起病,首发症状为发热(38.2~40.0 ℃)、头痛伴恶心、呕吐,发病第3~5天出现脑神经麻痹、吞咽困难和肢体瘫痪等脑干受累的症状,发病第5~8天进展至呼吸衰竭和意识障碍。3例患者均于入院后第3~5天经脑脊液培养确诊,初期的脑脊液乳酸均明显升高,分别为12.3、12.0及10.0 mmol/L;细胞数分别为416×10^6/L、760×10^6/L及793×10^6/L;蛋白分别为0.76、0.57及1.47 g/L。3例患者颅脑影像学均提示脑干受累,其中例1和例3合并小脑受累,例2累及上颈髓,例1出现幕上脑积水。经敏感抗生素治疗后例1痊愈,例2死亡,例3遗留吞咽障碍。结论对于发热、头痛起病,快速出现脑神经麻痹、急性呼吸衰竭的可疑颅内感染者,如影像学提示脑干受累、脑脊液细胞数增多伴乳酸明显升高时要想到李斯特菌脑干脑炎的可能,尽早给予敏感抗生素治疗对改善患者预后至关重要。

Objective To describe the features of clinical, imaging and cerebral spinal fluid (CSF) of listerial rhombencephalitis to improve the understanding of this disease in clinical practice. Methods All the clinical data of three cases of listerial rhombencephalitis from April to August 2017 in Qilu Hospital were collected and analyzed retrospectively. Results All the three cases were healthy adult women before, with a rapidly progressive course, beginning with fever (38.2-40 ℃), headache accompanied by nausea and vomiting, followed by cranial paralysis, dysphagia and paralysis of the limbs on the 2nd to 5th day of onset, and developed to acute respiratory failure and unconsciousness on the 5th to 8th day of onset. All the three patients were diagnosed with CSF culture positive for Listera monocytogenes on the 3rd to 5th day after admission. The initial CSF lactic acid increased significantly, representing 12.3, 12.0 and 10.0 mmol/L respectively;CSF white blood cells were 416×10^6/L, 760×10^6/L and 793×10^6/L, respectively, and the protein levels were 0.76 g/L, 0.57 g/L and 1.47 g/L, respectively. Brain images showed brain stem was involved in all the three patients, therein cases 1 and 3 with cerebellar hemisphere involved, case 2 with upper cervical spinal cord involved, and case 1 with supratentorial hydrocephalus involved. After treatment with sensitive antibiotics, case 1 recovered, case 2 died, and case 3 lived with dysphagia. Conclusions Listerial rhombencephalitis should be suspected when a patient started with fever and headache, rapidly progressed to cranial nerve paralysis, brainstem symptoms, and acute respiratory failure, especially when the brain imaging suggested brainstem involved with increased white blood cells and apparently elevated lactic acid level of CSF. The earlier the sensitive antibiotics initiated, the better the patients′ prognosis.