急性原发性阿米巴性脑膜脑炎1例

A case of acute primary amoebic meningoencephalitis

患者,男,50岁,湖北武汉人,建筑工人。2022年8月3日在因发热就诊于武汉市江夏区第一人民医院/协和江南医院发热门诊,行相关检查后予口服抗生素及退热处理,病情无好转;次日家属发现患者精神差、躁动不安且胡言乱语,遂转入神经内科。家属代诉,患者曾于2022年7月29日在工地附近的湖泊游泳,8月3日出现发热,体温最高达39.0℃,伴头部、后颈部疼痛,呕吐。入院查体:神志清,有轻度谵妄状,查体不能配合,双侧巴氏征阳性,颈强4指,双侧克氏征阳性。血常规示:白细胞17.5×10^(9)/L,中性粒细胞86.5%,降钙素原0.16 ng/ml。8月5日行腰椎穿刺,脑脊液检查示:脑脊压正常,为145 mmH2O(1 mmH2O=9.779 Pa),白细胞数升高(4265.00×10^(6)/L),多核细胞升高(88.00%),潘氏蛋白试验呈阳性,总蛋白升高(2394.2 mg/L),葡萄糖降低(0.15 mmol/L),氯正常(114.66 mmol/L),钾降低(2.75 mmol/L)。头颅CT检查示,左侧基底节区腔隙性脑梗死。脑脊液病原学微生物高通量基因检测检出福勒耐格里阿米巴,相对丰度为98.76%。结合流行病学史、临床症状和实验室检查结果,诊断为原发性阿米巴性脑膜脑炎。予脱水降颅压、抗感染、抗癫痫、维持水电解质平衡等治疗,予甘露醇(125 ml/6 h)、头孢曲松钠(2.0 g/12 h)、两性霉素B(8月6日1 mg、8月7日2 mg、8月8日3 mg、8月9日4 mg)等。患者经治疗虽控制癫痫发作,但病情进行性加重,于8月9日形成脑疝而死亡。

The 50-year-old male patient is a construction worker from Wuhan,Hubei.On August 3rd,2022,he was administrated with oral antibiotics and antipyretic treatment at the fever clinic of the First People's Hospital/Union Medical College Jiangnan Hospital in Jiangxia District,Wuhan due to fever.However,his condition did not improve.The next day,the family discovered that the patient was mentally ill,restless,and talking nonsense,so the patient was transferred to the neurology department.The family reported that the patient swam in a lake near the construction site on July 29th,2022.On August 3rd,he developed a fever with a maximum body temperature of 39.0℃,accompanied by pain in the neck and vomiting.Admission examination showed clear consciousness,mild delirium,unable to cooperate with the examination,positive bilateral Pap sign,stiffed neck with a gap of 4 fingers,and positive bilateral K sign.Blood routine examination shows that white blood cell count is 17.5×10^(9)/L with 86.5%neutrophils and procalcitonin 0.16 ng/ml.Lumbar puncture cerebrospinal fluid examination on August 5th showed a normal cerebrospinal pressure(145 mmH2O,1 mmH2O=9.779 Pa),an increase in white blood cell count(4265.00×10^(6)/L),multinucleated cells were increased(88.00%),Pan's protein test was positive,the total protein increased(2394.2 mg/L),glucose was decreased(0.15 mmol/L),chloride was normal(114.66 mmol/L),potassium wad decreased(2.75 mmol/L).The head CT scan showed lacunar infarction in the left basal ganglia area.The high-throughput genetic examination of pathogenic microorganisms in the cerebrospinal fluid revealed Naegleria fowleri,with a relative abundance of 98.76%.Based on the epidemiological history,clinical symptoms and laboratory examination results,the diagnosis of primary amoebic meningoencephalitis was made.Dehydration,intracranial pressure reduction,anti-infection,anti-epilepsy,and maintenance of water-electrolyte balance were administered with mannitol(125 ml/6 h),ceftriaxone sodium(2.0 g/12 h),amphotericin B(1 mg on August 6th,2 mg on August 7th,3 mg on August 8th,and 4 mg on August 9th)were administered.Although the patient managed to control the seizure after treatment,the condition worsened gradually and on August 9th,he developed a cerebral hernia and died.