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.,1,病毒性脑炎诊断的困惑,.,2,脑出血,炎症,病毒性脑炎,.,3,病毒性脑炎引发的脑出血,Herpes zoster encephalitis presenting as multiple cerebral hemorrhages a rare presentation:a case report.Journal of Medical Case Reports 2013, 7:155,.,4,Herpes simplex 1 encephalitis presenting as a brain haemorrhage with normal cerebrospinal fluid analysis: a case report. Journal of Medical Case Reports 2008, 2:387,.,5,单纯疱疹病毒性脑炎合并出血性脑卒中1例报告.新医学,2007,11(38)752-753.,.,6,病毒感染破坏脑组织的同时波及病灶中的血管，一般只表现为出血坏死性炎症反应，如损害较大动脉，则会发生蛛网膜下隙出血和脑实质血肿。,Neuropathology of viral infections. Handbook of Clinical Neurology, Vol. 123 (3rd series),2014.,.,7,诊断的困惑,.,8,病毒性脑炎的诊断依据,.,9,感染性脑炎,自身免疫性脑炎,.,10,感染性脑炎,自身免疫性脑炎,.,11,自身免疫性脑炎的临床分类,自身免疫性脑炎中国专家共识 2017,.,12,自身免疫性脑炎的诊断条件,.,13,.,14,4 合理地排除其他病因,.,15,.,16,.,17,确诊,鉴别,病原学 检测,.,18,病毒一览,Epidemiology of viral encephalitis in 2011. Mdecine et maladies infectieuses 41 (2011) 453464,.,19,.,20,.,21,诊断思路,病毒性脑炎患者病毒学诊断需要首先考虑以下因素:,A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin InfectDis. 2013;57:e22-e121. Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clin Infect Dis. 2013;57:1114-1128.,.,22,Brain regions affected by viruses that cause meningitis and encephalitis,Viral diseases of the central nervous system. Current Opinion in Virology 2015, 11:4454,.,23,.,24,影像学的帮助,单纯疱疹病毒脑炎,Central nervous system infections in cancer patients. Semin Neurol,2010,30: 296310.,.,25,水痘-带状疱疹病毒脑炎,Postvaricella basal ganglia infarction in children. AJNR Am J Neuroradiol,1995,16:449452.,.,26,St. Louis encephalitis and the substantia nigra: MR imaging evaluation.AJNR Am J Neuroradiol,1999,20: 12811283.,圣路易斯脑炎,.,27,Comparison of CT scan and MRI findings in the diagnosis of Japanese encephalitis. J Neurol Sci,2010, 174: 38.,日本脑炎,.,28,Multiple reversible MR signal changes caused by Epstein-Barr virus encephalitis. AJNR Am J Neuroradiol ,2006,27: 14471449.,EB病毒脑炎,.,29,Congenital cytomegalovirus infectionand disease. Adv Pediatr Infect Dis ,1996,11: 135162.,巨细胞病毒脑炎,.,30,Prospective casecontrol study of encephalopathy in children with dengue hemorrhagic fever. Am J Trop Med Hyg ,2001,65: 848851.,登革热,.,31,Chikungunya fever: CNS infection and pathologies of a re-emerging arbovirus. Prog Neurobiol,2010, 91: 121129.,切昆贡亚热,.,32,LaCrosse viral encephalitis mimics herpes simplex viral encephalitis. Pediatr Neurol 25: 413415.,La Crosse 病毒脑炎,.,33,Fatal encephalitis due to novel paramyxovirus transmitted from horses. Lancet,1997, 349: 9395.,Hendra病毒性脑炎,.,34,Imaging of topographic viral CNS infections. Neuroimaging Clin N Am ,2008,18: 8592, viii.,Nipah病毒脑炎,.,35,实验室诊断手段,Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clin Infect Dis. 2013;57:1114-1128.,.,36,脑脊液PCR 的敏感性及特异性均超过95%，有研究建议在治疗2周后，再次进行脑脊液PCR检查，如果结果仍为阳性，则需要继续抗病毒治疗。研究显示，PCR在神经系统症状出现3-7日后的阳性率最高，第二周病毒DNA减少至3050%，15天后减少至25%。,Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clin Infect Dis.2013;57:1114-1128. Diagnosis of herpes simplex encephalitis: application of PCR to CSF from brain-biopsied patients and correlation with disease. J Infect Dis 1995;171:857-863.,.,37,RT-PCR以敏感性高、特异性高、污染少、可定量等优点著称。PCR在部分确诊的脑炎患者中呈阴性结果，因此对于具有典型脑炎临床及影像学特征的患者，不要因为此阴性结果而排除病毒性脑炎诊断。,European consensus on viral encephalitis. Lancet ,1997,349: 299300. Development and Field Testing of a Real-Time PCR Assay for Caprine Arthritis-Encephalitis-Virus (CAEV).Open Virol J. 2012;6:82-90.,.,38,脑脊液白细胞计数少于10/mm3时，PCR检测阳性率明显下降。研究证实，单纯疱疹病毒脑炎的病毒负荷在102-107单纯疱疹病毒基因组/mL脑脊液，经治疗后，其数量级将下降，否则标志预后不佳。,Monitoring of herpes simplex virus DNA types 1 and 2 viral load in cerebrospinal fluid by real-time PCR in patients with herpes simplex encephalitis. J Med Viro,2009,l 81: 14321437. Prognostic value of intrathecal antibody production and DNA viral load in cerebrospinal fluid of patients with herpes simplex encephalitis. J Neurol 256: 12431251.,.,39,体征,影像,电生理,病原学检测,症状,排他,.,40,Backman et al.The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis. Implementation Science (2015) 10:37,患者路径、延误及原因,.,41,士不可以不弘毅，任重而道远。孔子论语泰伯,
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