A 58-year-old woman was admitted
to the hospital because of left limbs focal tonic seizure and
marked confusion.
The patient had been well until
nine years ago, when diabetes mellitus developed. It was
managed with insulin. The dosage of the insulin had not changed
recently. She suffered from general malaise on 12/23. Fever,
chills, nausea, vomits, and headache developed on 12/25. The
patient was admitted to local hospital where laboratory tests
revealed leukocytosis (WBC: 11,820/uL with 74% seg.) and
pyuria (WBC: 15-20/HPF). A urine culture yielded
methicillin-resistant Staphylococcus aureus.
Intravenous cefazolin and gentamicin were administered. But
she became disoriented (self-talking and change of sleep
pattern) on 12/27. Haloperidaol was given under the impression
of delirium. The WBC was 9140/uL on 12/31. Antibiotics were
shifted to oral form on 1/1, but fever up to 38.5℃ was noted
on 1/2 morning. Left focal seizure with left limbs tonic
movement with mouth angle deviation and neck stiffness was
noted. The patient was transferred to this hospital on 1/2.
On examination, the temperature was
38.5℃ , the pulse rate was 110/min, and
the respiration rate was 24/min. The blood pressure was
105/60 mm Hg. On neurologic examination, the patient was
confused and could be aroused to speak a few
words. She could not know her name, location,
or date. Pupils were isocoric, rounded and reactive to
light. Facial expression was symmetric. Neck was stiff.
Muscle strength by observation was 3 in the left
arm and 4 in the right arm and legs. Muscle bulk
and tone were normal. There were no hyperreflexia and
plantar reflex.
Laboratory tests revealed
that WBC was 30,060/uL with 7% band form and 76%
segment, hemoglobin 15.5 g/dL, platelets 263K/uL, serum glucose 350
mg/dL, serum sodium 145 mmol/L, potassium 3.67 mmol/L, chloride
99 mmol/L, calcium 2.15 mmol/L, albumin 3.4 g/dL and ammonia
29 umol/L. Her renal function was BUN 19.5 mg/dL and Cre 0.93 mg/dL. A
specimen of arterial blood revealed that pO2 was 126mm Hg,
pCO2 28.4mm Hg, HCO3- 15.5mmol/L, pH 7.35, base excess
-8.4 mEq/L, and anion gap 26 mEq/L. The urine was positive for
glucose (>= 1.0g/dL) and ketones (3+). Urine
sediment was normal. A lumbar puncture revealed that WBC was 10/uL
with L:N=
9:1,RBC 2/uL, protein 69 mg/dL, and glucose 188 mg/dL. A CT
of the head with and without contrast showed no definite focal
mass or abnormal enhancement and the ventricles were normal
in size. Phenytoin was prescribed. Shock developed and
conscious level deteriorated at general ward. The patient
entered the intensive care unit. Confusion and disorientation
persisted after serum glucose, pH and hemodynamic status were
corrected. Antibiotics with acyclovir, ceftriaxone and
penicillin G were given for treatment of meningoencephalitis.
On 1/4, EEG revealed one episode of subclinical seizure,
periodic generalized epileptic form discharge and moderate
diffuse cortical dysfunction. Brain MRI examination showed
increased hyperintense signal in the bilateral medial temporal
areas and insulas. The patient's conscious level improved in
the following days. After the condition improved, the patient
was transferred back to general ward on 1/10. Ceftriaxone and
penicillin G were discontinued because there was no evidence
of bacterial infection. The blood sugar was under control by
insulin injection. We kept acyclovir use for 14 days and her
conscious recovered gradually. Then he was discharged with
mild sequela on 91/01/21.
病案分析
本病例是一單純(ㄆㄠˋ)疹病毒所致之腦膜腦炎(Herpes simplex
meningoencephalitis)。Herpes
simplex meningoencephalitis常易被誤診,而延誤治療。主要是臨床的表現並無特一性,病人一開始可能發燒、頭痛、噁心,而被誤為其他感染症。在給予抗生素下,病人持續惡化,產生精神方面的症狀 (psychotic
symptoms);譬如:性格改變,甚至被誤認為acute psychosis。然後可能發生抽搐,以及
focal
neurological signs,此時大家一定會做電腦斷層,但結果可能如本病例般,電腦斷層沒有發現異常。此時須高度懷疑meningoencephalitis,需要做CSF 的檢查,Herpes
simplex meningoencephalitis
CSF中淋巴球稍微增加、有紅血球、蛋白質稍微增高、sugar可能正常。此時高度懷疑是herpes
simplex meningoencephalitis,給予intravenous acyclovir。進一步安排EEG,有典型的periodic
lateralized epileptiform
discharge,以及MRI有localized temporal abnormalities。
CSF之HSV DNA
PCR具有高度sensitivity及specificity幾乎可以取代brain biopsy。而CSF之HSV
culture在成年病患中較少培養出來。
當懷疑herpes simplex
meningoencephalitis時就必須即早使用acyclovir。延遲使用acyclovir將使病人預後非常差(死亡或有嚴重的neurological
deficits)。
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