<Brief
History>
The 43-year-old man had fever, headache for about one week
and loss of consciousness for one day.
He had been in good health before until 1 week before
admission when he had fever, headache, generalized malaise and
myalgia. There were no rhinorrhea, no cough, no sorethroat or
cutaneous exanthems. The headache was over the fronto-temporal
area without photophobia or visual disturbance. He visited LMD
where acute tonsillitis was told. However, the headache and
fever did not subside after medication. He loss his
consciousness four days after the initial presentation. He was
taken to local hospital where high fever and neck stiffness
were noted. Brain CT scan did not reveal abnormal findings. He
was then referred to our hospital.
At our hospital, fever, leukocytosis,
neck stiffness and impaired consciousness were noted. A recent
travel history to Thailand one month ago was told. Lumbar
puncture revealed pleocytosis with neutrophil predominant (WBC
63/ul L/N 3/60, open/close pressure 165/140cmH2
O, protein 86 mg/dl, glucose 77
mg/dl). Brain MRI study revealed meningitis with brain
parenchymal change. However, prolonged and repeated generalized
tonic-clonic seizure without regain of consciousness developed
on the next day. He was put on antibiotics with ceftriaxone,
and acyclovir for meningitis and phenytoin for generalized
tonic-clonic seizures. Under the impression of
meningoencephalitis with status epilepticus without defined
pathogens, he was admitted to ICU for further care.
<Physical
Examination>
Consciousness:comatous, vital sign:BP 124/80 mmHg, T/P/R:
36.8/92/20,HEENT: grossly normal ,Conjunctiva not pale, sclera
not icteric, pupils isocoric, light reflex: +/+, Neck: stiff,
no lymphadenopathy, no jugular vein engorgement, Chest:
symmetric expansion, breathing sound clear, Heart: regular
heart beat, no murmur Extremities: freely movable, no
cyanosis, no pitting edema, Kernig's sign (+), Brudzinski's sign
(+)
<Laboratory>
[ CBC+PLT ]
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/Dl |
K/μL |
17.93 |
5.16 |
11.8 |
35.1 |
68.0 |
22.9 |
33.6 |
127.0 |
Seg |
Eos |
Baso |
Mono |
Lym |
% |
% |
% |
% |
% |
76.1 |
0.1 |
0.4 |
9.6 |
13.8 |
[ Coagulation Rout
]
PT |
PT Cont |
INR |
PTT |
PTT Cont |
sec |
sec |
|
sec |
sec |
12.4 |
11.4 |
1.0 |
38.3 |
31.5
|
[ Biochemistry ]
GLU |
UN |
CRE |
T-BIL |
AST |
mg/dl |
mg/dl |
mg/dl |
mg/dl |
U/l |
105.0 |
6.0 |
0.8 |
0.5 |
23.0 |
Na |
K |
Cl |
Ca |
Mg |
mmmole/l |
mmole/l |
mmole/l |
mmole/l |
mmole/l |
135.0 |
3.7 |
100.0 |
1.97 |
0.8 | 檢 體 : C.S.F
Count (L:N:M&H) |
TP |
GLU AC |
AFS |
GS |
Indian Ink |
Cytology |
/ul |
g/dL |
mg/dl |
|
|
|
|
63 ( 3:60:0) |
0.086 |
77 |
(-) |
(-) |
(-) |
(-) |
15 (13:2:0) |
0.044 |
70 |
(-) |
(-) |
(-) |
(-) |
Blood Culture & Sensitivity
test: No aerobic&anaerobic pathogens C.S.F. HSV-PCR :
positive C.S.F: No aerobic&anaerobic pathogens C.S.F Fungus: No
fungus
項 目 |
檢驗值 |
Anti-HIV |
Non-Reactive |
項 目 |
檢驗值 |
Virus isolation: Blood |
Negative |
項 目 |
檢驗值 |
Virus isolation: C.S.F. |
Negative |
[ Blood pH/Gas
]
PH |
PCO2 |
PO2 |
HCO3 |
BaseExc |
mmHg |
mmHg |
mEq/l |
mEq/l |
|
7.41 |
37.5 |
93.0 |
23.0 |
-0.9 |
<Course and
Treatment>
After admission, repeated generalized tonic-clonic
seizures without regain of consciousness still persisted. HSV-PCR
was strong positive and HSV meningoencephalitis was diagnosed.
He was treated with phenytoin and intermittent
intravenous diazepam. Repeated cerebrospinal study 3 days later
showed pleocytosis with lymphocyte predominant ( WBC 15/ul,
L:N 13/2). Due to prolonged seizures under
anti-epileptic medications with unstable oxygenation and hemodynamics, he
was intubated and transferred to ICU. Acyclovir (10 mg/kg q8h)
was given for 14 days. Thiopental with titration from 50mg to 125
mg/hr for 21 days, lamotrigine with titration from 200 mg to
400 mg/day and midazolam continuous infusion with 0.2 mg/kg/hr
to 0.8 mg/kg/hr were used to control seizure activity. Serial
EEG study revealed gradual improvement without frequent
seizure spikes. The attack of generalized tonic-clonic seizure
decreased but not totally subsided. He underwent tracheostomy
for airway protection and off-ventilatory support smoothly.
Intermittent generalized tonic-clonic seizure which lasted for
about 1 minute persisted. His consciousness was clear during
interictal periods with labile moods and some impairment of
higher cortical function. Rhabdomyolysis due to repeated
generalized tonic-clonic seizure gradually imporved after
hydration and urine alkalization. He was transferred to
neurologic general ward on for further care.
<病歷分析>
本病例為一中年男性發燒頭痛數日後,出現頸部僵硬和意識障礙,而進入昏迷狀態。腰椎穿刺腦脊髓液中出現噬中性白血球、蛋白增加等發炎現象。三天後之腦脊髓液檢查發現發炎細胞變成淋巴球為主,腦部MRI檢查顯示腦膜和腦實質有發炎反應,診斷為急性腦膜腦炎。後續腦脊髓液之炮疹病毒PCR呈陽性反應,因此確診為炮疹病毒造成之腦膜腦炎。病人在住院期間出現癲癇之重積狀態,因為對一般抗癲癇藥物反應不佳,因此病人被轉送至加護病房治療。隨後病人接受thiopental,
lamotrigine,
midazolam等藥物治療,其癲癇之重積狀態才被控制。病人之後恢復意識,但殘存部分神經之損傷。
炮疹病毒性腦膜腦炎,男女的發生率相近,其發生並無地域或季節之區別。臨床表現以發燒頭痛(frontal,
retrobulbar, with photophobia or pain on moving the
eyes),和腦膜刺激之症狀。腦脊髓液內之發炎反應,以淋巴球增多為主,蛋白質的含量稍增加,而葡萄糖的含量正常。當有腦炎發生時,會出現意識狀態改變,人格改變,50%之嚴重腦炎會出現癲癇的現象。診斷此疾病主要是由腦脊髓液檢查發現淋巴球為主的發炎現象,同時利用CSF
nucleic acid
amplification的方法(PCR)偵測炮疹病毒的核酸存在來診斷,CSF的病毒培養常常並無結果。此病之治療,主要是給予acyclovir
10 mg/kg q8h for 14 days,加上支持療法。
癲癇的重積狀態,其定義為二次以上次第的癲癇發作,其間病人的意識狀態無法恢復,或者是持續的癲癇發作超過30分鐘(有人定義5分鐘)以上。其原因可分成急性原因:代謝障礙(電解質異常、腎衰竭、敗血症等)、中樞神經系統感染、中風、頭部外傷、藥物中毒和組織缺氧。慢性原因:本來就存在的癲癇症因停藥而發作,酒精成癮等。癲癇的重積狀態其原因是多重的,主要是因為使癲癇停止的機轉失常。如興奮性的神經傳導物過多或抑制性的神經傳導機制失常等。臨床上,處理的原則第一是要保持呼吸道的暢通,必要時需氣管插管。當有體溫升高時要降溫。當病人使用長效之肌肉麻痺劑或長期使用抗癲癇藥物而效果不佳時,需監測腦電圖。
藥物的治療:當診斷確立後就要馬上開始使用抗癲癇藥物,80%的病人在30分鐘內使用第一線藥物(diazepam
followed by phenytoin)後癲癇可被控制。當使用benzodiazepine,
phenytoin或phenobarbital後癲癇的重積狀態無法被控制,稱為refractory status
epilepticus,此時須要更積極的治療。持續的靜脈滴注midazolam,
propofol或barbiturate等麻醉劑最有效。midazolam的劑量為 0.2 mg/kg slowly
IV,然後 0.75∼10μg/kg/min;propofol 1-2 mg/kg IV,然後 2-10
mg/kg/hr持續12至24小時,若臨床或EEG監測,癲癇不再發作再慢慢減量。 |