脊髓灰質(zhì)炎的診斷和鑒別-Poliomyelitis

脊髓灰質(zhì)炎Poliomyelitis中南大學(xué)兒科學(xué)教研室,第十章第一節(jié)（2）,目的要求,熟悉本病病因、流行病學(xué)及發(fā)病機(jī)制掌握本病的典型臨床經(jīng)過(guò)和診斷熟悉本病的鑒別診斷掌握本病不同病期的治療及本病的預(yù)防措施,脊髓灰質(zhì)炎是由脊髓灰質(zhì)炎病毒引起的急性傳染病。90%發(fā)生在歲以下兒童(Poliomyelitis is an acute infectious disease caused by polioviruses infection.90% of patients occurs before 5 years old).,概述(overview),概述(overview),病變主要在脊髓灰質(zhì)，表現(xiàn)為弛緩性肌肉麻痹，可留下癱瘓后遺癥(The pathologic lesions of poliomyelitis occurs chiefly in the gray matter of spinal cord.The main clinical feature is flaccid paralysis. Sequelae of paralysis may be left over)。,AFP（acute flaccid paralysis）急性弛緩性麻痹,AFP定義：指臨床表現(xiàn)為急性起病，以肢體運(yùn)動(dòng)障礙為主，并伴有肌肉弛緩性麻痹（軟癱）的一組疾病。AFP病例：任何15歲以下出現(xiàn)急性軟癱的兒童。,概述(overview),脊髓灰質(zhì)炎病毒屬腸道病毒(Poliovirus is an enterovirus, a small RNA virus that affects the central nervous system.),病因(ETIOLOGY),病因(ETIOLOGY),按抗原性分、型，各型間很少交叉免疫，以型病毒最易致癱（There are three antigenically distinct serotypes of poliovirus, type 1,2,and 3,less cross-immunization.Most paralytic disease is caused by type 1.).,發(fā)病機(jī)制(PATHOGENESIS),病毒 口或上呼吸道 腸道粘膜上皮細(xì)胞 局部淋巴組織咽分泌物及糞便排病毒免疫力強(qiáng)隱性感染covert infection 血液：第一次病毒血癥 潛伏期,病毒增殖,全身淋巴組織中血液：第二次病毒血癥 前驅(qū)期 病毒 毒力 多強(qiáng)血腦屏障CNS 癱瘓前期 NC受損輕 NC受損重 無(wú)癱瘓型 癱瘓型癱瘓期 (nonparalytic type) (paralytic type),頓挫型abortive type,病理(pathology),病變主要在中樞神經(jīng)系統(tǒng)，以脊髓受累最多見(jiàn)，并以頸段與腰段脊髓前角運(yùn)動(dòng)細(xì)胞受損最嚴(yán)重。其次是腦干及中樞神經(jīng)系統(tǒng)其他部位。 (Lesions occur chiefly in central nervous system , particularly in spinal cord , where destruction of anterior horn motor cells of cervical and waist segments is most serious, in the next place ,in brainstem and the rest part of central nervous system) .,一般514天,可3-35 天(It usually lasts 5-14 days,range:3-35 days)無(wú)臨床表現(xiàn)(no symptom),潛伏期(incubation stage),臨床表現(xiàn),前驅(qū)期(prodromal stage),多持續(xù)14天(usually lasts 1-4 days)病毒血癥的癥狀(fever,asthenia,malaise and so on)上呼吸道癥狀(cough,rhinorrhea,sore throat and so on),臨床表現(xiàn),前驅(qū)期(prodromal stage),消化道癥狀(anorexia,nausea,vomiting, diarrhea, constipation and so on) 若經(jīng)14天后熱退，癥狀消失，疾病終止稱頓挫型。,臨床表現(xiàn),雙峰熱(double peaked fever)中樞神經(jīng)系統(tǒng)感染的表現(xiàn)(symptoms of central nervous system infection: severe headache,vomiting,the presence of signs of meningeal irritation),臨床表現(xiàn),癱瘓前期(preparalytic stage),癱瘓前期(preparalytic stage),感覺(jué)過(guò)敏，頸、背、四肢肌肉強(qiáng)直疼痛(hyperesthesia,soreness and stiffness of the posterior muscles of the neck,trunk,and limbs)三角架征（tripod sign）吻膝試驗(yàn)陽(yáng)性(kiss-the knee test)頭下垂征（head drop sign）自主神經(jīng)功能紊亂(dysfunction of autonomic nerve),臨床表現(xiàn),根據(jù)病變部位，可分型： 脊髓型(spinal form) 延髓型(bulbar form) 腦 型(encephalitic form) 混合型(mixed form),臨床表現(xiàn),癱瘓期 (paralytic stage),最常見(jiàn)弛緩性癱瘓(flaccid paralysis):不對(duì)稱，肌張力減退，腱反射消失， (asymmetric,hypomyotonia , disappearance of tendon reflexes),脊髓型(spinal form),臨床表現(xiàn),脊髓型(spinal form),近端肌群癱瘓較遠(yuǎn)端出現(xiàn)得早且重，下肢受累最常見(jiàn)，大肌群較小肌群更易受累，常無(wú)感覺(jué)障礙（Proximal muscle of the extremities tend to be more involved than distal, the legs are more commonly involved than the arms,and the large muscle groups of the hand are at greater risk than the small ones.Sensory loss in polimyelitis is very rare.),臨床表現(xiàn),脊髓型(spinal form),頸胸部脊髓受累可致膈肌、肋間肌麻痹(Involvement of cervical and thoracic spinal cord segments results in paralysis of diaphragm and intercostals )。,臨床表現(xiàn),顱神經(jīng)運(yùn)動(dòng)神經(jīng)核受損(involvement of motor cranial nerve nuclei) 血管運(yùn)動(dòng)中樞受損(involvement of vasomotor center) 呼吸中樞受損(involvement of respiration center),延髓型(bulbar form),臨床表現(xiàn),高熱、煩躁不安、驚厥、昏迷上運(yùn)動(dòng)神經(jīng)元痙攣性癱瘓(high fever,irritability, convulsion,coma, spastic paralysis of upper motor neurons),腦 型(encephalitic form),臨床表現(xiàn),體溫正常后，病情不再進(jìn)展?；謴?fù)從肢端開(kāi)始，逐漸向上。 (Progression of paralysis almost invariably halts when the patient becomes afebrile.Recovery occurs from distal of limps to proximal of limps).,恢復(fù)期(convalescent period),臨床表現(xiàn),后遺癥期(sequela period),病程18個(gè)月后，恢復(fù)可能性已不大。可形成永久性癱瘓和肌肉萎縮，導(dǎo)致受 累肢體畸形。,臨床表現(xiàn),合并 癥(complications),呼吸麻痹者易繼發(fā)支氣管炎、肺炎、 肺不張。尿潴留者易并發(fā)泌尿系感染。長(zhǎng)期臥床者易發(fā)生褥瘡、骨質(zhì)脫鈣、肌萎縮等。,腦脊液檢查癱瘓前期：細(xì)胞蛋白分離，癱瘓期：前蛋白細(xì)胞分離期呈細(xì)胞蛋白分離。病毒分離 臨床實(shí)用價(jià)值不大,實(shí)驗(yàn)室檢查,實(shí)驗(yàn)室檢查,血清學(xué)檢查抗體檢查特異性IgM抗體；感染后10-15天出現(xiàn)，持續(xù)1月后消失，具有早期診斷價(jià)值。中和抗體：起病時(shí)出現(xiàn)，2-3周達(dá)高峰，持續(xù)終身。補(bǔ)體結(jié)合抗體：出現(xiàn)較中和抗體遲，不能早期診斷，但僅持續(xù)2-3月，表示近期感染。,診斷,前驅(qū)期的診斷：?jiǎn)慰颗R床癥狀無(wú)法診斷。癱瘓前期的診斷：此期臨床表現(xiàn)，腦脊液：細(xì)胞蛋白分離，血清學(xué)檢查陽(yáng)性。癱瘓期的診斷：典型臨床表現(xiàn)，腦脊液：蛋白細(xì)胞分離。血清學(xué)檢查陽(yáng)性。,鑒 別,治療,無(wú)特殊治療 (no specific therapy)。所有措施均是對(duì)癥處理 (Treatment is entirely supportive and symptomatic ) 。 處理原則：減輕恐懼，減少骨骼畸形，預(yù)防及處理合并癥，康復(fù)治療 （to allay fear,to minimize ensuing skeletal deformities, to anticipate and treat complications, rehabilitation),前驅(qū)期及癱瘓前期的治療,1. 臥床休息(重要治療方法)：持續(xù)至熱退1周，避免體力活動(dòng)至少2周。可減少癱瘓的病發(fā)數(shù)或減輕其程度(To minimize occurrence and severity of paralysis, bed rest until the childs temperature is normal for 1 week and avoidance of exertion at least for 2 weeks are desirable.),前驅(qū)期及癱瘓前期的治療,2. 對(duì)癥治療：退熱鎮(zhèn)痛劑、鎮(zhèn)靜劑緩解全身肌肉痙攣和疼痛；濕熱敷，熱水浴。(symptomatic treatment: antipyretics, analgesics and sedatives are indicated to relief the spasm and soreness；hot moist packs and hot water baths are sometimes useful.),癱瘓期的治療,正確的姿勢(shì)：睡平板床，臥床時(shí)身體成一直線；癱瘓肢體置功能位，膝部稍彎曲，髖部及脊柱可用板或沙袋使之挺直，踝關(guān)節(jié)成90； 疼痛消失后立即作主動(dòng)和被動(dòng)鍛煉，以防骨骼畸形。,癱瘓期的治療,2.適當(dāng)?shù)臓I(yíng)養(yǎng)：營(yíng)養(yǎng)豐富的飲食和大量水分。3.藥物治療： 促進(jìn)神經(jīng)傳導(dǎo)功能藥物：地巴唑；加蘭他敏 促進(jìn)神經(jīng)細(xì)胞代謝藥物：VitB12,癱瘓期的治療,4. 延髓型癱瘓： 保持呼吸道通暢：采用低頭位(雙腳抬高成2025)，最初數(shù)日避免胃管喂養(yǎng)。 每日測(cè)血壓，防治高血壓腦病。 聲帶麻痹，呼吸肌癱瘓者，行氣管切開(kāi)，呼吸受損行人工輔助呼吸。,恢復(fù)期及后遺癥期的治療,功能恢復(fù)治療：按摩、針灸、主動(dòng)和被動(dòng)鍛煉及其他理療措施(rehabilitation:massage, acupuncture,active and passive motions,and other physical therapy)。,傳染源： 各型患者及病毒攜帶者。,管理傳染源： 病人和疑似病人及時(shí)隔離 時(shí)間：自發(fā)病之日起至少40天。 方式：第周呼吸道消化道，以后消化道）； 密切接觸易感者 醫(yī)學(xué)觀察20天。,流行病學(xué)epidemiology,預(yù)防措施prevention,流行病學(xué) 預(yù)防措施,傳播途徑： 糞-口傳播： 主要途經(jīng) 呼吸道飛沫傳播： 早期,切斷傳播途徑： 搞好衛(wèi)生，加強(qiáng)水、糞、食物管理，患者排泄物與用具消毒。,流行病學(xué)預(yù)防措施,人群易感性 普遍易感，感染后對(duì)同型病毒產(chǎn)生持久免疫力；四個(gè)月以下嬰兒很少患病。,保護(hù)易感者 主動(dòng)免疫： 減毒活疫苗（OPV） 被動(dòng)免