Today I would like to share with you a case with a tortuous process. I believe that after seeing this case, everyone will have a new understanding of this disease group.
A 28-year-old female patient with the surname Mai.
1 month ago, Miss Mai began to have headaches, and there was a fever, the highest body temperature of 39 ° C, initially thought it was a cold, went to the pharmacy to buy fever reducer, but the fever was still repeated, and then vomited, she was nervous, will not be a common cold, hurry to the hospital for examination.
When the doctor heard that she had a headache and vomiting, he was worried that there might be a brain problem, whether it was a cerebrovascular accident or a brain infection, there might be headaches and vomiting, but because the patient had a significant fever, the possibility of intracranial infection was greater, so he asked to do a skull CT and also draw blood for testing.
The results came out, almost all of them were normal, plus the physical examination did not find other abnormalities, to say that the abnormality, that is, the patient still has a slight cough, the lung auscultation has a little wet sound, shooting chest CT indicates a little tracheitis, so it is diagnosed as a respiratory infection.
Miss Mai's fever, headache, and vomiting may all be caused by respiratory infections, and people may have headaches and vomiting when the fever is severe, which is not unusual, the doctor explained. Antibiotics and antipyretic drugs were given.
After menstruation, the body temperature can come down a little, but the headache is still there.
Worse, the day after returning home, Miss Mai was in a worse condition, the whole person was in a trance, and she was talking nonsense, such as seeing a python pulling poop on the ground, and seeing a large truck carrying a house moving fast..... The family thought she had collided with an evil spirit and was about to take her to the hospital, when suddenly Miss Mai began to shout, as if she had seen something terrible.
There is a grassroots hospital near the hospital patient's home, the family first took Miss Mai to the hospital, found a doctor, the doctor saw miss Mai's previous CT, and then looked at her current symptoms, and also asked Miss Mai's father, learned that Miss Mai's aunt has schizophrenia, while saying that Miss Mai is likely to be schizophrenia, this disease has a certain genetic tendency, you have to pay attention.
This sentence completely cast a shadow over the family, Miss Mai's father knew what schizophrenia meant, and his bitter sister was suffering day after year, and he burst into tears at the thought that his daughter would also face this situation.
This disease has to take medicine for a long time, if the patient does not cooperate, it must be closed, and find a way to let her take medicine. The doctor said.
Miss Mai's mother did not believe that the child would be schizophrenic and decided to take her to the big hospital in the city to see her.
After returning home that day, Mai seemed to be in better condition, but in the evening, the situation changed again.
Just after dinner, Miss Mai fell to the ground, and the whole person fell to the floor with a thud, convulsing, and smoked for 2 minutes before stopping.
120 cars of doctors said it was epilepsy and pulled back to the hospital.
Miss Mai grew so old that she had never had a seizure, and that day was the first time. The local hospital doctor listened to miss Mai's parents mention schizophrenia, said that the patient was feverish and vomiting, and epileptic, where is schizophrenia, it is estimated that there is a high possibility of intracranial infection, and it is recommended to review the head CT.
Also, a lumbar puncture is done.
The most common pathogenic microorganisms of intracranial infection include viruses, bacteria, fungi, etc., which may cause encephalitis, meningitis, etc. These intracranial infections will have symptoms such as fever, headache, vomiting, epilepsy, etc., and may also cause mental disorders, which is not schizophrenia, but caused by intracranial infection.
Not schizophrenia. The doctor's words made Miss Mai's family breathe a sigh of relief. But then there is a problem, intracranial infection is not a good stubble, and if it is not good, it will lose a small life.
Intracranial infections are also severe, with damage to the brain parenchyma (which can also involve meninges) in the case of viral encephalitis, and mortality of more than 50% if not treated appropriately. However, if it is viral meningitis, the meninges (not the brain parenchyma) is damaged, which is a self-limiting disease and has a good prognosis. There is a difference between viral encephalitis and meningitis, just like a mango, the mango flesh is broken, which means that the damage is serious, that is encephalitis; the mango skin is broken, the meat is still good, that is called meningitis, relatively mild. One mile and one outside, probably that's what it means.
But not always, if the pathogen is bacteria (especially purulent bacteria), the resulting meningitis is called purulent meningitis, the structure of the meninges is seriously damaged, bacteria multiply, and the pressure on the skull is significantly increased, and the condition is much more serious than that of viral meningitis. Both are meningitis, but the severity varies due to the different pathogenic bacteria. It is like the skin of the mango is damaged, but one is slightly scratched, and the other is that the skin is so bad that it even spreads to the meat, which shows the severity.
In general, there are still many types of encephalitis and meningitis, which is somewhat difficult to distinguish, and the treatment methods of different encephalitis and meningitis are not the same, so it is still necessary to find a way to make a clear diagnosis. The doctor explains.
Many times, head CT and MRI can provide certain information, but Miss Mai's skull CT review still did not see obvious abnormalities, which is not surprising, 50% of patients with viral encephalitis can not see obvious abnormalities in the early stage.
At this time, further lumbar puncture is done, and the cerebrospinal fluid is extracted for testing.
Pumping cerebrospinal fluid sounds scary. A relatively thick needle, pierced from the middle of the lower back, penetrates the skin ligament, enters the meningeal cavity, and withdraws the liquid (cerebrospinal fluid) inside, which is the process of lumbar puncture.
Although Miss Mai's parents are afraid of lumbar puncture, it sounds cruel and painful, but it still has to be done, and the doctor said that it is anesthesia and will not be very painful. As long as you get cerebrospinal fluid, it is of great help to judge the condition.
Cerebrospinal fluid refers to cerebral fluid, spinal fluid, collectively known as cerebrospinal fluid, in the human brain and spinal cord around there will be part of the fluid, these fluids and brain, spinal cord is interactive, can play a role in protecting the brain and spinal cord, can also regulate intracranial pressure, but also play a role in the material metabolism of brain tissue and so on. When there is a lesion of the brain parenchyma, meninges, or spinal cord, the cerebrospinal fluid will change accordingly. So we take the cerebrospinal fluid out for testing, which can indirectly determine what lesions the cerebrospinal cord has.
As a result, the number of cells in the cerebrospinal fluid increased slightly, and the protein level was also slightly increased, which was consistent with viral encephalitis or alteration.
Combined with the later BRAIN MRI examination, the patient's temporal lobe and frontal lobe have edema, considering that it is viral encephalitis, rather than viral meningitis, this diagnosis is of great significance. As we said earlier, if viral encephalitis is not properly treated, the mortality rate is still quite high, and viral meningitis, generally speaking, does not kill people.
When the patient's family heard this diagnosis, their legs went soft. In their consciousness, brain problems are certainly not trivial, not to mention that the daughter still has seizures, gibberish, and now the doctor says that it is viral encephalitis, that the brain tissue is damaged by the virus, and it feels like the sky has collapsed.
Doctors say it doesn't look very serious yet, but if it is not treated aggressively, it may get worse rapidly in the next few days, the patient will be unconscious, and even the intracranial edema will quickly occur and the brain hernia will die.
At all costs, active treatment. Miss Mai's parents signed, any treatment, no matter how much it costs, as long as it helps, then use it.
Since it is viral encephalitis, antiviral therapy is definitely needed.
But there are many viruses, which one causes encephalitis? The most common is the herpes simplex virus, and the encephalitis caused by this virus is also the most serious, also called acute necrotizing encephalitis, which is not a good stubble to hear this name. Unfortunately, the later cerebrospinal fluid pathogenic examination did not find a specific virus, and not finding it did not mean that there was none, the anti-virus was still on, and it should be on as soon as possible.
Acyclovir was used on the same day, acyclovir is an antiviral drug, which may take 1 month to have an effect, and it is necessary to be mentally prepared.
During that time, Miss Mai had to beat Acyclovir every day. Everyone expects this drug to suppress viral encephalitis and not to aggravate it further.
Unfortunately, acyclovir is not very effective.
Doctors also tried other antiviral drugs, which were used for a few days, but the results were not very good. The patient still had a fever, and although the epilepsy had not recurred, Miss Mai still felt a headache, which was very uncomfortable, and ordinary painkillers did not work at all.
Why is the antiviral effect not good? The doctor fell into thinking and also followed the patient's parents to communicate.
Some doctors believe that perhaps encephalitis is established, but it is not necessarily caused by viruses, it may be bacteria, or rare tuberculosis bacteria, fungi, rickettsia and so on. But this argument was quickly overturned, because if it is caused by bacteria, especially purulent bacteria, there will be a large number of cells in the cerebrospinal fluid, and the cerebrospinal fluid will be cloudy, and there will be bacterial infections in the blood, but this does not hold.
What about mycobacterium tuberculosis? It is also not true, on the one hand, the cerebrospinal fluid is not like, the patient does not have tuberculosis poisoning manifestations, and a series of other tuberculosis tests have been improved, all of which are negative, and the patient is unlikely to be infected with tuberculosis bacillus.
Fungi are also not supported, and various indicators are not like that.
It seems that the evidence of infection caused by the virus is the best. So why does acyclovir work badly? Is it drug resistant? Or is it a combination of glucocorticoids?
Glucocorticoids, the strongest anti-inflammatory drugs. But whether to use glucocorticoids for viral encephalitis is controversial. Some doctors say that no matter what pathogen, as long as the treatment effect is not good, the inflammation is prominent, you can use hormones, with hormones powerful anti-inflammatory effects, first press the inflammation down, otherwise the head will continue to be damaged.
But some doctors say that hormones will suppress immunity and weaken the body's resistance, which is very likely to cause the spread of infection, resulting in further aggravation of viruses, tuberculosis, etc. Who will bear the consequences?
The public said that the public was reasonable, but in the end there was no hormone. Hormones are a double-edged sword, and everyone knows it.
At this time, another doctor put forward an insight: Could it be that the patient is not infectious encephalopathy at all? Will it be that from the beginning to the end, it is not caused by viruses, bacteria, tuberculosis and other pathogens? Autoimmune encephalitis? A type of encephalitis caused by an immune response to the antigens of the central nervous system mediated by autoimmune mechanisms, in layman's terms, is that the patient's immune system is confused and attacks his own brain cells, so encephalitis occurs.
This speculation is somewhat bold.
But this speculation is also reasonable, in fact, at the beginning the doctor has considered whether the patient will be autoimmune encephalitis. After all, there are so many encephalitis patients in neurology, about 10% of them are caused by immune system disorders, which is not much, but it is definitely not uncommon.
It's just that when the patient is admitted to the hospital, the indicators look like infectious diseases, especially like viral encephalitis, so everyone has relaxed their vigilance against this autoimmune encephalitis, and more importantly, to clarify whether it is autoimmune encephalitis, it is necessary to send a part of the cerebrospinal fluid to the institution outside the hospital to detect related antibodies, this examination is more expensive, thousands, all at their own expense, the family may not agree, so the doctor did not forget to cast a wide net in this regard.
The superior physician made a summary: In this way, since it is not clear what pathogen causes encephalitis, nor can it be ruled out that it is encephalitis caused by autoimmune disorders, simply let's do another lumbar puncture, leave more cerebrospinal fluid specimens, send them outside for further examination, do a pathogenic microorganism high-throughput gene sequencing (as far as possible to find microorganisms in the cerebrospinal fluid), and do a related antibody test, as soon as possible to improve the examination.
Hormones are not used first, and acyclovir is continued.
The tube bed doctor told Miss Mai and her parents the results of the discussion, and said the necessity and cost of testing at this hospital institution, and several items may add up to more than 10,000 yuan, purely at their own expense.
Money is not the biggest issue, agree to do.
Lumbar puncture is still to be done, and this is the fourth time it has been done. Although there is anesthetic, but every time there is still pain, Miss Mai clenched her teeth, nodded, do it, as long as it is helpful to diagnose the disease, it can be endured.
Originally thought it was a common cold, and then thought it was schizophrenia, it was hard to be clear that it was viral encephalitis, who knew that the treatment for so long the effect was not good, lumbar puncture was done several times, headache, fever has not been alleviated, Miss Mai is really physically and mentally exhausted.
Everyone pinned their hopes on this lumbar spine.
It was hard to survive until the results returned, and everyone's eyes widened.
The results of the high-throughput gene sequencing of pathogenic microorganisms were not obviously abnormal, and no suspicious pathogenic microorganisms were found in the cerebrospinal fluid, and there were no viruses and no bacteria.
However, one of the CSF-associated antibodies is positive.
Positive for anti-NMDA receptor antibodies.
This antibody is positive, which makes all the doctors excited. Because this confirms the diagnosis of the patient is autoimmune encephalitis, and this is also a relatively rare disease, this antibody-positive autoimmune encephalitis is rare, the local hospital doctor invited the professor of the higher hospital to come to consult and agree to the diagnosis.
The professor said that the NMDA receptor is an ionic glutamate receptor, which can be activated by the synthesized amino acid N-methyl-D-aspartate (NMDA), and the NMDA receptor belongs to the cation channel of the postsynaptic membrane, distributed in the hippocampus, prefrontal cortex, and is closely related to learning, memory and mental behavior. Speaking of this, Miss Mai basically knows, because she herself does have a slight memory loss, especially recent memory.
In addition, the clinical symptoms of anti-NMDA receptor encephalitis include flu-like symptoms (fever, headache, fatigue), accompanied by serious mental and behavioral abnormalities, such as delusions, confusion and hallucinations, etc. Some patients are treated as mental patients, over time, patients have symptoms such as unconsciousness, seizures, movement disorders, etc., and in severe cases, coma, status epilepticus, hypopnea, etc.
Most patients have insignificant MRI changes in the head, but electroencephalogram (EEG) often shows widespread abnormalities and mild lymphocytic inflammation of the cerebrospinal fluid, which can easily lead to misdiagnosis.
Stone Hammer! Miss Mai is an autoimmune encephalitis. Not viral, nor bacterial, but encephalitis caused by autoimmune disorders, in which the immune system attacks its own brain cells, causing damage. No wonder the anti-virus effect has not worked well for so long.
But fortunately, Miss Mai has not yet developed severe language dysfunction, movement disorders, impaired consciousness, etc., and her condition is relatively mild, the professor said.
The next step is to discuss the treatment options.
Since it is autoimmune encephalitis, then suppressing immunity and anti-inflammatory is the key, and the glucocorticoids mentioned earlier can finally come in handy this time. Glucocorticoids for viral encephalitis are controversial, but the treatment of autoimmune encephalitis is a big contributor and must be used! And use large doses to try to control the inflammation as soon as possible.
After using a large dose of hormone for a few days, it is necessary to maintain it with a small dose of hormone for a longer period of time. This can lead to many side effects, including buffalo back, full moon face, gaining weight, acne, hormone disorders, and more.
The doctor said that the hormone is cheap and the effect is exact, that is, the side effects are large.
Miss Mai heard about the side effects of hormones and retreated. She wasn't afraid to die, but she couldn't stand the thought that long-term use of hormones could lead to all sorts of side effects, especially one that would make her ugly.
Then use immunoglobulin, human blood immunoglobulin, can also be anti-inflammatory, the effect is outstanding, is expensive. Use 8 bottles a day, about 700 yuan per bottle, use for 5 consecutive days, a course of treatment down to tens of thousands, all at your own expense.
Miss McGonagall agreed to use immunoglobulins.
But the doctor also said that if the immunoglobulin effect is not good, you have to use hormones back, and you must be mentally prepared. Moreover, the disease of autoimmune encephalitis will be repeated by some people after treatment, and it is also necessary to be psychologically prepared.
Miss Mai is lucky, after 5 days of immunoglobulin down, the fever has subsided, the headache has also been alleviated, like such a comfortable day, Miss Mai has not enjoyed it for more than half a month.
After follow-up treatment, Miss Mai's condition stabilized and she was discharged from the hospital shortly after.
Miss Mai talked about her illness, saying that she spent a lot of money, but it was precisely because she threw so much money into it (there are tens of thousands of self-funded projects) that she picked up a small life, especially this rare disease, it is really not easy to survive.
The subsequent 2 consecutive years of re-examination were normal and there was no recurrence.
Really lucky.
![It rained and the man became gibberish! Who is the culprit?[fig]](data:image/gif;base64,R0lGODlhAQABAIAAAP///wAAACwAAAAAAQABAAACAkQBADs=)