Mental disorders associated with sporadic encephalitis
Introduction
Introduction to mental disorders associated with sporadic encephalitis It is currently believed that many intracranial infections are caused by viruses, in addition to various acute encephalitis with defined viral types, as well as lentiviral or lentiviral diseases, the main lesions being demyelinating and/or degenerative chronic The disease process. Pathological changes mainly include direct damage of the virus and pathological reactions of the tissue. The latter is the result of the body's immune response to the viral antigen. Due to the different types of viruses (such as plant type), various pathological reactions are caused. The nature and extent of the lesion are directly related to the pathogen and body reaction of the infection. Sporadic (viral) encephalitis is not an independent disease. From the clinical practice, the current clinical classification is mostly divided into two categories according to the important characteristics of onset (quick) and pathological changes: 1 acute viral encephalitis: including epidemic encephalitis, herpes simplex Viral encephalitis, etc.; 2 Lentiviral encephalitis: Subacute sclerosing panencephalitis, progressive multifocal leukoencephalopathy, etc. are known. basic knowledge The proportion of illness: 0.007%-0.008% Susceptible people: no special people Mode of infection: non-infectious Complications: disturbance of consciousness
Cause
Causes of mental disorders associated with sporadic encephalitis
Virus infection (30%):
Most domestic researchers believe that this immune disorder is induced by viral infection, and external factors can cause immune disorders and affect the onset of the disease, but the exact pathogenesis remains to be further explored.
Drugs (30%):
Some researchers believe that the cause of immune disorders may not be limited to viral infections. Some units in China have found some cases of encephalitis after taking deworming nets. Deworming nets contain levamisole, which can change the immune response. Promote allergic encephalitis by changing the immune status of the body.
Pathophysiology
Visual examination of the brain tissue revealed diffuse or focal lesions in the damaged meninges and brain parenchyma, edema of the brain tissue, widening of the cerebral gyrus, narrowing of the sulci, and white matter edema in the corresponding part of the localized lesion. Necrosis, necrotic tissue is honeycomb, sometimes a little bleeding around.
Microscopic examination, in primary sporadic (viral) encephalitis, because nerve cells are the main target of viral parasitism and damage, you can see neuronal degeneration, phagocytosis, disappearance and the appearance of inclusion bodies, glial cell proliferation, Demyelination and softening lesions are formed, and inclusion bodies may be present in glial cells.
In allergic reactive demyelin encephalitis, significant loss of myelin can be seen, while axons, ganglion cells, glial cells, etc. are relatively intact or slightly altered, and myelin-leaked lesions are scattered in the white matter of the brain and spinal cord. Especially around the small veins or around the ventricles.
With the advancement of virology and immunology technology, it is confirmed that sporadic (viral) encephalitis is a disease caused by intracranial virus infection, which is an inflammatory change of brain tissue caused by direct invasion of the virus, resulting in immunological demyelination. It can also be caused by immune system disorders (which can be induced by viral infection or external factors acting on sensitive individuals), but the exact pathogenesis remains to be further explored.
Pathogenesis
The pathogenesis of sporadic (viral) encephalitis mainly involves two aspects: virological examination and immunological research.
Virological examinations include virus isolation, immunofluorescence and serological examination, isolation of adenoviruses in patients' blood, cerebrospinal fluid and brain tissue, and DNA and RNA viruses to be identified.
In immunological studies, blood and cerebrospinal fluid immunoglobulin examination showed that IgG content was higher than normal and consistent with Guillain-Barré syndrome and Devie disease. Sichuan Medical College measured cerebrospinal fluid immunoglobulin, and the patient group had an average IgG of 5.27. ±1.76 was higher than the control group, and there was significantness in the study of cerebrospinal fluid cytology and lymphocyte subsets in Nanjing Medical College. It was found that cerebrospinal fluid has immunocompetent cells, including plasma cells, transformed lymphocytes and activated monocytes. The T cells of the patients were higher than those of the control group, and the B cells were lower than the control group, but there was no significant difference in the D cells. Therefore, it is considered that the central nervous system of the patient has an immune response mainly involving T cells and humoral immunity, which is similar to multiple occurrences. See the cerebrospinal fluid of demyelinating diseases such as sexual sclerosis.
Prevention
Prevention of mental disorders associated with sporadic encephalitis
The key to the prevention of sporadic encephalitis lies in early diagnosis, early treatment, promotion of scientific health, labor and relaxation, relaxation, degree of relaxation, prevention of overwork, prevention of overwork, adherence to disease, and other unscientific ways to treat diseases. Exercise, enhance physical fitness, improve self-immunity, children should receive vaccination according to regulations.
Complication
Symptoms of mental disorders associated with sporadic encephalitis Complications
Ambiguous, involuntary movement.
Symptom
Symptoms of mental disorders associated with sporadic encephalitis Common symptoms psychomotor excitability involuntary movement typhoid face response slow stunned
Most patients with subacute and chronic infections have insidious onset and develop progressively. In acute phase, acute or subacute onset, most of the symptoms peak within 2 weeks, mainly brain damage signs, generally diffuse Symptoms and signs of brain damage, in some cases may have clinical manifestations of focal lesions, intelligent disorders and progress to dementia.
1. Prodromal symptoms: Some cases have upper respiratory tract infection or gastrointestinal symptoms before the onset, such as headache, mild or moderate fever, some cases have normal body temperature, and may also have nausea, vomiting, diarrhea and so on.
2. Mental disorders: The incidence rate can reach 81%, appearing in various stages of the disease period, and even constitute the main clinical symptoms of the disease. The onset of mental disorders is often similar to the performance at the peak of the disease. People with mental disorders as the first symptom are often misdiagnosed as mental illness, so it is necessary to correctly identify the symptoms of encephalitis.
(1) disturbance of consciousness: the most common, domestic reports reached 90%, some are the first symptoms, but also after other mental symptoms, the consciousness of some cases is always clear, the disturbance of consciousness is lethargy, sputum, turbid, sputum, There are many disordered states. As the condition worsens, there may be coma. The disturbance of consciousness is more fluctuating in the early stage. When the day is light and heavy, when the condition is aggravated, the consciousness disorder is deepened and persistent.
(2) Schizophrenia-like symptoms: self-speaking, association disorder, emotional instability, wounding and disfigurement, etc. Some patients have mental activity diminished, apathy, unresponsiveness, laziness, reduced speech or activity, and even silence No words, no food, there may be repeated and stereotypes, violations, etc., in the state of sub-arsenal or stupor, some of them after 1 to 2 days of exercise excitement into the stupor, and some start with stupor state, and later Developed into sports excitement, similar to the schizophrenia tension type, the language movement excitement is similar to the schizophrenia youth type, some illusion delusion state, the hallucination is mainly auditory hallucination, individual patient content is fixed, lasting, and even prolonged, still There may be unfixed relationship delusions, murderous delusions, suspected delusions and other similar schizophrenia paranoia, individual cases of sub-wood stiffness, stupor state is a periodic episode.
(3) Intelligent barriers: mild memory impairment, distracted attention, misconstruction, fiction, and even severe dementia. Some cases have prominent memory impairments, and they have been prolonged for a long time. Near memory and mechanical memory are particularly affected. Some people think that memory The disorder is one of the characteristics of herpes simplex encephalitis.
3. Physical and neurological symptoms and signs Neurological symptoms can occur simultaneously or intermittently with prodromal symptoms, or immediately following prodromal symptoms.
Neurological damage can be seen in central facial paralysis, optic disc edema, and other symptoms of cranial nerve damage.
Among motor dysfunction, about half of the patients have onset of seizures, of which the most common are the most common episodes, followed by focal seizures and tendon attacks. Some patients may have multiple types of seizures, with an incidence of 27% to 86. %, is most common with hemiplegia, the incidence of muscle tension changes by 40% to 70%, mostly extrapyramidal, increased muscle tone has variability, time hidden, sometimes upper limbs, sometimes lower limbs, tendon reflex Hyperthyroidism, a small number of weakened, pathological reflex detection rate of 50% to 80%, mostly bilateral, some patients with palmar reflex and sucking reflex positive, in the disease progression, often involuntary movement.
Meningeal irritation accounts for about 30% to 60%, most of them are mild or moderate, and the patient shows a slight resistance to the neck or a positive Kelnigue sign.
Autonomic dysfunction, increased sweating is one of the characteristic manifestations of this disease, patients often sweat, even in the cold winter sweating, sweating accounts for about 20%, some reports as high as 86%, increased sweating It suggests that the hypothalamus is damaged, and the condition is heavier. Others have increased saliva secretion, facial flushing, and increased facial fat. Domestic reports of incontinence are more prominent, especially urinary incontinence, accounting for 30% to 89%, and early One of the symptoms, clinical urinary incontinence often indicates signs of substantial damage to encephalitis associated with viral infection. Some patients cannot control bowel movements due to disturbance of consciousness, but some patients have clear consciousness and still have urinary incontinence, which is a urinary dysfunction. Therefore, it is inferred that the lesion may affect the paracentral lobule, and a few may be expressed as urinary retention.
Children's cases are also sporadic, no obvious seasonality, 1 to 2 weeks before the disease, may have upper respiratory tract infections and gastrointestinal symptoms, to coma, convulsions suddenly onset more common, the main symptoms are disturbance of consciousness, convulsions, epilepsy, urine Incontinence, hyperhidrosis, cranial nerve damage, limb paralysis, involuntary movement, ataxia, pathological reflex positive, meningeal irritation positive, when reported viral encephalitis in children, symptoms of whole brain damage such as disturbance of consciousness, convulsions or epilepsy Positive pathological reflexes and meningeal irritation signs are prominent.
Acute herpes simplex encephalitis (HSE) is one of the most common forms of acute lethal encephalitis. It is reported to account for 10% of viral encephalitis and 20% to 75% of necrotizing encephalitis. It is considered to be the main cause of severe viral encephalitis. Herpes simplex virus encephalitis is divided into type I and type II. Type II is mostly infected by genital mucosa, which is more common in infants, causing skin herpes and encephalitis. Type I is from oral mucosa. Infection, through the olfactory nerve and the trigeminal nerve into the brain, the lesion is the weight of the temporal lobe and frontal lobe, this type is more adult.
1. Acute or subacute onset, 1 to 2 weeks before the onset of infection symptoms or a clear history of pre-infection, such as respiratory or gastrointestinal infections.
2. At the same time of exercise excitement or exercise inhibition, accompanied by varying degrees of disturbance of consciousness, it can gradually deepen as the disease progresses.
3. Psychiatric symptoms and neurological signs in different stages of the disease, especially extrapyramidal signs such as increased muscle tone and hyperhidrosis, urinary incontinence, clinical signs of encephalitis caused by viral infection.
4. Cerebrospinal fluid pressure and white blood cells and proteins are slightly elevated or normal, but no evidence of bacterial (including Mycobacterium tuberculosis, etc.) infection is detected.
5. EEG has diffuse abnormalities (some can be focal).
6. Serum antibody titer IgG is significantly increased (especially the recovery period is more than 4 times higher than the acute phase).
7. The cerebrospinal fluid finds viral antigens or specific antibodies.
Examine
Examination of mental disorders associated with sporadic encephalitis
1. The total number of white blood cells in the peripheral blood is normal or slightly increased, the neutrophils in the white blood cells increase, and the erythrocyte sedimentation rate is normal or slightly accelerated.
2. Cerebrospinal fluid routine examination, increased cerebrospinal fluid pressure, mild increase of white blood cells and / or protein, sugar, chloride normal, but normal is not uncommon, on the basis of the immune-active cell-based cellular response, mainly lymph Cellular response, a small number of transformed lymphocyte reaction, mononuclear cell reaction and mononuclear phagocytic reaction, mainly in the acute phase before the three major, the recovery phase is mainly mononuclear-like reaction, acute phase cytological abnormalities can exceed 90 %, half of the cases can increase protein, sugar and chloride are normal, and the sugar content of individual cases is increased, and occasionally the paralyzed rubber-like gold curve.
3. Domestic reports: IgM and IgG antibodies in cerebrospinal fluid and blood were detected by capture antibody method (ELISA) for early diagnosis of herpes simplex encephalitis. Under physiological conditions, IgM antibodies could not pass the blood-brain barrier, and virus-specific IgM was detected in cerebrospinal fluid. The antibody suggests that the nervous system has an antibody response after viral infection. The method itself requires only a single serum and cerebrospinal fluid, and the result can be obtained in one day. In herpes simplex encephalitis, it can be positive on the second day of the onset of neurological symptoms. IgM can be detected in herpes simplex encephalitis type I within 2 to 12 days of onset, and IgM antibodies can be detected from cerebrospinal fluid to about 7%. IgG antibodies can also be detected from a serum and cerebrospinal fluid.
4. Conditional units can also perform early virus isolation.
(1) EEG examination: EEG showed diffuse changes or focal changes on this basis, and returned to normal as clinical symptoms improved.
The EEG abnormalities reported in this disease ranged from 85% to 96%. The Qingdao Medical College reported that all 160 cases were abnormal EEG, mainly diffuse high amplitude slow waves, which may have aggravated changes in the background of diffuse abnormalities, sometimes Spike waves, sharp waves or spine-slow wave complexes and periodic complex waves, etc., mostly persistent and different abnormalities, but also paroxysmal, sporadic and rhythmic, these changes are the same as other viruses caused by encephalitis There is no specificity. Generally, the abnormality of EEG is mild in the acute phase. As the disease progresses, the abnormal degree of EEG is gradually aggravated, and the abnormal degree is the highest at the peak of the disease. As the disease recovers, the EEG gradually returns to normal, and there are also The recovery is slightly slower than the clinical one.
Viral encephalitis with mental abnormalities as the main symptom, the EEG is basically the same as the general viral encephalitis, the majority of the light is diffuse low to medium amplitude and wave, and a few cases have high amplitude spikes or Focal high amplitude delta wave.
Viral encephalitis with seizures, about 82.4% of EEG are diffuse abnormalities, a few are high-amplitude spikes, and 5.8G have episodes of discharge after encephalitis, and EEG is still abnormal after acute phase. And there are paroxysmal discharges, indicating that the patient will have seizures.
Some literatures emphasize brain tumor encephalitis, EEG localization abnormalities are more common, but most reports are on the background of diffuse abnormalities, with focal mid-high amplitude amplitude wave or wave.
Some researchers have suggested that the number of slow waves increases, the period is prolonged and the amplitude becomes parallel with the degree of conscious turbidity, but there are also different opinions. Sometimes slow waves appear earlier than conscious disturbances, but sometimes, EEG of viral encephalitis There is no specificity, and the diagnosis of encephalitis cannot be determined accordingly. It must be combined with clinical and other examinations to have the auxiliary diagnostic significance. It is easy to be misdiagnosed as functional psychosis in the early stage of the disease before the occurrence of positive neurological signs, but the EEG abnormality occurs early in the disease. Reflecting diffuse damage in the brain, EEG is one of the important basis for differential diagnosis.
(2) Brain ultrasound examination: In the acute phase, heavier cerebral edema occurs on one side, and the midline shift is visible.
(3) Head CT examination: There have been many reports. Head CT examination has certain value in the diagnosis of demyelin encephalitis. It can be seen in low-density areas, and cerebral edema, space-occupying lesions or liquefaction foci can be found.
Diagnosis
Diagnosis and diagnosis of mental disorders associated with sporadic encephalitis
Diagnostic criteria
Some viral encephalitis with mental disorders as the first or main symptom, its neurological signs, such as changes in pyramidal tract signs or tendon reflexes, mostly appear after psychiatric symptoms, and do not necessarily exist constantly, the location and nature of the signs are also Can be changed, therefore, must be repeatedly and carefully checked to determine, in some cases throughout the course of the disease are always psychiatric symptoms, no disturbance of consciousness and signs of the nervous system, the diagnosis is mainly due to the importance of organic psychotic symptoms, therefore, this The diagnosis of the disease should be comprehensively considered, comprehensive analysis, early diagnosis, should be followed up to avoid delay in treatment.
Herpes simplex encephalitis is one of the most common viral encephalitis. The age of onset is more than 30 years old. It is more common in autumn. It is very common in the early stage when there is obvious mental abnormality. This is more likely to involve the frontal lobe. Related to the leaves, there are also obvious disturbances of consciousness and severe symptoms, and there are also relatively many limb paralysis.
Cerebrospinal fluid cells, protein increase is quite obvious, some visible red blood cells, EEG more common abnormalities, may be related to severe disturbance of consciousness, head CT abnormalities are also more common, mainly for the frontal lobe low density area, a few low density There is a little flaky high-density shadow in the area, which is the manifestation of hemorrhage of brain parenchyma. When conducting diagnosis, comprehensive analysis should be carried out, and comprehensive consideration should be made. If the diagnosis cannot be confirmed at an early stage, follow-up observation should be carried out.
Differential diagnosis
First of all, it needs to be differentiated from functional psychosis. It is reported that 23% of mental disorders caused by acute viral encephalitis are misdiagnosed as functional psychosis, and the rate of misdiagnosis of outpatients with mental symptoms is 77%.
1. Early disease: Because of the excitement of speech movement, such as excitement and incitement, wounding and destruction, noisy, self-speaking, self-smiling, and sexually excited, it is easy to be misdiagnosed as youthful schizophrenia, but memory, understanding, calculation Decreased power and judgment, reflecting brain damage, due to speech motility inhibition, such as eating less, eating less, less speech, stupid or sub-chicken state, easily misdiagnosed as nervous schizophrenia or responsive Mental illness, but there may be incontinence, hyperhidrosis and disturbance of consciousness, and signs of nervous system appear earlier, there are perceptions and thinking disorders, such as illusion, auditory hallucinations, visual distortion, implicature, suspicion, misdiagnosis as Schizophrenia is paranoid, but has mild disturbance of consciousness, has certain mental factors, manifests insomnia, chest tightness, and is easily misdiagnosed as snoring. However, after the mental factors are relieved, the symptoms are not improved, so it can be distinguished from snoring.
2. In the middle of the disease: mainly for different levels of disturbance of consciousness, the presence of disturbance of consciousness can also have fever, which is easier to distinguish from functional psychosis, the disturbance of consciousness first excited, and gradually enters sleepiness, shallow coma, coma or paralysis State, conscious disturbances occur, often begin to appear fever, should be differentiated from other infectious psychosis and other brain organic diseases.
3. Acute infection with toxic encephalopathy: Psychiatric symptoms may occur acutely or subacutely, but there are obvious physical infections. In physical examination and bacterial immunological examination, various positive infections can be found, and consciousness disorders are paralyzed. The state is more common, and mental symptoms often appear after infection, and often change with changes in physical illness.
When there are symptoms of meningeal irritation, it should be differentiated from various types of meningitis. For example, purulent, tuberculous, suppurative, tuberculous meningitis has obvious specific changes in cerebrospinal fluid, and the corresponding bacteria or Mycobacterium tuberculosis can be found in cerebrospinal fluid. .
The symptoms of infection, fever and cerebrospinal fluid in primary viral encephalitis are relatively more common than demyelin encephalitis. Corticosteroids have better therapeutic effects and visual evoked potential changes, which can be used as demyelin encephalitis. Diagnostic reference, virus isolation, immune antibodies to serum and cerebrospinal fluid, pathological examination, is more conducive to diagnosis.
4. Identification of intracranial space-occupying lesions: Head CT scans can reveal shadows with increased density.
