paralytic dementia
Introduction
Introduction to paralytic dementia Paralytic dementia, also known as syphilitic meningoencephalitis, is a chronic meningoencephalitis caused by the invasion of the brain parenchyma by Treponema pallidum, and is the most serious form of neurosyphilis. In 1798, Haslam first reported the disease, which is a brain-borne disease characterized by progressive mental decline and dementia and tremor. Its main pathological changes are in the brain parenchyma, but it can also involve other parts of the nervous system, and cause a decline in somatic function, which eventually leads to paralysis and increasing mental retardation and personality changes. Because the disease is often gradually developed, eventually physical decline, intelligent damage, personality decline and limb paralysis, it is also known as progressive paralysis or generalized paralysis. basic knowledge The proportion of illness: 0.003% Susceptible people: no special people Mode of infection: non-infectious Complications: dementia
Cause
Cause of paralytic dementia
Disease factors (35%):
The detection of spirochetes in the brains of patients with dementia is a milestone in the history of psychiatry. The mental disorders associated with organic causes are sufficient to show that the same cause can lead to different mental symptoms, damage to the brain parenchyma, brain atrophy, And the pathological changes of the frontal lobe are prominent, brain atrophy, neuronal degeneration, loss of cortical structure may be the cause of dementia and mental symptoms.
Virus infection (45%):
The disease was caused by the invasion of the brain parenchyma by Treponema pallidum. In 1822, Bayle believed that all mental and physical symptoms of the patient were manifestations of chronic meningitis. In 1857, Rokitansky pointed out that the primary lesion of the disease was an interstitial brain. Inflammation, and the damage of the brain's parenchyma is secondary. By 1857, Esmark and Jenssen found that most of these patients had syphilis. In 1894, Fournier analyzed the disease from a statistical point of view, and initially pointed out the disease and syphilis. The relationship, until Wassermann invented the syphilis complement test in the early 20th century, in 1913, Noguchi and Moore found 14 cases of Treponema pallidum in the brains of 70 patients, and the etiology and nature of the disease were confirmed.
Other factors (20%):
In addition, the body's reactivity and functional status are also related to the occurrence of this disease. Head injury, excessive fatigue, alcoholism, other infectious diseases, trauma and other adverse factors can also weaken the body's defense ability and become the cause of the disease. Some people think that this disease is caused by a special pro-neural system of Treponema pallidum, while others believe that it is an "allergic" or "allergic" disease, but there is currently no sufficient basis for it to be determined.
Pathogenesis
The disease is caused by Treponema pallidum invading the brain parenchyma. The pathological changes involve a wide range of diseases and complex nature. The inflammatory reaction of the brain caused by syphilis infection, so-called chronic meningitis, is observed by the naked eye. Thickening, the frontal lobe is the most serious, the whole cerebral cortex is significantly atrophied, the ventricle is enlarged, the ependymal membrane of the ventricle is thickened, especially in the bottom of the fourth ventricle, there is a fine sand-like bulge, called granular ependymitis, in this disease The pathological changes have characteristic significance.
The general pathological changes under the microscope are mainly characterized by inflammatory and degenerative changes. Plasma cells and lymphocytes infiltrate around the meninges and blood vessels, and glial cells proliferate. In a considerable range, nerve cells exhibit degeneration. A large number of cells have necrosis and loss, and most of the cortical internal structure is severely damaged, resulting in disordered cortical cell hierarchy, especially in the small pyramidal cell layer and the middle pyramidal cell layer. The degree of lesion is most in the frontal lobe. Significantly, there are similar changes in the pons, medulla and other parts.
In addition, two special phenomena can be found in the cerebral cortex, namely, the presence of free iron in the cortex and the presence of spirochetes in the middle and deep layers of the cortex.
Because the Treponema pallidum invades different parts of the brain, causing pathological changes in different affected parts, and thus clinically producing different neurological and spiritual signs.
Prevention
Paralytic dementia prevention
As with other infectious diseases, we should first strengthen health publicity and education, oppose unfair sexual behavior, eliminate prostitution, do not engage in extramarital or premarital sexual activities, fix a sexual partner, and actively accept patients who have been discovered and cured. Regular treatment, regular review, re-treatment if necessary, to seek radical treatment, and if necessary, preventive treatment, specific preventive measures:
1. All suspected patients should be examined and tested for syphilis serum in order to detect new patients early and treat them promptly.
2. Patients with syphilis must be forced to undergo isolation treatment. The patient's clothing and supplies, such as towels, clothes, razors, tableware, bedding, etc., should be strictly disinfected under the guidance of medical personnel to eliminate the source of infection.
3. Track the patient's sexual partners, including patient self-reports and medical personnel visits, find all sexual contact patients, conduct preventive examinations, follow up observations and perform necessary treatments. The spouse is absolutely forbidden to have sex before the cure.
4. For pregnant women with suspected syphilis, preventive treatment should be given in time to prevent the infection of syphilis to the fetus; unmarried men and women patients can not get married before the cure.
5. Patients who have received treatment should be given regular follow-up treatment.
Complication
Paralytic dementia complications Complications dementia
The disease caused by dementia caused by treponema pallidum infection, so the patient's immunity, resistance and quality of life decreased, it is easy to suffer from a variety of chronic physical diseases and secondary systemic infection or failure, and often with HIV infection, the disease is treated The Jarish-Herxheimer response is sometimes complicated during the course and is particularly high in patients with GPI. It is characterized by flu-like symptoms within hours to 24 hours after the first injection of penicillin, elevated body temperature, general malaise, increased syphilis damage, worsening of visceral and central nervous system syphilis symptoms, which can be life-threatening. Therefore, oral prednisone before treatment can reduce the incidence of treatment complications.
Symptom
Symptoms of paralytic dementia Common symptoms Eyes sluggish, feeling allergic persecution, imaginary cries, laughter, ataxia, fatigue, paralysis, depression, irritability, ruin, or suspicion
According to the pathological changes of the disease, the characteristics of inflammatory and degenerative changes, the extent of lesion damage, and the progressive course, the clinical manifestations are complex and diverse.
Mental symptoms
Under normal circumstances, mental disorders first attract people's attention, the core symptoms are progressive dementia, general onset of insidious, early manifestations of neurasthenia are not easy to be found, can appear to decline in work ability, thinking slower, alertness And the loss or loss of shame, etc., after the symptoms are fully developed, there may be obvious personality and intellectual disabilities, performance misconduct, calculation, understanding, judgment and memory are significantly reduced; about half of the patients have various delusions, to exaggerate the most common thoughts There may also be suspicions of suspicion, suspicion, sin, etc., delusions have obvious characteristics of dementia, that is, full of contradictions, stupidity and absurdity; about 15% of patients have hallucinations, with auditory hallucinations, illusion as the main; emotional reaction is dull, also Depressed or excited, or emotionally fragile, euphoric or compulsory, with the development of the disease, delusions become fragmented, emotions are declining, and late stages end in severe dementia, generally dividing mental symptoms into three stages:
(1) Early stage: The disease often has a recessive onset, which is slow to develop. It often shows mild symptoms like neurasthenia. Even the most close patients are often not easy to detect, such as headache, dizziness, and sleep disorders. Excitable, irritating or irritating, inattention, memory loss, fatigue, this period is also known as paralytic neurasthenia, usually lasting for weeks to months.
This period can also be accompanied by changes in intelligence, such as work, the gradual decline of learning ability, slow thinking activities, thinking very difficult, speech disorder, understanding, analysis and judgment skills are also reduced with memory loss, especially near Memory loss is more obvious, emotional, performance, depression, dissatisfaction or depression, depression, instinct activity and personality also change, such as low-level intentions have increased, sometimes behavioral rude behavior, personality, patient temper and Interest is different from the past, but it is generally not obvious.
In addition, there are abnormalities in the body, such as changes in the pupil, and the Kang-Wa reaction of the blood and cerebrospinal fluid is positive.
(2) Development stage: At this time, mental disorders are becoming more and more obvious. The most noticeable ones are changes in personality and intelligence. Performance is negligent in business, perfunctory, emotionally irritable, lack of responsibility, no credit, and behavioral aspects. Against the normal state of the past, the performance is rash, the moral and ethical concepts disappear, the slutty, the jokes, the rude behavior, and even the shamelessness, some become extremely selfish, very embarrassing to others, or profligate, only personal enjoyment, indifferent to the loved ones, The patient's lifestyle, behavior and habits of interest are completely different from the past, and are not commensurate with the patient's identity. They even make some actions that steal or violate social morality and ethics, but they are obviously stupid. In addition, the patient is personally Hygiene is also careless, not trimming the edges, and the dress is not perfect.
In this period, the intellectual barriers are getting heavier and heavier, and the memory is significantly reduced. From near memory to far memory, it is impossible for the simplest calculations. In addition, the ability to abstract, generalize, understand, reason, and judge is obviously impaired. The obstacles of thinking can appear absurd, stupid exaggeration, suspicion, suspicion, delusion, exaggeration, and exaggeration. The patient claims to be the richest person in the world, the commander of the entire planet, and sometimes Responsibility, self-sin, suspected or persecuted delusions, etc., can also appear in the context of sexual decline, although the patient's delusions are different, but there is a common feature that delusions often reflect the nature of dementia and pre-disease Personality characteristics, its content is ridiculous, but stupid, contradictory and ridiculous, such as the patient boasting is a millionaire, but often sucks on other people's cigarettes, as the disease progresses and the dementia increases, the delusional content gradually becomes more fragmented. Or irregular.
The patient has an emotional disorder, manifested as emotional instability, irritability, depression or anger, or stupid joy; sometimes emotionally fragile, can cause a strong emotional reaction due to some trivial little things, or mandatory Crying and laughing.
(3) Late stage: mainly manifested as severe symptoms of dementia. At this time, dementia is getting worse. Even simple questions cannot be understood. The sporadic parts of speech are vague and unintelligible. They are unrecognizable to the family and have apathy. Instinctive activities are relatively advanced, and even intentional inversion.
2. The body includes symptoms and signs of the nervous system
Most occur in the middle and late stages. Pathological changes not only invade the brain parenchyma and meninges, but also include the cranial nerves and spinal cord. The body is also directly or indirectly invaded.
Paresthesia: In the early stage of the disease, due to the influence of inflammatory lesions, patients often complain of headache, dizziness, hyperesthesia or paresthesia. If the lesion involves the spinal cord, it may cause an archery-like tingling in the lower limbs.
Pupil changes are a common early symptom. The pupils are narrowed and the sides are not the same size. The edges are not complete. About 60% of the cases show that the pupils completely disappear or are dull to light reflection, and the regulation or polymerization remains, called A-Ro ( Argyll-Robertson) pupil, an important feature of this disease, vision loss, eyelid drooping, widening of the eyelids; due to ocular paralysis of the eye muscles, the face has a special face.
Among them, 20% to 30% of cases can have primary optic atrophy, visual acuity is significantly reduced, other cranial nerves can also show varying degrees of paralysis, especially after stroke episodes, due to numbness of the oculomotor nerve, both sides The ptosis of the upper eyelids, the orbicularis muscles are paralyzed, and the eye cracks become wider. The patient looks like a blind eye. The incomplete paralysis of the facial muscles makes the patient's face expressionless, looks very dull, the mouth is drooping, and the nasolabial fold becomes shallow, forming a kind of The special mask face, the hypoglossal nerve can also be incomplete paralysis, when the patient stretches the tongue can be biased to the affected side.
50% of patients have speech and writing disorders. This is another important feature. Patients have difficulty in articulating, unclear words, slow tones, monotonous content, often accompanied by stuttering, often incomplete fonts, typos, missing words, etc. .
Tremor is another common symptom, manifested as a subtle fibrillation that can affect the eyelids, the around the lips, the tongue and fingers, and sometimes the tremors are quite large, so that the fonts are written in varying sizes, and the handwriting and outline are blurred. , often write a special "font", in addition, there may be gait instability and ataxia, abnormal sputum reflexes, generally with knee reflex hyperthyroidism, after stroke episodes, there may be pathological reflexes, such as combined spinal cord When sputum, the sputum reflexes disappear or disappear, stroke or spasmodic convulsions can occur multiple times, after the paralysis and dementia phenomenon is more significant, and even lead to death, at this time, the bladder and rectal sphincter function disorders, resulting in frequent bowel movements Detention or incontinence, physical weight loss, weakness and exhaustion are increasing, because the long-term bed bone becomes loose, it is prone to fracture, and at the same time can form limb contracture, stroke or spasm convulsion often occur, making paralyzed dementia more serious The length of the disease varies from 3 to 6 months, and the elders are more than 10 years old. If not actively treated, they often die from concurrent infection within 2 to 3 years. Paralysis or status epilepticus.
3. Clinical classification
In addition to the above-mentioned general common symptoms, paralytic dementia may have different symptoms (or syndromes) in clinical cases, and the length of disease and prognosis are different. Clinically, it can be summarized as follows. Types.
(1) exaggerated (manic type): This is the most typical type of this disease, accounting for about 20% to 30%, with exaggerated delusion as the main, accompanied by a class of manic thinking, emotional response, the main performance is the patient Emotions are high, they are very euphoric, emotional activities are unstable, irritating, and often accompanied by quite strong sports excitement, thinking associations increase, often have obvious pathological narratives and exaggerated delusions, the content of delusions is extremely absurd and Bizarre and behavior do not cooperate, and are unstable, and are easily changed by implied influence. The characteristic of exaggerating delusion is that it does not cooperate with its behavior, giving people a naive, stupid and stupid impression. This type has a better prognosis. The reaction is also good and can be relieved.
(2) Dementia type: This type is the most common, accounting for about 55%. The type of this type is slow and gradually progresses. In addition to personality changes and occasional exercise excitement, the clinical manifestations are significant mental defects and dementia, and the thinking is slow. , speech reduction, generally no delusion, apathy, revealing no desire, slow movement, reduced will or even lack, poor prognosis, rarely relieved.
(3) Paranoid type: This type is common to the victim, and may be accompanied by illusion, and the emotion is mostly indifferent, but there is also a corresponding fear performance under the influence of the victim.
(4) Depression: This type is similar to the depression state of manic depressive psychosis. Its performance is: depression, sorrow, grief, and often self-blame and sin. Sometimes it can cause doubts and illusions. It is extremely grotesque and ridiculous.
(5) Spinal cord sputum type: This type of spinal cord hernia is associated with the disease, so the clinical manifestations of hypotonia, sputum reflexes disappear, joint movement disorders, calf archery-like tingling, tactile and deep sense of dullness or loss, optic nerve Atrophy, the course of the disease is generally longer.
(6) Lissauer type (limited lesion type): The main pathological changes of this type are in the parietal lobe and frontal lobe, where the cerebral cortex shows local atrophy. Therefore, patients can produce aphasia, apraxia, hemiplegia, Epileptic seizures, etc., and often die from stroke episodes, this type of dementia generally appears later.
(7) juvenile type: extremely rare, children, juvenile onset, the patient's infection is transmitted by the mother through the placenta 5 months after pregnancy, and therefore generally on the basis of congenital syphilis, is mental development One of the causes of delay is statistically about 1% of congenital syphilis. The incidence of patients is mostly between 5 and 20 years old. If the incidence is between 6 and 12 years old, it is called a child type. The clinical manifestation is mainly determined by brain lesions. The severity of the disease, about 1/3 of patients with somatic growth retardation, 40% of the manifestations of intelligent dysplasia, these patients with insidious onset, gradually progressing, and increasingly serious, in addition, patients are irritated, confused, often do something meaningless The action may sometimes have seizures, optic atrophy is quite common, body weight loss, often death due to failure, the prognosis of this type is serious, the latter three types, also known as atypical paralytic dementia.
(8) Other types: relatively rare, some are similar to schizophrenia, some show acute multiple organic reactions, and some show Korsakov mental illness.
Examine
Examination of paralytic dementia
Blood test
The Kangwa reaction of the blood is strongly positive, and the general positive rate is 90% to 95%, or even as high as 100%.
2. Cerebrospinal fluid examination
The pressure is mostly in the normal range, the appearance is colorless and transparent, and the number of cells generally increases, mostly in the range of 10 to 50/mm3. The number of cells reflects the activity of the disease and the state of the therapeutic response, and the protein is generally positive. The gold test often shows a special curve, such as 5555443210 or 5554431000. Such reactions reflect abnormalities in the protein content of cerebrospinal fluid, but do not indicate the activity of the disease.
The results of both blood and cerebrospinal fluid tests must be considered together, but the results of cerebrospinal fluid should be considered as large, such as blood Kangwa reaction is negative, and cerebrospinal fluid is positive, cerebrospinal fluid positive reaction is more important, should be combined with the history of treatment The situation is analyzed. Generally speaking, after treatment, the negative rate of blood is often faster than that of cerebrospinal fluid. Therefore, the negative reaction of single blood does not mean negation of diagnosis.
The electroencephalogram showed a progressive slow wave increase, lost the normal alpha rhythm, and showed extensive abnormalities. CT showed brain atrophy, and the ventricle enlargement was particularly evident in the anterior horn of the lateral ventricle.
Diagnosis
Diagnosis and diagnosis of paralytic dementia
diagnosis
The disease is a serious disease, and early detection of timely treatment is extremely important.
1. Patients with a history of 30 to 50 years old or older have a clear or suspicious history of smelting and syphilis infection 5 to 20 years ago. They have neurasthenia syndrome, mental dysfunction, memory and judgment. Defects, etc., should take into account the possibility of the disease.
2. Psychiatric symptoms are characterized by significant personality changes and intelligent defects, which are of great significance for diagnosis, often begin to sneak, and develop slowly, so it is easy to be ignored, so when mental examination, it must be observed in detail.
3. Physical symptoms have obvious eye changes, speech, writing disorders, tremors and other characteristic features, including neurological signs, early changes in pupils, speech, writing disorders and tremors, etc., also have their characteristics.
4. Laboratory tests found that serum and cerebrospinal fluid Vapor reaction and Kang's test were positive; serum and cerebrospinal fluid syphilis were positively separated; cerebrospinal fluid pressure was in the normal range, the number of cells generally increased, protein qualitative is generally positive, rubber-like gold The test often showed a special curve. The auxiliary examination showed that the EEG showed progressive slow wave increase, loss of normal rhythm, and extensive abnormal performance. CT showed brain atrophy, ventricle enlargement, and lateral ventricle anterior horn enlargement was particularly obvious, which was helpful for diagnosis. .
Differential diagnosis
The differential diagnosis is easily confused with the following mental illness and must be distinguished.
Neurasthenia
In the early stage, paralytic dementia often has neurasthenia syndrome, which is very similar to neurasthenia, but there is a fundamental difference between the two, neurasthenia and no intelligent change, paralyzed dementia in addition to neurasthenia symptoms, abnormal body visible Such as changes in the pupil, blood and cerebrospinal fluid Vapor reaction and Kang's test positive.
2. Affective mental disorders
The exaggerated and depressive type of paralytic dementia is similar to that of bipolar disorder, but it lacks the basic characteristics and course characteristics of bipolar disorder. The nature and content of delusion are also very different. Patients with paralytic dementia have no thinking, emotion, Behavioral coordination, and organic symptoms; patients with bipolar disorder have no personality changes and intelligent defects, and the nervous system and blood, cerebrospinal fluid examination are also not positive.
3. Schizophrenia
Although paralytic dementia may have schizophrenia-like manifestations, it is still significantly different from schizophrenia. Patients with paralytic dementia have intelligent changes and definitive laboratory evidence. The latter have neither intelligent defects nor nervous systems and tests. The positive indication of the examination, and the delusional nature and content of the two are also very different.
4. Cerebral arteriosclerotic psychosis
The mental disorder of this disease is mainly characterized by limited dementia. It still maintains a critical ability for the disease and the external environment for a long time. In addition, the personality remains relatively intact, and the blood and cerebrospinal fluid have no special changes in paralytic dementia.
5. Alzheimer's disease
Although the disease has personality changes and intelligent defects, its manifestations are different, and there is no special change in blood and cerebrospinal fluid, and the medical history can also be identified.
6. Brain syphilis
The disease also belongs to the syphilis of the advanced nervous system, but the pathological changes of the two are different. The brain syphilis mainly invades the meninges and blood vessels, the nature is mainly inflammatory lesions, the incubation period is shorter, the age of onset is earlier, and the pathological changes of the nervous system It is also more scattered, local symptoms are more common, mental symptoms are milder, neither serious comprehensive dementia nor obvious personality changes, and the positive rate and intensity of blood and cerebrospinal fluid Vapor response are low, but the cells of cerebrospinal fluid The number is more, the rubber-like gold curve is also different, it is syphilis type, that is, 0123321000, the treatment response is faster, so the yin is earlier.
