脊髓灰質(zhì)炎Poliomyelitis兒科教研室word版本

1、脊髓灰質(zhì)炎Poliomyelitis兒科教研室脊髓灰質(zhì)炎脊髓灰質(zhì)炎是由脊髓灰質(zhì)炎病毒引是由脊髓灰質(zhì)炎病毒引起的急性傳染病。起的急性傳染病。90%90%發(fā)生在歲以下發(fā)生在歲以下兒童兒童(Poliomyelitis is an acute (Poliomyelitis is an acute infectious disease caused by infectious disease caused by polioviruses infection.90% of polioviruses infection.90% of patients occurs before 5 patients occ

2、urs before 5 years old).years old).概述概述(overview)概述概述(overview)n病變主要在脊髓灰質(zhì)，表現(xiàn)為病變主要在脊髓灰質(zhì)，表現(xiàn)為弛緩性肌肉麻痹弛緩性肌肉麻痹，可留下癱瘓后遺癥可留下癱瘓后遺癥(The pathologic (The pathologic lesions of poliomyelitis occurs lesions of poliomyelitis occurs chiefly in the gray matter of chiefly in the gray matter of spinal cord.The main cl

3、inical spinal cord.The main clinical feature is flaccid paralysis. feature is flaccid paralysis. Sequelae of paralysis may be Sequelae of paralysis may be left over)left over)。AFPAFP（acute flaccid paralysisacute flaccid paralysis）急性弛緩性麻痹急性弛緩性麻痹AFP定義定義：指臨床表現(xiàn)為急性起病，以肢指臨床表現(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體運(yùn)動(dòng)障礙

4、為主，并伴有肌肉弛緩性麻痹（軟癱）的一組疾病。痹（軟癱）的一組疾病。AFPAFP病例病例：任何任何1515歲以下出現(xiàn)急性軟癱的兒歲以下出現(xiàn)急性軟癱的兒童。童。概述概述(overview)脊髓灰質(zhì)炎病毒脊髓灰質(zhì)炎病毒屬腸道病毒( (Poliovirus is an enterovirus, Poliovirus is an enterovirus, a small RNA virus that affects a small RNA virus that affects the central nervous system.) the central nervous system.) 病因病因(

5、ETIOLOGY)病因病因(ETIOLOGY)按抗原性分按抗原性分、型，各型間很少型，各型間很少交叉免疫，以交叉免疫，以型病毒最易致癱型病毒最易致癱（There are three antigenically There are three antigenically distinct serotypes of poliovirus, distinct serotypes of poliovirus, type 1,2,and 3,less cross-type 1,2,and 3,less cross-immunization.Most paralytic immunization.Most

6、 paralytic disease is caused by type 1.).disease is caused by type 1.).發(fā)病機(jī)制發(fā)病機(jī)制(PATHOGENESIS) 病毒病毒 口或上呼吸道口或上呼吸道 腸道粘膜上皮細(xì)胞腸道粘膜上皮細(xì)胞 局部淋巴組織局部淋巴組織咽分泌物及糞便排病毒咽分泌物及糞便排病毒免疫力強(qiáng)免疫力強(qiáng)隱性感染隱性感染covert infectioncovert infection 血液：第一次病毒血癥血液：第一次病毒血癥 潛伏期潛伏期病毒增殖病毒增殖全身淋巴組織中全身淋巴組織中血液：第二次病毒血癥血液：第二次病毒血癥 前驅(qū)期前驅(qū)期 病毒病毒 毒力毒力 多強(qiáng)多

7、強(qiáng)血腦屏障血腦屏障CNSCNS 癱瘓前期癱瘓前期 NCNC受損輕受損輕 NCNC受損重受損重 無癱瘓型無癱瘓型 癱瘓型癱瘓型癱瘓期癱瘓期 (nonparalytic type) (paralytic type) 頓挫型頓挫型abortive type病理病理(pathology)n病變主要在中樞神經(jīng)系統(tǒng)，以脊髓受累最多見，病變主要在中樞神經(jīng)系統(tǒng)，以脊髓受累最多見，并以頸段與腰段脊髓前角運(yùn)動(dòng)細(xì)胞受損最嚴(yán)重。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。其次是腦干及中樞神經(jīng)系統(tǒng)其他部位。 (Lesions occur chiefly in central nervou

8、s 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) .一般一般5 51414天天, ,可可3-35 3-35 天天(It usually lasts 5-14 (It usually lasts 5-14 days,range

9、:3-35 days)days,range:3-35 days)無臨床表現(xiàn)(no symptom)(no symptom)潛伏期潛伏期(incubation stage)臨床表現(xiàn)臨床表現(xiàn)前驅(qū)期前驅(qū)期(prodromal stage)多持續(xù)多持續(xù)1 14 4天天(usually lasts 1-4 days)(usually lasts 1-4 days)病毒血癥的癥狀病毒血癥的癥狀(fever,asthenia,malaise and so on)(fever,asthenia,malaise and so on)上呼吸道癥狀上呼吸道癥狀(cough,rhinorrhea,sore throa

10、t and (cough,rhinorrhea,sore throat and so on)so on)臨床表現(xiàn)臨床表現(xiàn)前驅(qū)期前驅(qū)期(prodromal stage)消化道癥狀消化道癥狀(anorexia,nausea,vomiting,(anorexia,nausea,vomiting, diarrhea, constipation and diarrhea, constipation and so on) so on) 若經(jīng)若經(jīng)1 14 4天后熱退，癥狀消失，天后熱退，癥狀消失，疾病終止稱頓挫型。疾病終止稱頓挫型。臨床表現(xiàn)臨床表現(xiàn) 雙峰熱雙峰熱(double peaked fever)(d

11、ouble peaked fever)中樞神經(jīng)系統(tǒng)感染的表現(xiàn)中樞神經(jīng)系統(tǒng)感染的表現(xiàn)(symptoms of central nervous (symptoms of central nervous system infection: severe system infection: severe headache,vomiting,the headache,vomiting,the presence of signs of presence of signs of meningeal irritationmeningeal irritation) )臨床表現(xiàn)臨床表現(xiàn)癱瘓前期癱瘓前期(prepa

12、ralytic stage)癱瘓前期癱瘓前期(preparalytic stage)感覺過敏，頸、背、四肢肌肉強(qiáng)直疼痛感覺過敏，頸、背、四肢肌肉強(qiáng)直疼痛(hyperesthesia,soreness and stiffness (hyperesthesia,soreness and stiffness of the posterior muscles of the of the posterior muscles of the neck,trunk,and limbs)neck,trunk,and limbs)三角架征三角架征（tripod signtripod sign）吻膝試驗(yàn)陽性吻膝試驗(yàn)

13、陽性(kiss-the knee test)(kiss-the knee test)頭下垂征頭下垂征（head drop signhead drop sign）自主神經(jīng)功能紊亂自主神經(jīng)功能紊亂(dysfunction of autonomic (dysfunction of autonomic nerve) nerve) 臨床表現(xiàn)臨床表現(xiàn) 根據(jù)病變部位，可分型：根據(jù)病變部位，可分型： 脊髓型脊髓型(spinal form)(spinal form) 延髓型延髓型(bulbar form)(bulbar form) 腦腦 型型(encephalitic form)(encephalitic fo

14、rm) 混合型混合型(mixed form)(mixed form)臨床表現(xiàn)臨床表現(xiàn)癱瘓期癱瘓期 (paralytic stage)最常見最常見弛緩性癱瘓弛緩性癱瘓(flaccid paralysis):(flaccid paralysis):不對(duì)稱，肌張力減退，腱反射消失，不對(duì)稱，肌張力減退，腱反射消失， (asymmetric,hypomyotonia ,(asymmetric,hypomyotonia , disappearance of tendon disappearance of tendon reflexes)reflexes)脊髓型脊髓型(spinal form)臨床表現(xiàn)臨床表

15、現(xiàn)脊髓型脊髓型(spinal form)n近端肌群癱瘓較遠(yuǎn)端出現(xiàn)得早且重，下肢受累最常近端肌群癱瘓較遠(yuǎn)端出現(xiàn)得早且重，下肢受累最常見，大肌群較小肌群更易受累，常無感覺障礙見，大肌群較小肌群更易受累，常無感覺障礙（Proximal muscle of the extremities Proximal muscle of the extremities tend to be more involved than distal, tend to be more involved than distal, the legs are more commonly involved the legs are

16、 more commonly involved than the arms,and the large muscle than the arms,and the large muscle groups of the hand are at greater risk groups of the hand are at greater risk than the small ones.Sensory loss in than the small ones.Sensory loss in polimyelitis is very rare.)polimyelitis is very rare.)臨床

17、表現(xiàn)臨床表現(xiàn)脊髓型脊髓型(spinal form)n頸胸部脊髓受累可致膈肌、肋間肌麻痹頸胸部脊髓受累可致膈肌、肋間肌麻痹(Involvement of cervical and (Involvement of cervical and thoracic spinal cord segments thoracic spinal cord segments results in paralysis of diaphragm results in paralysis of diaphragm and intercostals )and intercostals )。臨床表現(xiàn)臨床表現(xiàn) 顱神經(jīng)運(yùn)動(dòng)神經(jīng)核

18、受損顱神經(jīng)運(yùn)動(dòng)神經(jīng)核受損(involvement of motor cranial nerve nuclei) 血管運(yùn)動(dòng)中樞受損血管運(yùn)動(dòng)中樞受損(involvement of vasomotor center) 呼吸中樞受損呼吸中樞受損(involvement of respiration center)延髓型延髓型(bulbar form) 臨床表現(xiàn)臨床表現(xiàn)高熱、煩躁不安、驚厥、昏迷高熱、煩躁不安、驚厥、昏迷上運(yùn)動(dòng)神經(jīng)元痙攣性癱瘓上運(yùn)動(dòng)神經(jīng)元痙攣性癱瘓(high fever,irritability, convulsion,coma, spastic paralysis of upper m

19、otor neurons)腦腦 型型(encephalitic form) 臨床表現(xiàn)臨床表現(xiàn)體溫正常后，病情不再進(jìn)展?；謴?fù)體溫正常后，病情不再進(jìn)展?；謴?fù)從肢端開始，逐漸向上。從肢端開始，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)期恢復(fù)期(convalescent period)臨床表現(xiàn)臨床表現(xiàn)后遺癥期后遺癥期(sequela period

20、) 病程病程1818個(gè)月后，恢復(fù)可能性已不大。個(gè)月后，恢復(fù)可能性已不大?？尚纬捎谰眯园c瘓和肌肉萎縮，導(dǎo)致受可形成永久性癱瘓和肌肉萎縮，導(dǎo)致受 累肢體畸形。累肢體畸形。臨床表現(xiàn)臨床表現(xiàn)合并合并 癥癥(complications)n呼吸麻痹者呼吸麻痹者易繼發(fā)支氣管炎、肺炎、易繼發(fā)支氣管炎、肺炎、 肺不張。肺不張。n尿潴留者尿潴留者易并發(fā)泌尿系感染。易并發(fā)泌尿系感染。n長期臥床者長期臥床者易發(fā)生褥瘡、骨質(zhì)脫鈣、易發(fā)生褥瘡、骨質(zhì)脫鈣、肌萎縮等。肌萎縮等。n腦脊液檢查腦脊液檢查癱瘓前期：細(xì)胞蛋白分離，癱瘓前期：細(xì)胞蛋白分離，癱瘓期：癱瘓期：前前蛋白蛋白細(xì)胞分離細(xì)胞分離期呈細(xì)胞蛋白分離。期呈細(xì)胞蛋白分離。

21、n病毒分離病毒分離 臨床實(shí)用價(jià)值不大臨床實(shí)用價(jià)值不大實(shí)驗(yàn)室檢查實(shí)驗(yàn)室檢查實(shí)驗(yàn)室檢查實(shí)驗(yàn)室檢查n血清學(xué)檢查血清學(xué)檢查抗體檢查抗體檢查特異性特異性IgMIgM抗體；感染后抗體；感染后10-1510-15天出現(xiàn)，持續(xù)天出現(xiàn)，持續(xù)1 1月月后消失，具有早期診斷價(jià)值。后消失，具有早期診斷價(jià)值。中和抗體：起病時(shí)出現(xiàn)，中和抗體：起病時(shí)出現(xiàn)，2-32-3周達(dá)高峰，持續(xù)終周達(dá)高峰，持續(xù)終身。身。補(bǔ)體結(jié)合抗體：出現(xiàn)較中和抗體遲，不能早期診補(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)斷，但僅持續(xù)2-32-3月，表示近期感染。月，表示近期感染。診斷診斷n前驅(qū)期的診斷：單靠臨床癥狀無法診斷。前驅(qū)期的診斷：單靠

22、臨床癥狀無法診斷。n癱瘓前期的診斷：此期臨床表現(xiàn)，腦脊癱瘓前期的診斷：此期臨床表現(xiàn)，腦脊液：細(xì)胞蛋白分離，血清學(xué)檢查陽性。液：細(xì)胞蛋白分離，血清學(xué)檢查陽性。n癱瘓期的診斷：典型臨床表現(xiàn)，腦脊液：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)檢查陽性。蛋白細(xì)胞分離。血清學(xué)檢查陽性。鑒鑒 別別脊髓灰質(zhì)炎脊髓灰質(zhì)炎格林巴利綜合征格林巴利綜合征癱瘓時(shí)發(fā)熱癱瘓時(shí)發(fā)熱都有發(fā)熱都有發(fā)熱絕大多數(shù)無絕大多數(shù)無頭痛頭痛可有可有常無常無對(duì)稱性癱瘓對(duì)稱性癱瘓肢體麻痹程度肢體麻痹程度近端重于遠(yuǎn)端近端重于遠(yuǎn)端遠(yuǎn)端重于近端遠(yuǎn)端重于近端感覺障礙感覺障礙 感覺過敏感覺過敏早期早期CSFCSF檢查檢查細(xì)胞蛋白分離細(xì)胞蛋

23、白分離蛋白細(xì)胞分離蛋白細(xì)胞分離脊灰病毒分離、抗體脊灰病毒分離、抗體 預(yù)后預(yù)后有后遺癥有后遺癥大多無后遺癥大多無后遺癥治療治療 無特殊治療無特殊治療 (no specific therapy)。所有措施均是對(duì)癥處理所有措施均是對(duì)癥處理 (Treatment is entirely supportive and symptomatic ) 。 處理原則處理原則：減輕恐懼，減少骨骼畸形，預(yù)防及：減輕恐懼，減少骨骼畸形，預(yù)防及處理合并癥，康復(fù)治療處理合并癥，康復(fù)治療 （to allay fear,to minimize ensuing skeletal deformities, to anticipa

24、te and treat complications, rehabilitation)前驅(qū)期及癱瘓前期前驅(qū)期及癱瘓前期的治療的治療1. 1. 臥床休息臥床休息( (重要治療方法重要治療方法) )：持續(xù)至熱退：持續(xù)至熱退1 1周，避免體力活動(dòng)至少周，避免體力活動(dòng)至少2 2周。可減少癱瘓的周?？蓽p少癱瘓的病 發(fā) 數(shù) 或 減 輕 其 程 度病 發(fā) 數(shù) 或 減 輕 其 程 度 ( To m i n i m i z e occurrence and severity of paralysis, bed rest until the childs temperature is normal for 1 w

25、eek and avoidance of exertion at least for 2 weeks are desirable.) 前驅(qū)期及癱瘓前期的治療前驅(qū)期及癱瘓前期的治療 2. 2. 對(duì)癥治療：退熱鎮(zhèn)痛劑、鎮(zhèn)靜劑緩解對(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。全身肌肉痙攣和疼痛；濕熱敷，熱水浴。(symptomatic treatment: (symptomatic treatment: antipyretics, analgesics and antipyretics, analgesics and sedatives are indicated to rel

26、ief sedatives are indicated to relief the spasm and sorenessthe spasm and soreness；hot moist hot moist packs and hot water baths are packs and hot water baths are sometimes useful.) sometimes useful.) 癱瘓期的治療癱瘓期的治療 正確的姿勢(shì)正確的姿勢(shì)：睡平板床，臥床時(shí)身體睡平板床，臥床時(shí)身體成一直線；癱瘓肢體置功能位，膝部成一直線；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稍彎曲，髖部

27、及脊柱可用板或沙袋使之挺直，踝關(guān)節(jié)成挺直，踝關(guān)節(jié)成9090； 疼痛消失后立即作主動(dòng)和被動(dòng)鍛煉，以疼痛消失后立即作主動(dòng)和被動(dòng)鍛煉，以防骨骼畸形。防骨骼畸形。癱瘓期的治療癱瘓期的治療2.2.適當(dāng)?shù)臓I養(yǎng)：適當(dāng)?shù)臓I養(yǎng)：營養(yǎng)豐富的飲食和大量水分。營養(yǎng)豐富的飲食和大量水分。3.3.藥物治療：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)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：促進(jìn)神經(jīng)細(xì)胞代謝藥物：VitBVitB1212癱瘓期的治療癱瘓期的治療 4. 4. 延髓型癱瘓：延髓型癱瘓： 保持呼吸道通暢：采用低頭位保持呼吸道通暢：采用低頭位( (雙腳抬雙腳抬高成高成20202525)

28、)，最初數(shù)日避免胃管，最初數(shù)日避免胃管喂養(yǎng)。喂養(yǎng)。 每日測血壓，防治高血壓腦病。每日測血壓，防治高血壓腦病。 聲帶麻痹，呼吸肌癱瘓者，行氣管切聲帶麻痹，呼吸肌癱瘓者，行氣管切開，呼吸受損行人工輔助呼吸。開，呼吸受損行人工輔助呼吸。恢復(fù)期及后遺癥期的治療恢復(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動(dòng)鍛煉及其他理療措施(rehabilitation:massage,(rehabilitation:massage, acupuncture,active and acupuncture,active and passive motions,and other passive motions,and other physical therapy)physical therapy)。 傳染源：傳染源： 各型患者及病毒攜各型患者及病毒攜帶者帶者。 管理傳染源：管理傳染源： 病人和疑似病人及時(shí)隔離病人和疑似病人及時(shí)隔離 時(shí)間時(shí)間：自發(fā)病之日起至少：自發(fā)病之