廣州管圓線蟲致嗜酸細(xì)胞性腦脊膜神經(jīng)根炎

1、    廣州管圓線蟲致嗜酸細(xì)胞性腦脊膜神經(jīng)根炎        【摘要】目的報道10例廣州管圓線蟲引起的嗜酸細(xì)胞性腦脊膜神經(jīng)根炎,以期提高對該病的認(rèn)識和重視。方法對10例患者的臨床全過程及實驗室檢查進(jìn)行系統(tǒng)的觀察及隨訪，并結(jié)合當(dāng)?shù)亓餍胁W(xué)資料及國內(nèi)外文獻(xiàn)，實行對比研究。結(jié)果該組病例具有如下特征：急性起?。?0例）；劇烈頭痛（10例）和（或）軀體痛性感覺障礙（8例），伴發(fā)熱（8例）、全身違和（10例）；可有腦神經(jīng)（3例）或脊神經(jīng)根（8例）受累；無明顯頸抵抗及病理征（10例）； 腦

2、脊液（6例）及外周血（10例）中嗜酸細(xì)胞數(shù)增高；血清和腦脊液廣州管圓線蟲蚴抗體均呈陽性（5/5例）；病程自限，預(yù)后良好（10例）；病前食用過生淡水螺肉（8例）；所在地為廣州管圓線蟲新疫源地；已排除其他蠕蟲感染。結(jié)論一度在溫州暴發(fā)流行的一種“怪病”實屬廣州管圓線蟲所致的嗜酸細(xì)胞性腦脊膜神經(jīng)根炎?！娟P(guān)鍵詞】管圓線蟲，廣州 管圓線蟲目感染神經(jīng)根炎 Eosinophilic meningoradiculitis caused by Angiostrongylus cantonensisCHEN Xiuyun, HUANG Xiangdong, ZENG Shibin. Department of Ne

3、urology, Wenzhou No.2 Hospital, Wenzhou 325000【Abstract】ObjectiveTo report ten cases of eosinophilic meningoradiculitis caused by Angiostrongylus cantonensis which should be well recognized and paid more attention to. MethodsThe ten cases consisted of six inpatients and four outpatients of our hospi

4、tal, including 6 females and 4 males. Their ages were 24-48 years with an average of 33.5 years. The whole clinical courses and laboratory data of the patients were systematically observed and followed up with epidemiological investigation for half a year. The previous reports were also studied as t

5、he controls. ResultsThe clinical manifestations of the ten patients comprised: acute onset (10/10), severe headache (10/10), painful paresthesia (8/10), fever (8/10) and malaise (10/10). Headache was the most prominent symptom occurring usually in intermittent attacks, the common sites being located

6、 in the occipital, frontal and bitemporal regions. Body paresthesia were expressed as severe skin pain exacerbated by the slightest touch (8/10), numbness (2/10), itching (2/10) and sensation like worms crawling on the skin (1/10). Occasionally diplopia (2/10) and facial paralysis (1/10) might be de

7、veloped. Signs of the central nervous system such as neck stiffness and kernigs sign were not evident. Tendon reflexes might be decreased (5/10) or increased (2/10). Pathologic reflexes (10/10) were not demonstrated. Laboratory findings were as follows: (1) Hemogram showed WBC count to be (8.5-12.5)

8、×109/L and Eosinophilic count to be 0.080.21. (2) The CSF became slight cloudy in gross appearance and the CSF pressures were found to be 1.672.25 kPa. WBC count in the CSF was (4701 100) ×106/L, Eosinophillic was 0.080.60 and protein was 0.731.44 g/L. Both glucose and chloride were normal

9、. Detection of the antibodies of A.Cantonensis by ELISA method in CSF and sera of 5 cases were all positive (5/5). No parasite was recovered. The bacteria cultures were negative. (3) Mild abnormalities on the EEG were found in eight cases and moderate abnormalities were seen on the EEG in only one c

10、ase. (4) Of 2 cases, the common peroneal nerve and tibial nerve showed sensory conducting velocities (SCV) decreased. (5) No abnormality was found on imaging scanning. The clinical course was 2860 days with an average of 36.4 days. No relapse or obvious sequaela was found after half a year of follow

11、ing up. Epidemiologic investigation demonstrated that 8 cases had a history of eating uncooked fresh water snails, Ampullaria gigas, before the onset. One patient had eaten uncooked shrimps and the remained did not remember what had been eaten in the past. Wenzhou as a new endemic area of A.cantonen

12、sis had been established recently and other larva migrans had been ruled out. As a whole, the above mentioned clinical characteristics were compatible with A.cantonensis previously reported at domestically and abroad. ConclusionThe “strange disease” of outbreak in Wenzhou is actually eosinophilic me

13、ningoradiculitis caused by A.cantonensis.【Key words】Angiostrongylus cantonensis Angiostrongyliasiseosinophilic meningoradiculitis 廣州管圓線蟲（angiostrongylus cantonensis）系陳心陶（1933）首先在廣州家鼠及褐家鼠的肺動脈中發(fā)現(xiàn)1。1944年首例在我國臺灣省一男孩CSF中檢到。從此，該蟲引起人類中樞神經(jīng)系統(tǒng)的感染被初次確認(rèn)。此后，來自太平洋群島、東南亞諸國及臺灣省的研究證實，廣州管圓線蟲是這些地區(qū)多數(shù)嗜酸細(xì)胞性腦膜炎的主要病因。迄今報道的

14、臨床病例已超過2 500例2，而我國大陸有關(guān)該病的報道極少?，F(xiàn)將我院于1997年1011月間診治的10例報道如下。臨床資料1.一般資料：住院6例，門診4例；女性6例，男性4例；年齡2448歲，平均33.5歲；于1997年10月下旬至11月上旬，相繼發(fā)病。該病當(dāng)時在溫州市內(nèi)小范圍暴發(fā)流行，民間稱其為“怪病”。2.臨床表現(xiàn):10例均呈急性起?。黄渲?例首發(fā)癥狀為肩背、頸枕及雙顳部自發(fā)性劇痛，伴軀干及四肢皮膚痛性感覺障礙（包括痛覺過敏、過度及倒錯）；另5例首發(fā)癥狀為打噴嚏、發(fā)熱、違和等類似感冒；伴有胸前一過性少許非對稱性細(xì)小丘疹，35天后消失。繼之，軀干或頭部開始劇烈疼痛（部分呈游走性，先軀干后頭部

15、，或先頭部后軀干）。頭痛(10例)是所有患者的主要突出癥狀，常見的部位在枕部、前額及雙顳，疼痛性質(zhì)被喻為刀劈或鞭抽樣，呈間歇性發(fā)作，每次持續(xù)10分鐘或至半小時不等，極頻繁，痛苦難忍，止痛藥無效。其次，是軀體痛性感覺障礙(8例)，呈頸、胸、臂或雙下肢發(fā)作性可忍或難以忍受的燒灼、刀割或針扎樣的疼痛，常因微風(fēng)吹拂，內(nèi)衣磨擦或輕微觸摸而誘發(fā)和加劇，個別患者注射度冷丁亦無效；其中2例伴軀干或四肢麻木、2例渾身瘙癢、1例雙下肢有蟲爬感。2例有持續(xù)2周以上的視力模糊及復(fù)視，10例均有不同程度全身違和，8例有發(fā)熱（體溫37.839.0)。查體：意識清，無腦膜刺激征，無皮下結(jié)節(jié)、遷徙性腫塊及匐行疹；單側(cè)外展神經(jīng)

16、不全麻痹2例；左側(cè)周圍性面癱1例；單側(cè)和雙側(cè)下肢痛覺及肌力減退各1例；腱反射減弱5例，亢進(jìn)2例；病理征均陰性。3.實驗室及特殊檢查：10例外周血象：白細(xì)胞數(shù)(8.512.5)×109/L，嗜酸細(xì)胞占8%21%，嗜酸細(xì)胞直接計數(shù)(5284 000)×106/L；6例分別在發(fā)病急性期和恢復(fù)期行CSF檢查，急性期CSF壓力1723 cmH2O(1 cmH2O=0.098kPa)，外觀微濁，無黃變，未見紅細(xì)胞，白細(xì)胞數(shù)(4701 100)×106/L，蛋白0.731.44 g/L,細(xì)胞分類:嗜酸細(xì)胞占8%60%,直接計數(shù)為(44308)×106/L；糖和氯化物均

17、正常；未找到蟲體,細(xì)菌培養(yǎng)陰性，Torch試驗陰性，IgG和IgM均正常。送檢的5例CSF及血清廣州管圓線蟲蚴抗體（ELISA法）均陽性，其他5例未檢。恢復(fù)期CSF檢查：腦壓正常，細(xì)胞數(shù)(35104)×106/L,細(xì)胞分類：淋巴細(xì)胞占93%98%，嗜酸細(xì)胞為零。10例EEG中：輕度異常8例，中度彌漫性異常1例，正常1例。8例頭顱CT均未見異常，其中1例MRI提示右側(cè)腦室旁點狀小缺血灶。6例EMG檢查，其中2例分別為右側(cè)腓總神經(jīng)和左側(cè)脛神經(jīng)潛伏期延長，運動及感覺傳導(dǎo)速度減慢。4.治療與轉(zhuǎn)歸：4例服用丙硫咪唑,每天0.4 g，共14天；4例服用甲苯咪唑,每天0.1 g，共7天；2例未服驅(qū)

18、蟲藥，僅應(yīng)用潑尼松每天15 mg及對癥治療，共7天；病程(發(fā)病至癥狀明顯緩解)2860天，平均36.4天。隨訪半年，無復(fù)發(fā)，無明顯后遺癥。所有癥狀逐漸改善，痊愈或基本痊愈。5.流行病學(xué)調(diào)查：8例病前在市區(qū)某飯店會后聚餐，食用過生淡水螺肉，1例病前曾食用生醉酒河蝦，另1例食生螺史不詳，但聚餐頻繁，不排除食入被污染的食物。據(jù)調(diào)查，該淡水螺系溫州蒼南縣的“福壽螺”（ampullaria gigas）。去年已在當(dāng)?shù)氐摹案勐荨眱?nèi)及褐家鼠的肺動脈和右心房處分別檢到了廣州管圓線蟲3期幼蟲和成蟲，感染率前者占69.4%，后者占19.5%3。最近，又從1例來自蒼南的2歲女幼兒CSF中找到廣州管圓線蟲（已經(jīng)鑒定

19、）, 其中第五期幼蟲43條，發(fā)育期雌成蟲1條4。討論一、臨床特征廣州管圓線蟲入侵人體神經(jīng)系統(tǒng)和骨骼肌可引起不同的臨床綜合癥，諸如嗜酸細(xì)胞性腦膜炎、腦炎、神經(jīng)根 脊髓炎、 顱神經(jīng)炎、周圍神經(jīng)炎與嚴(yán)重的肌痛2。臺灣（1976）報道125例(88例<10歲)，以嗜酸細(xì)胞性腦膜炎及腦膜腦炎為特征5。泰國（1975）報道484例(18例<10歲)，美國夏威夷（1979）報道34例(10例<10歲)均以嗜酸細(xì)胞性腦膜炎為主要表現(xiàn)6,7。成人病例常具如下特征：急性起??；頭痛突出（90%99%）；頸僵直感（56%64%）；嘔吐（49%56%）常見；軀體感覺異常（37%54%），以夏威夷組居多

20、；可伴發(fā)熱（37%41%）；其他較少見的表現(xiàn)有復(fù)視或視物模糊（38%），眼外肌麻痹（3%9%）；面癱（4%）。大多數(shù)病例無明顯陽性神經(jīng)體征，少數(shù)嚴(yán)重者可出現(xiàn)頸僵直（15%）、克氏征（6%）、意識障礙（5%），罕見昏迷、抽搐、癱瘓或死亡。我國臺灣病例以兒童居多,病情較重，有較高比例的嗜睡、發(fā)熱、違和、肌肉抽搐、四肢無力或輕癱、昏迷、反射改變、頸強直、克氏征、病理征5。CSF初壓大多輕或中度增高，外觀可見無色透明、微混或混濁；白細(xì)胞總數(shù)（292 410)×106/L，（1501 500）×106/L占80%;泰國病例半數(shù)以上在(5002 000)×106/L之間；嗜酸

21、細(xì)胞為10%92%(平均38%),白細(xì)胞總數(shù)高者嗜酸細(xì)胞亦高；蛋白輕中度增高,平均1.0 g/L；糖含量處正常低值,平均0.5 g/L；氯化物正常。CSF中檢獲蟲體的機率極低。周圍血象白細(xì)胞（7.024.5)×109/L,大于10.0×109/L占56%75%,嗜酸細(xì)胞比例大多在10%50%之間。本組病例除神經(jīng)根痛較明顯外，其他表現(xiàn)均與國內(nèi)外已報道的病例相符。無匐行疹、遷徙性皮下腫塊、眼臉?biāo)[、肌肉觸痛、腦脊髓實質(zhì)損害及血性CSF，結(jié)合流行病史可排除棘腭口線蟲病、旋毛蟲病及肺吸蟲病。二、流行病學(xué)特征廣州管圓線蟲成蟲寄生于鼠的肺動脈內(nèi)，螺類、蝸牛、蛞蝓等為其中間宿主。人類發(fā)病

22、因食用了未熟或生的含有第三期幼蟲的上述軟體動物或被污染的果菜飲水所致。幼蟲在消化道穿過腸壁進(jìn)入循環(huán)系統(tǒng)再進(jìn)入中樞神經(jīng)系統(tǒng)，引起了腦脊膜、腦及脊髓等處的損害。主要病變是蟲體移行或死亡引起的組織損傷或炎癥反應(yīng)。病情的嚴(yán)重性與攝入的活動蟲體數(shù)量成正相關(guān)1。病蟲主要流行分布于熱帶和亞熱帶，感染率的高低與動物宿主的生態(tài)種系、寄生蟲賴以生存的環(huán)境因素以及當(dāng)?shù)鼐用竦奈幕蛩赜嘘P(guān)2。溫州地處東海之濱，氣候溫濕，是軟體及甲殼類動物繁殖的適宜生態(tài)環(huán)境。溫州居民的生活習(xí)慣與粵臺、東南亞相近，均有生食水產(chǎn)品嗜好。新近發(fā)現(xiàn)溫州“福壽螺”和“褐家鼠”體內(nèi)存在嚴(yán)重的廣州管圓線蟲感染，且有人在孩童的CSF中檢獲大量幼蟲?？梢?/p>

23、，溫州暴發(fā)此病有其流行病學(xué)背景。三、診斷依據(jù)在患者CSF中找到病原蟲體固然是診斷廣州管圓線蟲入侵中樞神經(jīng)系統(tǒng)的金標(biāo)準(zhǔn)，但在活體CSF中蟲體的檢獲率甚低。泰國484例中均未在活體內(nèi)檢獲蟲體，夏威夷34例活體內(nèi)僅找到1例，臺灣以兒童居多檢獲率較高，125例中檢獲8例5-7。研究表明，CSF中有與沒有檢獲蟲體的病例，其臨床表現(xiàn)雷同。因而，至今流行區(qū)絕大多數(shù)病例的診斷，仍主要依賴于流行病史、典型的臨床表現(xiàn)和病程特點。近年采用的免疫學(xué)技術(shù)（如皮內(nèi)試驗、蟲體抗體檢測及蟲體抗原檢測等）有助不典型病例的診斷。根據(jù)該組病例的特點：急性暴發(fā)起病；劇烈頭痛和（或）軀體痛性感覺障礙，伴發(fā)熱、全身違和；可有腦神經(jīng)或脊神

24、經(jīng)根受累；無明顯頸抵抗與病理征；CSF及外周血中嗜酸細(xì)胞明顯增高；血清及CSF廣州管圓線蟲蚴抗體（ELISA法）陽性；病程自限，預(yù)后良好；有明確的流行病學(xué)佐證；已排除棘腭口線蟲病、旋毛蟲?。ǚ橇餍袇^(qū)）、肺吸蟲?。o溪蟹攝入）。認(rèn)為該組暴發(fā)流行病例（曾被稱為“怪病”），在臨床上可以診斷為廣州管圓線蟲引起的嗜酸細(xì)胞性腦脊膜神經(jīng)根炎。遺憾的是，雖經(jīng)努力，尚未能在患者的CSF中檢獲病原蟲體。作者單位：浙江省溫州市第二人民醫(yī)院神經(jīng)內(nèi)科325000參考文獻(xiàn)1趙慰先，主編人體寄生蟲學(xué)第2版北 京：人民衛(wèi)生出版社，1994.777-7882Hung TP. Human infection with rat lungworm angiostorngylus cantonensis: epidemiology