中南大學(xué)兒科教研室麻疹專(zhuān)題

麻疹

Measles第十章第一節(jié)（1）中南大學(xué)兒科學(xué)教研室7/31/20231麻疹目的要求熟悉麻疹的病因、流行病學(xué)及發(fā)病機(jī)制掌握麻疹早期診斷要點(diǎn)及典型臨床經(jīng)過(guò)熟悉其它類(lèi)型麻疹的臨床表現(xiàn)熟悉麻疹常見(jiàn)并發(fā)癥掌握麻疹與其它發(fā)疹性傳染病的鑒別要點(diǎn)掌握麻疹的防治原則及方法7/31/20232麻疹概述(overview)

麻疹是一種由麻疹病毒引起的急性呼吸道傳染病(Measlesisanacuterespiratorycontagiousdiseasecausedbymeaslesvirus)7/31/20233麻疹概述(overview)

臨床特征為：發(fā)熱、上呼吸道炎癥、結(jié)合膜炎、Koplik斑及全身性斑丘疹(clinicalfeatures:fever,upperrespiratoryinflammation,conjunctivitis,Koplik’sspotsandgeneralizedmaculopapularrash)

7/31/20234麻疹病原(ETIOLOGY)麻疹病毒(measlesvirus)屬副粘液病毒，無(wú)亞型，僅一種抗原型(RNA-containingvirusoftheParamyxovirusfamily,onlyoneserotype)

7/31/20235麻疹病原(ETIOLOGY)麻疹病毒(measlesvirus)麻疹病毒不耐熱，對(duì)日光和消毒劑均敏感，但在低溫中能長(zhǎng)期保存(Measlesvirusarerapidlyinactivatedbyheat,light,andallkindsofdesinfectant,butcanbestoredindefinitelyatlowtemperature)。7/31/20236麻疹病原(ETIOLOGY)麻疹病毒(measlesvirus)存在于患者前驅(qū)期和出疹期的眼結(jié)膜、鼻、咽、氣管等分泌物中(Duringtheprodromalperiodanderuptionperiod,itisfoundinsectionsofconjunctiva,nose,pharynx,tracheaandsoon)。7/31/20237麻疹麻疹的發(fā)病機(jī)制

鼻、咽短期繁殖病毒局部粘膜血流遠(yuǎn)處器官單核眼結(jié)膜（第一次）巨噬細(xì)胞系統(tǒng)潛伏期大量繁殖局部癥狀血流（第二次）前驅(qū)期全身癥狀

7/31/20238麻疹病理(PATHOGEY)全身淋巴組織增生，有多核巨細(xì)胞形成

(Hyperplasiaofalllymphoidtissueusuallyoccurs,multinucleatedgiantcellsmaybefound

)7/31/20239麻疹病理(PATHOGEY)多核巨細(xì)胞(multinucleated

giantcells)：多個(gè)巨噬細(xì)胞融合形成的具有核內(nèi)外包涵體的巨細(xì)胞網(wǎng)狀內(nèi)皮巨細(xì)胞也稱(chēng)華-佛細(xì)胞（reticuloendothelialgiantcellsorWarthin-Finkeldeycells)：存在于全身淋巴組織和肝、脾等臟器中上皮巨細(xì)胞（epithelialgiantcells）：主要位于皮膚、眼結(jié)合膜、呼吸道和消化道粘膜等處7/31/202310麻疹病理(PATHOGEY)皮膚、眼結(jié)合膜、鼻咽部、支氣管、腸道粘膜等處可見(jiàn)單核細(xì)胞增生及圍繞在毛細(xì)血管周?chē)亩嗪司藜?xì)胞，淋巴樣組織肥大(Prolifierationofmononuclearcellsisfoundintheskin,inthe

conjunctivaeandinthemucousmembranesofthenasopharynx,bronchi,andintestinaltract,multinucleatedgiantcellsoccuraroundthecapillaries.Hyperplasiaoflymphoidtissueoccurs.)7/31/202311麻疹病理(PATHOGEY)頰粘膜下層的微小分泌腺發(fā)炎，其病變內(nèi)有漿液滲出及內(nèi)皮細(xì)胞增殖形成Koplik斑

(Aninflammatoryreactionoccursinthefinesecretorofthebuccalmucosa,whereserousexudateandproliferationofendothelialcellsresultin

Koplik’s

spots)

7/31/202312麻疹病理(PATHOGEY)麻疹引起的間質(zhì)性肺炎為Hecht巨細(xì)胞肺炎(Interstitialpneumonitisresulting

frommeaslesvirustakestheformofHechtgiantcellpneumonia)7/31/202313麻疹病理(PATHOGEY)麻疹皮疹的病理改變：真皮毛細(xì)血管內(nèi)皮增生、血漿滲出、紅細(xì)胞相對(duì)增多形成淡紅色斑丘疹(Maculopapularrashconsistsofproliferationofcapillary

endothelialcellsinskin,serousexudateandrelativeincreaseofredcells)疹退后，表皮細(xì)胞壞死、角化形成脫屑。皮疹處紅細(xì)胞裂解，疹退后形成棕色色素沉著。7/31/202314麻疹典型麻疹(Typicalmeasles)潛伏期(Incubationstage)一般為10~14天(亦可短至1周)，此期可有輕度體溫上升(Itlastsusually10~14daysaftercontact,maybeasshortas1week.Thetemperaturemayincreasedslightly)。

臨床表現(xiàn)7/31/202315麻疹典型麻疹前驅(qū)期

(Prodromalstage)

指從發(fā)熱至出疹,一般為3-4天(fromfevertorashappearance,usuallylasts3-4days)

臨床表現(xiàn)7/31/202316麻疹

典型麻疹

主要表現(xiàn)：發(fā)熱、上呼吸道炎癥、眼結(jié)合膜炎、Stimson線(fever,upperrespiratoryinflammation,conjunctivitis)麻疹粘膜斑(Koplik’sspots)前驅(qū)期

(Prodromalstage)臨床表現(xiàn)7/31/202317麻疹Koplik’sspots

(麻疹粘膜斑)

時(shí)間：發(fā)疹前24—48小時(shí)出現(xiàn)(24-48hoursbeforetheappearanceoftherash)；位置：開(kāi)始對(duì)著下臼齒的頰粘膜上；以后累及整個(gè)頰部并蔓延至唇部粘膜(initiallyoppositethelowermolarsbutmayspreadtherestofthebuccalandlipmucosa)。臨床表現(xiàn)7/31/202318麻疹Koplik’sspots

(麻疹粘膜斑)形態(tài)：直徑約1㎜的灰白色小點(diǎn)，外有紅暈(grayishwhitedotswith1mmindiameter,usuallyassmallasgrainsofsand,thatreddishareolae)；發(fā)展：1天內(nèi)很快增多，皮疹出現(xiàn)后逐漸消失(Theyspreadrapidlywithinonedayanddisappeargraduallyaftertheappearanceoftherash)。臨床表現(xiàn)7/31/202319麻疹7/31/202320麻疹典型麻疹出疹期

(eruptionstage)

在發(fā)熱3-5天后出現(xiàn),持續(xù)3-5天

出疹順序:耳后、發(fā)際→額、面部→頸→軀干→四肢,達(dá)手掌、足底(initiallyoccurringbehindtheearsandhairlineandspreadingdownfromtheforeheadandfacetoneck,thetrunkandtheextremities).

臨床表現(xiàn)7/31/202321麻疹典型麻疹出疹期

(eruptionstage)皮疹性質(zhì):紅色斑丘疹，疹間皮膚正常(redmaculupapularrash,thereisnormalskinamongrashes.)臨床表現(xiàn)7/31/202322麻疹7/31/202323麻疹典型麻疹

恢復(fù)期

(convalescentperiod)

皮疹按出疹先后順序消退,伴有糠麩樣脫屑及棕色色素沉著,經(jīng)7~10天消失(Therashfadesdownwardinthesamesequenceinwhichitappeared.Astherashfades,brannydesquamationandbrownishdiscolorationoccurandthendisappearwithin7-10days)臨床表現(xiàn)7/31/202324麻疹

并發(fā)癥(complications)肺炎(pneumonia)

是麻疹常見(jiàn)的并發(fā)癥，多見(jiàn)于出疹期，繼發(fā)細(xì)菌或其它病毒感染喉、氣管、支氣管炎(laryngitis,trachitis,bronchitis)心肌炎(myocarditis)

7/31/202325麻疹并發(fā)癥(complications)麻疹腦炎及亞急性硬化性全腦炎（measlesencephalitisandsubacute

sclerosing

panencephalitis

簡(jiǎn)稱(chēng)SSPE)結(jié)核病惡化(tuberculosisexacerbating)營(yíng)養(yǎng)障礙與維生素A缺乏癥(malnutritionandvitaminAdeficiency)7/31/202326麻疹診斷(DIAGNOSIS)麻疹接觸史(exposuretomeaslespreviously)典型臨床表現(xiàn)(typicalclinicalmanifestations)7/31/202327麻疹診斷(DIAGNOSIS)前驅(qū)期鼻咽部找多核巨細(xì)胞及尿中檢測(cè)包涵體細(xì)胞(Duringtheprodromalstage,multinucleatedgiantcellsarefoundinnasopharynx,intrancuclearandintracytoplasmicinclusionbodiescellsarefoundinurine)7/31/202328麻疹診斷(DIAGNOSIS)ELISA法檢測(cè)麻疹抗體(MeaslesvirusantibodiesbecomedetectablebyELISAwhentherashppears;testingofacuteandconvalescentserashowsthediagnosticseroconversionorfourfoldincreaseintiter)7/31/202329麻疹鑒別診斷病原全身癥狀和其他特征皮疹特點(diǎn)發(fā)熱與皮疹的關(guān)系麻疹(rubeola)麻疹病毒卡他癥狀結(jié)膜炎、發(fā)熱Koplik斑紅色斑丘疹，特別的出疹順序，退疹后有色素沉著幾細(xì)小脫屑發(fā)熱3～4天，出疹時(shí)體溫更高風(fēng)疹(rubella)風(fēng)疹病毒耳后、頸后、枕后淋巴結(jié)腫大退疹后無(wú)色素沉著及脫屑發(fā)熱半天或一天后出疹