Ueda Madoka, Kanamori Aya, Mihara Takateru, Hara Hideo, Mutoh Tatsuro
Department of Neurology, Fujita Health University, School of Medicine.
Rinsho Shinkeigaku. 2009 Feb-Mar;49(2-3):96-9. doi: 10.5692/clinicalneurol.49.96.
A 58-year-old man was admitted to our hospital with fever, vomiting and disturbance of consciousness after common cold-like symptoms for 2 days. Physical examination showed high fever, moderate hypertension and tachycardia. There were no superficial lymph nodes swelling nor skin rashes. Cerebrospinal fluid (CSF) examination revealed increased protein level (467 mg/dl) and pleocytosis (508 cells/mm3), but no glucose was detected. CSF smear test detected the pneumococcus. Intravenous cefotaxime was administered along with intravenous immunoglobulins and steroid pulse therapy. However, DIC developed, so FOY therapy was started. With these treatments, level of consciousness gradually improved and he became able to eat. At 11th days after the onset, the patient suddenly developed left facial palsy and paresis of the left arm. Head T2-weighted magnetic resonance imaging demonstrated tumor-like hyperintensity signal lesions (28 x 16.6 mm) with ring enhancements in the right frontal lobe. Acute disseminated encephalomyelitis (ADEM) was diagnosed based on MRI and CSF findings, and then additional corticosteroid pulse therapy was administered twice. Herpes simplex virus and herpes zoster virus DNA in the CSF were undetectable by PCR. After 6 days of treatment with corticosteroid pulse therapy, left facial palsy and paresis of the left arm gradually improved and MRI showed the disappearance of tumor-like hyperintense signals. Although ADEM usually develops as a complication after viral infection such as measles, rubella, mumps and herpes zoster, this case suggests that ADEM complication should be considered even after pneumococcal meningoencephalitis.
一名58岁男性在出现类似感冒症状2天后，因发热、呕吐和意识障碍入院。体格检查显示高热、中度高血压和心动过速。未触及浅表淋巴结肿大，也无皮疹。脑脊液（CSF）检查显示蛋白水平升高（467mg/dl）和细胞增多（508个细胞/mm³），但未检测到葡萄糖。脑脊液涂片检查发现肺炎球菌。给予静脉注射头孢噻肟以及静脉注射免疫球蛋白和类固醇冲击疗法。然而，发生了弥散性血管内凝血（DIC），因此开始进行抑肽酶（FOY）治疗。经过这些治疗，意识水平逐渐改善，患者能够进食。发病后第11天，患者突然出现左侧面神经麻痹和左臂无力。头部T2加权磁共振成像显示右额叶有肿瘤样高信号病变（28×16.6mm），伴有环形强化。根据MRI和脑脊液检查结果诊断为急性播散性脑脊髓炎（ADEM），随后又进行了两次额外的类固醇冲击疗法。脑脊液中的单纯疱疹病毒和带状疱疹病毒DNA经聚合酶链反应（PCR）检测未检出。经过6天的类固醇冲击疗法治疗，左侧面神经麻痹和左臂无力逐渐改善，MRI显示肿瘤样高信号消失。虽然ADEM通常在麻疹、风疹、腮腺炎和带状疱疹等病毒感染后作为并发症出现，但该病例提示，即使在肺炎球菌性脑膜脑炎后也应考虑ADEM并发症。
