ICAAC online 小児感染症 症例検討会 （Session 113)
本日も小児感染症です。同じ演者
＃：概要
・17歳アフリカ系アメリカ人
・４／２５：何となく様子が変。しかし発熱、頭痛、疲労感などは無い
・翌日、Panicに。更に発語が少し変。
・最近、麻薬（Marijuana）を使用している。
・非常にCKが上昇（2200）
・次第に改善。帰宅
・翌日、”副鼻腔炎による”頭痛Sinus headacheを訴え、更に意識不明・全身痙攣となる。
・改めてPertinent negatvies:
No fevers, preceding lethargy or irritability, headaches ， 、
congestion rhinorrhea ，cough, chest pain,
abdominal pain, vomiting, diarrhea, rashes, oral ulcerations,
joint pain or swelling
・家族歴に自己免疫疾患無い
・特にPet、Travel、Sick contact無し
＃：所見など
T- 36.8, HR:54-128.BP:120/79, RR:19 .Sp02:100% on room air.
HEENT:NC/AT, no conjunctival injection or icterus, PERL
Chest breath sounds clear to auscultation bilaterally
Cardiovascular:RRR no murmur
Abdomen:soft.non tender.without HSM
GU : normal female
Musculoskeletal:Full ROM all join
Skin:no rashes, papules, petechiae
Lymph Nodes:no adenopathy
Neurological:sedated, follow verbal commands, no meningisms, non focal
＃：検査－1
Chem: Na 140, K 3.6, BUN< 2, Cr 0.66, AST3 9, ALT 31 ,
Bili 1.0 ; CK:1 173
Drug screen: negative
CSF: WBC:22, (all mono), RBC:0, Protein and Glucose: wnl
<font color="maroon">＃：治療経過
・Acyclovir開始。少ししてHSV/PCR陰性と判明
・MRIを施行 w/wo Contrast
• Mild edema in the right temporal cortex, right inferior parietal cortex, and right insular cortex.
• Edema in the right > left hippocampi with some enhancement and
diffusion restriction on the right.
• Meningeal enhancement about the lateral aspect of the right frontal , temporal , and parietallobes.
• Patent but diffusely narrowed arteries about the circle of Willis.
＃：検査－2
・血液
HIV: ELlSA(-)
Enterovirus and HSV PCRs:negative
CMV IgG/lgM: negative
Parvovirus IgM: (negative), IgG: (positive)
EBV IgG/IgM : > 10240, IgM: <10
Arbovirus panel:negative
・髄液
Gram stain:moderate WBCs, culture negative
Viral culture:pending
Enterovirus and HSV PCRs:negative
Adenovirus qPCR:pending
Arbovirus panel:negative
Baltonella IgG/lgM:negative
<font color="maroon">＃：最終的には：Anti-NMDA Receptor Encephalitis
・CSF anti-NMDA IgG:positive
＃：Anti-NMDA Receptor Encephalitis臨床像：
・Prominent psychiatric manifestations (anxiety, agitation, bizarre behavior, hallucinations, delusions, disorganized thinking); isolated psychiatric episodes may rarely occur at initial onset or at relapse
・Insomnia
・Memory deficits
・Seizures
・Decreased level of consciousness, stupor with catatonic features
・Frequent dyskinesias: orofacial, choreoathetoid movements, dystonia, rigidity, opisthotonic postures
・Autonomic instability: hyperthermia, fluctuations of blood pressure, tachycardia, bradycardia, cardiac pauses, and sometimes hypoventilation requiring mechanical ventilation.
・Language dysfunction: diminished language output, mutism. Echolalia is often noted in the early stages or in the recovery phase of the disorder.
＃：Acyclovir中止？
・駄目！！ 理由↓
・Preceding infections (mycoplasma, varicella zoster, herpes simplex) have been suspected to play a role in cases of nonparaneoplastic, presumed auto-immune anti-NMDA receptor encephalitis
本日も小児感染症です。同じ演者
＃：概要
・17歳アフリカ系アメリカ人
・４／２５：何となく様子が変。しかし発熱、頭痛、疲労感などは無い
・翌日、Panicに。更に発語が少し変。
・最近、麻薬（Marijuana）を使用している。
・非常にCKが上昇（2200）
・次第に改善。帰宅
・翌日、”副鼻腔炎による”頭痛Sinus headacheを訴え、更に意識不明・全身痙攣となる。
・改めてPertinent negatvies:
No fevers, preceding lethargy or irritability, headaches ， 、
congestion rhinorrhea ，cough, chest pain,
abdominal pain, vomiting, diarrhea, rashes, oral ulcerations,
joint pain or swelling
・家族歴に自己免疫疾患無い
・特にPet、Travel、Sick contact無し
＃：所見など
T- 36.8, HR:54-128.BP:120/79, RR:19 .Sp02:100% on room air.
HEENT:NC/AT, no conjunctival injection or icterus, PERL
Chest breath sounds clear to auscultation bilaterally
Cardiovascular:RRR no murmur
Abdomen:soft.non tender.without HSM
GU : normal female
Musculoskeletal:Full ROM all join
Skin:no rashes, papules, petechiae
Lymph Nodes:no adenopathy
Neurological:sedated, follow verbal commands, no meningisms, non focal
＃：検査－1
Chem: Na 140, K 3.6, BUN< 2, Cr 0.66, AST3 9, ALT 31 ,
Bili 1.0 ; CK:1 173
Drug screen: negative
CSF: WBC:22, (all mono), RBC:0, Protein and Glucose: wnl
<font color="maroon">＃：治療経過
・Acyclovir開始。少ししてHSV/PCR陰性と判明
・MRIを施行 w/wo Contrast
• Mild edema in the right temporal cortex, right inferior parietal cortex, and right insular cortex.
• Edema in the right > left hippocampi with some enhancement and
diffusion restriction on the right.
• Meningeal enhancement about the lateral aspect of the right frontal , temporal , and parietallobes.
• Patent but diffusely narrowed arteries about the circle of Willis.
＃：検査－2
・血液
HIV: ELlSA(-)
Enterovirus and HSV PCRs:negative
CMV IgG/lgM: negative
Parvovirus IgM: (negative), IgG: (positive)
EBV IgG/IgM : > 10240, IgM: <10
Arbovirus panel:negative
・髄液
Gram stain:moderate WBCs, culture negative
Viral culture:pending
Enterovirus and HSV PCRs:negative
Adenovirus qPCR:pending
Arbovirus panel:negative
Baltonella IgG/lgM:negative
<font color="maroon">＃：最終的には：Anti-NMDA Receptor Encephalitis
・CSF anti-NMDA IgG:positive
＃：Anti-NMDA Receptor Encephalitis臨床像：
・Prominent psychiatric manifestations (anxiety, agitation, bizarre behavior, hallucinations, delusions, disorganized thinking); isolated psychiatric episodes may rarely occur at initial onset or at relapse
・Insomnia
・Memory deficits
・Seizures
・Decreased level of consciousness, stupor with catatonic features
・Frequent dyskinesias: orofacial, choreoathetoid movements, dystonia, rigidity, opisthotonic postures
・Autonomic instability: hyperthermia, fluctuations of blood pressure, tachycardia, bradycardia, cardiac pauses, and sometimes hypoventilation requiring mechanical ventilation.
・Language dysfunction: diminished language output, mutism. Echolalia is often noted in the early stages or in the recovery phase of the disorder.
＃：Acyclovir中止？
・駄目！！ 理由↓
・Preceding infections (mycoplasma, varicella zoster, herpes simplex) have been suspected to play a role in cases of nonparaneoplastic, presumed auto-immune anti-NMDA receptor encephalitis