Japanese encephalitis (JE). Part I: clinical profile of 1,282 adult acute cases of four epidemics
Japanese encephalitis (JE). Part I: clinical profile of 1,282 adult acute cases of four epidemics
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DOI：
10.1007/s00415-011-6118-6
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发表时间：
2012-01-01
影响因子：
6
通讯作者：
Sarkari, M.
中科院分区：
文献类型：
--
作者：
Sarkari, N. B. S.;Thacker, A. K.;Sarkari, M.
从数量上看，日本脑炎（JE）是全球最重要的脑炎病因，迄今为止已证实在印度引起了重大流行病。大多数报告的研究都是针对儿童的。这项最大规模的研究仅涉及成年人，属于四种流行病，是从戈勒克布尔报道的。本研究的目的是详细说明急性临床特征（非病毒）结果并对出院时的后遗症进行分类。这项前瞻性研究纳入了 1,282 名在 1978 年、1980 年、1988 年和 1989 年流行期间被初步诊断为乙脑的成年患者，其临床表现和脑脊液检查相同。与此同时，乙脑的诊断仅通过血清学和/或病毒学研究在代表性数量的样本（1,282 例中的 649 例）中得到证实。 83 人在不同阶段拒绝接受医疗建议 (LAMA)，因此 1,282 人中有 1,199 人可以参加这项研究。临床疑似病例的发病高峰为9月15日至11月2日[1,061例，共1,282例（83%）]。血清IgM和IgG呈高滴度阳性，占50.87%（649例中的330例），脑脊液IgM阳性率为88.75%（123例中的109例）。 5 个样本中的 5 个和 5 个样本中的 4 个分别可以从脑脊液和脑组织中分离出乙脑病毒。发病第三天住院的主要症状是感觉（AS）改变（96%）、抽搐（86%）和头痛（85%）。其他神经系统特征包括 1,282 例中的 593 例 (46%) 出现多动性运动，490 例 (83%) 出现类舞蹈症，103 例 (17%) 出现奇异、不明确的运动。脑干受累的特征包括视眼阵挛（20%）、凝视麻痹（16%）和瞳孔变化（48%）。小脑体征明显缺失。肌张力障碍和去大脑强直分别占 43% 和 6%，麻痹特征为 17%，癫痫发作为 30%。许多对预后具有重要意义的非神经学特征包括呼吸模式异常 (ABP) (45%)、肺水肿 (PO) (33%) 和上消化道出血 (UGIH) (16%)。 1978年共208例采用注射地塞米松，其中PO 21例。随后，患者被随机分为 dexa 组和非 dexa 组。来自非 dexa 组的 46 例 PO 被转移到 dexa 组，作为最终的救生措施。因此，1,199 名患者中的 737 名患者（包括后来流行病中的 529 名患者）以每 8 小时静脉注射 4 mg 的剂量给药，持续 7 天。在 1,199 人中，有 462 人没有收到。 dexa 组（42.47%）和非 dexa 组（42.86%）之间的死亡率没有显着差异（p > 0.05）。所有 PO 案例均已过期；因此，从 dexa 组中排除 PO 病例后，6.14%（42.86 和 36.72）的差异变得显着（p < 0.01）（1,199 例中的 511 例（43%）过期，[511 例中的 320 例（63%）在住院 3 天内死亡]）。在总共 1,199 名接受治疗的患者中，688 名患者（57%）出院； 688 人中有 23 人（3%）没有任何后遗症，688 人中有 665 人（97%）有神经精神缺陷，分为九组。在这四次流行期间，乙脑的诊断基本上是基于相同的急性脑炎综合征（AES）临床表现，包括（1）突然发热、头痛和AS，（2）肌张力障碍和各种运动障碍，（3）眼阵挛和凝视麻痹，（4）脑脊液表现，以及（5）残留的神经精神和神经学特征 在幸存者中。
Japanese encephalitis (JE) is numerically the most important global cause of encephalitis and so far confirmed to have caused major epidemics in India. Most of the reported studies have been in children. This largest study involving only adults, belonging to four epidemics, is being reported from Gorakhpur. The aim of this study is to detail the acute clinical profile (not viral) outcome and to classify the sequelae at discharge. This prospective study involved 1,282 adult patients initially diagnosed as JE admitted during the epidemics of 1978, 1980, 1988, and 1989, on identical clinical presentation and CSF examination. In the meantime, the diagnosis of JE was confirmed by serological and/or virological studies in only a representative number of samples (649 of 1,282 cases). Eighty-three left against medical advice (LAMA) at various stages, so 1,199 of 1,282 were available for the study. Peak incidence of [1,061 of 1,282 (83%)] of clinically suspected cases was from September 15 to November 2. Serum IgM and IgG were positive in high titers in 50.87% (330 of 649) and IgM positive in CSF in 88.75% (109 of 123) of the cases. JE virus could be isolated from CSF and brain tissue in 5 of 5 and 4 of 5 samples, respectively. Altered sensorium (AS) in (96%), convulsions (86%), and headache (85%) were the main symptoms for hospitalization by the third day of the onset. Other neurological features included hyperkinetic movements in 593 of 1,282 (46%)-choreoathetoid in 490 (83%) and bizarre, ill-defined in 103 (17%). The features of brain stem involvement consisted of opsoclonus (20%), gaze palsies (16%), and pupillary changes (48%) with waxing and waning character. Cerebellar signs were distinctly absent. Dystonia and decerebrate rigidity was observed in 43 and 6%, respectively, paralytic features in 17% and seizures in 30%. Many non-neurological features of prognostic importance included abnormal breathing patterns (ABP) (45%), pulmonary edema (PO) (33%), and upper gastrointestinal hemorrhage (UGIH) (16%). Injection dexamethasone was used in 1978 in all 208 cases, including 21 of PO. Patients were later randomized alternately in dexa and non-dexa groups. Forty-six cases of PO from the non-dexa group were transferred to the dexa group as an ultimate life-saving measure. Thus, it was administered in 737 of 1,199 patients including 529 patients from the later epidemics in doses of 4 mg IV every 8 h for 7 days. Of 1,199, 462 did not receive it. There was no significant difference in mortality (p > 0.05) between the dexa (42.47%) and the non-dexa group (42.86%). All PO cases expired; so after the exclusion of the PO cases from dexa group, the difference of 6.14% (42.86 and 36.72) became significant (p < 0.01) (511 of 1,199 (43%) expired, [320 of 511 (63%) died within 3 days of hospitalization]). Out of a total of 1,199 patients treated, 688 (57%) were discharged; 23 of 688 (3%) without any sequelae and 665 of 688 (97%) with neuropsychiatric deficits classified into nine groups. During the four epidemics, the diagnosis of JE was basically on identical clinical presentation of acute encephalitic syndrome (AES) consisting of (1) abrupt onset of fever, headache, and AS, (2) dystonias and various movement disorders, (3) opsoclonus and gaze palsies, (4) CSF findings, and (5) the presence of residual neuropsychiatric and neurological features in the survivors.