Case information:

***, male, 20 years old, unmarried.

He was admitted to the hospital for 1 week, headache, dizziness for 3 days.

I started to have fever 7 days ago, with a maximum of 39.5℃, accompanied by chills, no chills, no headache, dizziness, no cough, phlegm, no runny nose, no sore throat, no nausea, vomiting, no abdominal pain, diarrhea, no frequent urinary urgency, such as urinary irritation, no rash, no joint pain, and no mental changes. I started to have headache 3 days ago, accompanied by dizziness and vomiting, twice, which was a stomach content and no coffee-like substance. I was treated with upper sensation in the local hospital for 3 days. The specific medication was ominous, and there was still repeated fever. The symptoms did not relieve the symptoms.

Physical examination: red pharyngeal, no swollen tonsils on both sides, soft neck, slightly resisted, big and round bilateral pupils on both sides, no abnormalities in the auscultation of the heart and lungs, no tenderness or rebound pain, no subsurface to the liver and spleen, no swelling of both lower limbs, and no pathological signs were introduced.

Past history: past health, no history of surgical trauma, no history of blood transfusion, no history of allergies.

Personal history: Have a history of smoking for 3 years, 3 bins a day, no history of drinking, and no other bad habits.

The blood sugar of the liver and kidney electrolytes is normal.

The results of lumbar puncture on the day of admission are as follows:

Clear appearance, measured intracranial pressure    250mm water column cerebrospinal fluid     IgG>108mg/l.

For 10 days of treatment, dehydration lowers cranial pressure, mannitol, glycerol fructose, ganciclovir antiviral    0.25    q12h, dexamethasone 5mg (2 days), ceftriaxone 2g    qd, the patient's symptoms improved, no fever, and significantly relieved headaches.

The review will be as follows after 10 days:

The results of the lumbar puncture were checked again: the appearance was clear, intracranial pressure was 265mm water column.

Judging from the patient's medical history, physical examination, cerebrospinal fluid and treatment, viral meningitis was considered in the first day of the lunar calendar, but there were some inconsistencies, that is, the number of cerebrospinal fluid cells is relatively high, sugar and chloride are relatively low, and the total protein is also relatively high. Combined with erectile dysplasia and CRP results, it also suggests tuberculous meningitis, but tuberculosis does not have targeted treatment. The improvement of blood and cerebrospinal fluid does not occur so quickly. The author said that the patient has twists and turns, basically it is not viral meningitis, because the disease brain is a self-limiting disease, and there are generally no twists and turns after improvement. Therefore, comprehensive analysis, the patient is a disease of the disease.

Consider: 1. Typhoid meningitis, the reason is high fever, the chills are not obvious, the blood is not high, the blood is eosinophilic, and the cerebrospinal fluid is more in line with the changes in typhoid fever. Exception, the treatment effect of ceftriaxone is also good, which is indirectly supported. 2. Autoimmune meningitis is to be discharged, and the cerebrospinal fluid IgG is high, and the patient's blood and cerebrospinal fluid indexes are rapidly improved after using hormones. 3. Exceptions should be paid attention to whether there is a tumor, and it is difficult to judge because there is no information on head images. It is recommended to provide blood culture, cerebrospinal fluid bacterial culture, and cerebrospinal fluid ink.

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Features: Male, 20 years old, unmarried.

He had fever for 1 week, headache, dizziness for 3 days and was admitted to the hospital. The maximum was 39.5℃, fear of chills, headache, accompanied by dizziness, and vomiting twice.

Physical examination: red pharyngeal, no swollen tonsils on both sides, soft neck, slightly resisted, big and round bilateral pupils on both sides, no abnormalities in the auscultation of the heart and lungs, no tenderness or rebound pain, no subsurface to the liver and spleen, no swelling of both lower limbs, and no pathological signs were introduced.

Past history: past health, no history of surgical trauma, no history of blood transfusion, no history of allergies.

Personal history: Have a history of smoking for 3 years, 3 bins a day, no history of drinking, and no other bad habits.

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Consider, 1, tuberculosis brain? 2, autoimmune encephalitis?

Examination, tuberculosis screening, cerebrospinal fluid tuberculosis culture, Tspot, autoimmune antibodies, brain MR.

Treatment, in the original treatment, has the financial ability to use C balls at home

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Intracranial infection (meningitis) is clear, and the pathogen needs to be considered: bacteria, viruses, tuberculosis, and cryptococcus. Antibacterial and antiviral symptoms seem to be effective, but since the questioner mentioned "twist and twists and turns", we must focus on the reasons other than bacteria and viruses.

Let's have a gamble, cryptococcal meningitis.

Atypical tuberculous meningitis, cryptococcal meningitis, and viral meningitis do not have very specific differences in the routine biochemical characteristics of cerebrospinal fluid. Although it is simple to stain smear ink, the positive rate is not too high, and I remember it is only about 65%. After centrifugation, the smear and culture can increase the positive rate a little bit, but the detection of cryptococcal capsular antigen is the simplest and crudest, with high specificity, and can also be used as an indicator of efficacy evaluation, which is almost equivalent to the significance of PCT in bacterial infection.

Looking forward to the results of culture and cryptococcal capsule antigen detection in the face

Medical history summary:

1. Male, 20 years old, has been healthy in the past, and this time it started to have an acute onset;

2. Fever for 1 week, headache, dizziness for 3 days; the maximum body temperature is 39.5℃. Fever first, then headache, vomiting, and treatment in a local hospital.

3. Physical examination: red pharyngeal, no swollen tonsils on both sides, slightly resisted neck, large and round bilateral pupils on both sides, no abnormalities in the auscultation of the heart and lungs, no tenderness or rebound pain, no subsurface to the liver and spleen, no swelling of both lower limbs, and no pathological signs were introduced;

4. Auxiliary test: blood routine: WBC    6.79×109/L    N    89.3%     E   0; CRP: 53mg/L; Blood subsidence: 30mm/h; No abnormalities were found in the routine blood transfusion; liver, renal function, blood sugar, and electrolytes were normal;

Cerebrospinal fluid examination:

Increased cerebrospinal fluid pressure;

Cerebrospinal fluid routine: nucleated cells    309×106/L                                                                                                               �

Cerebrospinal fluid biochemistry: protein    1483.2mg/L, sugar normal range, chloride     119.4mmol/L.

Initial cerebrospinal fluid smear? Blood culture? Head CT or MR? Chest imaging?

From the above information, the patient's diagnosis of central nervous system infection/inflammatory can be established.

to be continued......

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The main differential diagnosis of CNS infection:

1. Bacterial meningitis: The patient had WBC peripheral blood, cerebrospinal fluid cell count, normal sugar, and did not meet the typical bacterial meningitis. However, it is not ruled out that he has received treatment (the so-called partially treated brain-removing), and meningitis caused by atypical bacteria, such as typhoid meningitis (although rare, the patient's blood WBC is not high, and the EOS is 0 twice. I don't know if there is a relatively slow pulse, splenomegaly, etc.).

2. Viral meningitis: Consider herpes virus more often, which generally does not cause cerebrospinal fluid cells to reach more than 250, blood sedimentation, and high CRP are difficult to explain, and it is not very supportive. 3

3. Tuberculous meningitis: Blood WBC and cerebrospinal fluid examination are more consistent, but tuberculous meningitis usually starts with hidden diseases. It is rare to have a fever for 7 days, and it is mainly low in fever, which is not very consistent.

4. Cryptococcal meningitis: There is a history of epidemiology, and it often has lung lesions when exposed to pigeons and pigeon feces. People with low immunity may suffer from AIDS patients. The prominent symptoms are headache and high cerebrospinal fluid pressure. At present, except for the cerebrospinal fluid pressure, there is no evidence to support it.

5. Brain abscess: It requires craniocerebral imaging examination.

In short, bacterial meningitis is still tending to be bacterial meningitis, that is, meningitis caused by partially treated bacterial meningitis or atypical bacteria, such as typhoid meningitis. The patient passes through ceftrium

Other test results should be explained: initial cerebrospinal fluid smear, blood culture, head CT or MR, chest imaging and sputum smear, etc.
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