叢林型斑疹傷寒合併腦膜腦炎：兩個病例報告

Scrub Typhus Complicated with Meningoencephalitis: A Report of Two Cases

賴俊宜(Chun-Yi Lai) ； 陳昶華(Chang-Hua Chen) ； 劉尊榮(Chun-Eng Liu) ； 蔡人文(Ran-Wen Tsay) ； 楊祖光(Tzuu-Guang Young)

《The Changhua Journal of Medicine》 7卷3期 (2002/07) Pp. 178-182

摘要

病例一是一位22歲女性原住民病患，因為發燒、意識不清轉到本院。病患剛到本院時的狀況為發燒、腹部疼痛、咳嗽、精神倦怠、但是意識清楚，皮膚沒有焦痂(eschar)。抽血檢查發現，白血球計數正常，血小板偏低，發炎指數上升，肝功能異常，黃疸指數上升，肌肉酵素指數上升。腦脊髓液(cerebrospinal fluid)發現有明顯的白血球增加。綜合判斷最可能的診斷是立克次體感染(rickettsial infection)，並且併發腦膜腦炎，給予抗生素治療及支持性治療。此病患的診斷主要是依據臨床表現與間接免疫螢光檢驗Orientia tsutsugamushi抗體的效價有四倍的變化。
病例二報告一位51歲女性病人，因間歇性發燒、寒顫、腹痛、頭痛七天，至地區醫院求診未見改善，後因意識改變而轉至本院。抽血檢查發現，白血球計數上升，血小板偏低，發炎指數上升，肝功能異常，黃疸指數上升。腦脊髓液發現有明顯的白血球增加且淋巴球佔優勢。初始投與抗結核藥物但病情持續惡化。在住院第四日，改投minocycline治療，病情持續改善終至出院。病人對Orientia tsulsugamushi之間接免疫螢光抗體反應IgM呈陽性反應，加上理學檢查在下腹壁有焦痂，恙蟲病之診斷始無疑義。在隨後一年內的追蹤情況良好。
叢林型斑疹傷寒合併腦膜腦炎在叢林型斑疹傷寒疾病早期並不常見，叢林型斑疹傷寒會發生併發症，跟延遲診斷與延後治療有很大的關係。在叢林型斑疹傷寒好發的地區，臨床醫師應該要注意叢林型斑疹傷寒的可能性，早期診斷與早期治療對於預後有很大的幫助。

關鍵字

叢林型斑疹傷寒 ； 腦膜腦炎 ； 四環黴素

並列摘要

We report two cases of scrub typhus who complicated with meningoencephalitis. The first one was a 22-year-old woman with a history of spiking fever and seizure attack. Before being transferred to our hospital, she was treated with empirical antibiotics at a local hospital for four days. Clonic seizure followed by consciousness change and fever occurred during the first few days following admission. Orientia tsutsugamushi infection with central nervous system involvement was diagnosed after serial studies showed cerebrospinal fluid pleocytosis. The indirect immunofluorescence assay showed a four-fold rise in antibodies to O. tsutsugamushi in paired sera, with an IgM antibody titer of 1:640. The patient responded favorably to parenteral minocycline treatment. The other one was a 51-year-old woman with chief complaints of intermittent fever, chills, abdominal pain, and headache for 7 days. She was referred to our hospital because of disturbed consciousness. Cerebrospinal fluid pleocytosis with a lymphocytic predominance was found. Initially, an anti-tuberculous agent was prescribed but the patient’s condition worsened. On the fourth day after admission, parenteral minocycline was administered. The response was gradual but favorable. Indirect immunofluorescence assay was positive for antibody to Orientia tsutsugamushi. In addition, she had an eschar over her lower abdomen by physical examination. Thus, the diagnosis of scrub typhus was confirmed.
The early recognition of scrub typhus and early prescription of anti-rickettsial agents are critical when caring for patients with rickettsial infections.

並列關鍵字

scrub typhus ； meningoencephalitis ； tetracycline