On the evening of 14 April 2021, a 54-year-old male did not know that his slipper had fallen while walking, and did not respond to the family's inquiries. At about eight o 'clock in the evening, the patient had a fever, with the highest temperature of 41 C. After the local hospital gave diclofenac sodium symptomatic antipyretic, the temperature gradually decreased to normal. During this period, the patient did not answer questions.
At about 10 o'clock in the evening, the patient began to lift the right upper limb involuntarily. The next morning, the patient was found to have a poor response. He could open his eyes when people called him, but did not respond, accompanied by involuntary twitching of the right limb. There was no nausea, vomiting, palpitation, shortness of breath, and incontinence during the course of the disease. To seek further diagnosis and treatment, he came to our hospital and was admitted to our department by the outpatient clinic with "consciousness disorder to be examined." Past history: found diabetes for half a month, denied any other special history. Physical examination: T 37.3 C, P 98 times/min, R 20 times/min, BP 129/95 mmhg, drowsiness, no obvious abnormalities found in skin, mucosa, lymph nodes and cardiopulmonary abdominal examination, equal size and equal circle of bilateral pupils with 3 mm in diameter, slow light reflex, involuntary twitching of right limb, negative meningeal irritation sign, and no positive signs found in other nervous systems physical examination. Initial diagnosis of consciousness disorder to be examined: intracranial infection, secondary epilepsy?
Improve related examinations, blood routine: WBC 8.7 g/L, NE 76.4%, HGB 163 g/L, PLT 111 G/L, blood biochemistry: TBil 53.4 umol/L, NCBil 43.3 umol/L, SAA 21.4 mg/L. There were no abnormalities in the electrolyte, liver function, renal function, blood glucose, high-sensitivity C-reactive protein, erythrocyte sedimentation rate and coagulation function, as shown in Table 1. Electroencephalogram (EEG): the main rhythm of each lead was 10 HZalpha with medium and low amplitude, and the parietal and occipital region was dominant, with left and right asymmetry and poor amplitude modulation. The left lead had more rhythm and activity of 4-7 HZtheta with medium and low amplitude, and slightly more activity of 3-3.5 HZdelta, and the front head was very biased. Brain magnetic resonance imaging (MRI): multiple spots and bands of abnormal signals were found in the left insula and temporal cortex, T2WI and T2 flair showed hyperintensity, T1 flair showed isointensity and hypointensity, and GD-DTPA enhanced scanning showed no obvious abnormal enhancement, as shown in Figure 1. Cranial MRA, MRV, neck vascular color ultrasound, chest CT, electrocardiogram, and heart color ultrasound showed no abnormalities. The patients were treated with epilepsy control, brain edema prevention, brain cell nutrition, anti-infection, water and electrolyte balance and liver protection, and closely monitor the changes of vital signs and mental pupils.
On 15 April, the patient was drowsy, still had intermittent twitching of the right lower limb, and coffee residue-like substances were extracted from the gastric tube. It was considered that stress ulcers occurred, and stomach protection drugs were added. In order to find out the cause, a lumbar puncture was performed to check the cerebrospinal fluid, and the pressure was 300 mm water column. The routine and biochemical results of cerebrospinal fluid are shown in Table 2. The diagnosis was considered viral encephalitis or autoimmune encephalitis, and antiviral combined with gamma globulin were added to the treatment. The serum and cerebrospinal fluid samples were sent to BGI for etiological second-generation sequencing examination, and the cerebrospinal fluid and serum were sent to kangshengda company for autoimmune encephalitis antibody detection. Dynamic monitoring of blood routine, electrolyte, liver and kidney function, blood glucose, CRP, and other related indicators during hospitalization are shown in Table 1. On 16 April, the patient was delirious, with a Glasgow (GCS) score of 3 points. He still had intermittent right limb twitching, intermittent fever, thick breathing sound, decreased blood oxygen saturation, and it was difficult to maintain stable vital signs. So he was urgently transferred to the central intensive care unit (ICU), and ventilator are assisted breathing was performed after endotracheal intubation.
On 19 April, the patient became drowsy. After people shouted, he could open his eyes and move according to the instructions. He still had an intermittent fever, the highest temperature was 38.6 C, there was no headache, the activity of the left limb was normal, the muscle strength of the right limb was grade 3, and there was no limb convulsion. Spontaneous breathing had been restored and the ventilator had been evacuated, but it is still in the state of endotracheal intubation. The second generation sequencing results of cerebrospinal fluid showed that it was infected with pseudorabies virus with a coverage rate of 1.86%, see Figure 2 for details. There was no abnormality in the second-generation sequencing of serum, and the antibodies of cerebrospinal fluid and serum to autoimmune encephalitis were negative. After inquiring about the medical history, we learned that the patient had been engaged in the pig industry for a long time. The patient had a clear diagnosis of viral encephalitis and continues to receive antiviral treatment. Considering that some of the patients were prone to retinitis leading to blindness, we invited ophthalmology to consult. Eye ophthalmologist examination: there was no congestion in the conjunctiva, the cornea was transparent, and the pupils of both eyes were very small, about 1.5 x 1 5 mm, direct and indirect light reflection existed, and it was difficult to peep into the fundus through ophthalmoscopy. On 22 April, the lumbar puncture was rechecked, the pressure was 220 mm water column, the routine and biochemical results of cerebrospinal fluid were not significantly changed. On 24 April, the patient's mind improved, the activity of the right limb was still poor, and the pupils on both sides were equal round, with a diameter of 3 mm. Re-examination of cranial MRI showed that the left frontotemporal insula had abnormal signals and meningeal changes, and the possibility of inflammatory lesions was high, which was better than before. On 27 April, the patient still had fever, the highest body temperature was 37.8 C, and the right muscle strength was grade 3. After pulling out the endotracheal intubation, the respiration was steady.
On 29 April, the patient could speak clearly, but the speech did not accord with the scene, and he was restless intermittently. Physical examination showed that memory and calculation ability were decreased, bilateral pupils were equal in size and circle, 5 mm in diameter, right muscle strength was grade 4, Risperidone was added for symptomatic treatment, and the rest remained unchanged. Therefore, we asked for ophthalmic consultation. Ophthalmic examination: VOD: 0.25, VOS: finger/2.5 m, fixed pupils in both eyes, mydriasis, 5 x 5 mm, fundoscopy showed that the retina at the posterior pole was flattened, no obvious hemorrhage or exudation was found. Therapeutically, antiviral eye drops and other local treatments were administered locally.
On 04 May, the patient was conscious, without irritability, and the muscle strength of the right limb was further improved, but the vision was still unclear. After reexamination of lumbar puncture, the cerebrospinal fluid pressure was 140 mm water column, the protein content increased, and there was no significant change in the rest. On 5 May, invited ophthalmology to consult again. Ophthalmic examination: VOD: 0.1 (+ 4.75d / + 1.25d x 155 corrections no response), VOS: 0.1 (+ 5.00d / + 1.50D x 180 corrections no response); Intraocular pressure: od 14 mmHg, os 14 mmHg; There was no congestion in the conjunctiva of both eyes, the cornea was transparent, the anterior chamber was deep, the crystal was transparent, the pupils of both eyes were fixed and dilated, 5 x 5 mm, the pupil margin was adhered to the front surface of the lens, pigmented keratic precipitates (KP) could be seen in the pupil area, fundus: vitreous cavity was turbid, the boundary of the optic disc could be seen faintly, and white linear changes could be seen in the peripheral omentum; The right eye macular OCT showed that the morphology of the right eye fovea was recognizable, the inner surface of the macular retina was still smooth, and the local ellipsoid structure was slightly disordered, see Figure 2 for details. The OCT of the left eye macular did not cooperate. B-ultrasound showed vitreous opacity in both eyes. It is necessary to continue to give eye drops to the patient for treatment.
On 12 May, the patient complained of transient dizziness when he got up and moving, which disappeared after standing. Both eyes were still blurred, bilateral pupils were dilated to the edge, the light reflex disappeared. The patient asked to be transferred to a superior hospital for treatment. On 3 June, the patient came to the hospital for follow-up visit, and the pathological changes in both eyes were no better than before. Reexamination of MRI showed that the range of inflammatory lesions was slightly smaller than before.