儿童病毒性脑炎临床诊疗指南

ManagementofsuspectedviralencephalitisinchildreneAssociationofBritishNeurologistsandBritishPaediatricAllergy,ImmunologyandInfectionGroupNationalGuidelinesR.Kneena,b,r,*,B.D.Michaelb,c,i,j,r,E.Mensond,k,B.Mehtaa,l,A.Eastone,m,C.Hemingwayf,n,P.E.Klapperg,o,A.Vincenth,p,M.Limd,k,E.Carrola,q,T.Solomonb,c,i,j,OnbehalfoftheNationalEncephalitisGuidelinesDevelopmentandStakeholderGroupsaAlderHeyChildren’sNHSFoundationTrust,EatonRoad,WestDerby,LiverpoolL122AP,UKbInstituteofInfectionandGlobalHealth,UniversityofLiverpool,8thFloorDuncanBuilding,DaulbyStreet,LiverpoolL693GA,UKcTheWaltonCentreNeurologyNHSFoundationTrust,LowerLane,Fazakerly,LiverpoolL97JL,UKdEvelinaChildren’sHospitalLondon,GuysandStThomas’,WestminsterBridgeRoad,LondonSE17EH,UKeEncephalitisSociety,32Castlegate,Malton,NorthYorkshire,Y0177DT,UKfGreatOrmondStreetHospital,40BernardStreet,LondonWC1N1LE,UKgUniversityofManchester,2ndFloor,ClinicalSciencesBuilding2,ManchesterRoyalInfirmary,OxfordRoad,Manchester,M139WL,UKhOxfordIonChannelandDiseaseInitiative,DepartmentofClinicalandExperimentalNeuroimmunology,WeatherallInstituteofMolecularMedicine,UniversityofOxford,OxfordOX39DS,UKiDepartmentofNeurologicalScience,UniversityofLiverpool,8thFloorDuncanBuilding,DaulbyStreet,LiverpoolL693GA,UKAccepted13November2011Availableonline18November2011*Correspondingauthor.Tel.:þ441512284811;fax:þ44151228032.E-mailaddresses:[e-mail](R.Kneen),[e-mail](B.D.Michael),[e-mail](E.Menson),[e-mail](B.Mehta),[e-mail](A.Easton),[e-mail](C.Hemingway),[e-mail](P.E.Klapper),[e-mail](A.Vincent),[e-mail](M.Lim),[e-mail](E.Carrol),[e-mail](T.Solomon).jTel.:þ441515295460;fax:þ441515295465.kTel.:þ442071887188.lTel.:þ441512284811;fax:þ44151228032.mTel.:þ441653692583;fax:þ441653604369.nTel.:þ442074059200x8308;fax:þ442078138279.oTel.:þ441612768853;fax:þ441612765744.pTel.:þ441865280528;fax:þ441865280535.qTel.:þ441512525160.rR.KneenandB.D.Michaelarejointfirstauthors.0163-4453/$36ª2012PublishedbyElsevierLtdonbehalfofTheBritishInfectionAssociation.doi:10.1016/j.jinf.2011.11.013(2012)64,449e477KEYWORDSEncephalitis;Viralencephalitis;Herpessimplexvirus;Immunocompromised;Varicellazostervirus;Enterovirus;Antibody-associatedencephalitisSummaryInthe1980stheoutcomeofpatientswithherpessimplexencephalitiswasshowntobedramaticallyimprovedwithaciclovirtreatment.Delaysinstartingtreatment,particu-larlybeyond48hafterhospitaladmission,areassociatedwithaworseprognosis.Severalcom-prehensivereviewsoftheinvestigationandmanagementofencephalitishavebeenpublished.However,theirimpactonday-to-dayclinicalpracticeappearstobelimited.Theemergencymanagementofmeningitisinchildrenandadultswasrevolutionisedbytheintroductionofasimplealgorithmaspartofmanagementguidelines.InFebruary2008agroupofcliniciansmetinLiverpooltobeginthedevelopmentprocessforclinicalcareguidelinesbasedaroundasimilarsimplealgorithm,supportedbyanevidencebase,whoseimplementationishopedwouldimprovethemanagementofpatientswithsus-pectedencephalitis.ª2012PublishedbyElsevierLtdonbehalfofTheBritishInfectionAssociation.IntroductionEncephalitisisdefinedasasyndromeofneurologicaldysfunctioncausedbyinflammationofthebrainparen-chyma.Encephalitishasmanycausesandsomearespecifictochildhood,butfortunatelyitisrelativelyrare.Howeverdoctorswhotreatacutelyillchildrenshouldbeawareofhowtomanageachildwithsuspectedencephalitisassomeoftheindividualcausesofencephalitiswillrespondtospecifictreatmentsanddelaysinthediagnosisinthesechildrencanbedevastating.Strictlyspeaking,inflammationofthebrainparenchymaisapathologicaldiagnosis,howeverduetothepracticallimitationsofthis,surrogateclinicalmarkersofinflammationareused(Table1.Definitions).ClassificationofencephalitisEncephalitiscanbecausedbymanyindividualdiseaseprocessesbutcanbroadlybedividedintothoseassociatedwithinfection(eitherdirectlyorindirectly)andnon-infectiouscauses.Directinfectionsofthecentralnervoussystem(CNS)canbecausedbymanyviruses,bacteria(especiallyintracellularbacteriasuchasMycoplasmapneu-moniae),parasitesandfungi(Table2.Viralencephalitis;Table3.Non-viralcausesofencephalitisorencephalopathy).Thoseindirectlyassociatedwithinfectionincludeanacutedemyelinatingprocess,whichisoftentemporallyrelatedtoapriorinfectionoutsideoftheCNS.Thisprocessmayalsofol-lowimmunisationandisknownasacutedisseminateden-cephalomyelitis(ADEM).Non-infectiouscausesincludeantibody-mediatedencephalitis,whichmaybeparaneoplas-ticforexamplelimbicencephalitisassociatedwithovarianteratomasormaybeanisolatedfinding.Initiallythesedisor-derswerereportedinadults,buttheyarebeingincreasinglyrecognisedinchildren.1Mostviralencephalitidesareacute,butsub-acuteorchronicpresentationsarecharacteristicofparticularpathogens,especiallyintheimmunocompromised(Table4.Sub-acuteandchronicencephalitis).EpidemiologyTheincidenceofencephalitisinchildrenisdifficulttoestablishasreportedstudieshaveusedd