中英099JAMA尸检病理挑战传统的NM
A62-year-oldmandevelopedconfusionandwasdiagnosedashavingencephalitis.Theetiologywasnotidentified.Hecontinuedtohavecognitiveimpairmentbutremainedclinicallystable.Fivemonthslater,hewokewithbilateralvisionloss.Onneurologicalexamination,hehadnolightperceptionbilaterally.Theremainderoftheneurologicalexaminationresultswerenormal.Magneticresonanceimagingofthebrainrevealedmultiplebrainlesions.Hewastreatedwithsteroidsandplasmapheresis,withmildimprovementinvision.Hewasthentransferredtoalong-termcarefacility,wherehedevelopedincreasingconfusionandultimatelydied.Anautopsywasperformed;thedifferentialdiagnosis,neuropathology,andfinaldiagnosisarediscussedhere.
一名62岁的男子出现意识模糊，被诊断为脑炎，病因不明，继而出现认知功能障碍，但是病情尚稳定。5个月后，睡醒觉后又出现双眼失明。神经系统检查双眼无光感，其余神经系统检查结果正常。头颅磁共振成像显示颅内多发病灶，给予激素和血浆置换治疗。患者视力轻度改善。患者被转移到一个长期护理机构，在那里意识模糊越来越重，最终死亡并进行了尸检。本文针对患者疾病的鉴别诊断、神经病理学机制、最终诊断进行讨论。
JAMANeurol.;70(7):-.doi:10./jamaneurol..
PublishedonlineMay27,.
A62-year-oldright-handedmanpresentedwithacutebilateralvisionloss.Afewdayspriortopresentation,hewokeupwithpainlessvisionlossinthelefteyeandwasadmittedtoanoutsidehospital.Duringthehospitalstay,hisvisionlossprogressedover2daysandinvolvedtherighteye.Hewasonlyabletoseeshapesandshadows.Alsonotedwerebriefepisodesofflexion/extensionofthekneeswithspasmsandposturingofextremitieswithoutanychangeinconsciousness.Initialophthalmologicexaminationwasnotableforpoorvisualacuitybilaterally(OD,20/70;OS,handwaving),relativeafferentpupillarydefect,andminimaldiscswellinginthelefteye.Slitlampexaminationresultswerenormal.Nobladder/bowelsymptoms,focalweakness,orsensorychangeswerepresent.Hewastransferredtoourinstitutionforfurthermanagement.
患者，男，62岁，右利手，表现为突发双眼失明。发病前几天，患者睡醒后出现无痛性左眼失明，医院住院治疗，2天后出现右眼失明，只能看到物体形状和阴影，并出现发作性膝关节痉挛(伸/缩)和姿势异常，不伴有意识改变。初始眼科检查发现双眼视力差（右眼，20/70；左眼，能见手摆动），相对性传入性瞳孔障碍，和左眼视盘水肿。裂隙灯检查正常。无大小便失禁，没有肢体力弱，无感觉障碍，为进一医院。
Fivemonthspriortohispresentation,hehadbeenadmittedtoanoutsidehospitalfornewonsetofconfusion.Hewasdiagnosedashavingviralencephalitis;however,nospecificetiologywasfound.Magneticresonanceimaging(MRI)ofthebrainatthattimerevealedleftmesialtemporalT2hyperintensitysignalwithedema.Resultsofcerebrospinalfluid(CSF)studiesshowedmildlymphocyticpredominantpleocytosiswithoutotherabnormalities.ResultsofanextensiveinfectiousworkupwerenegativeincludingCSFpolymerasechainreactionforherpessimplexvirusandantibodiestoenterovirusandWestNilevirus.Electroencephalography(EEG)showedlefttemporalepileptiformdischarges;treatmentwithlevetiracetamwasstarted.Hecontinuedtohavecognitiveimpairmentandrequiredconstantsupervisionafterhospitaldischarge.
患者发病前5个月，因意识模糊被送往外院，诊断为病因不明的病毒性脑炎。头颅MRI示左侧颞叶内侧T2像高信号，伴有水肿。脑脊液（CSF）检查示淋巴细胞轻度升高，其他指标正常。脑脊液病毒学检查单纯疱疹病毒聚合酶链反应和肠道病毒、西尼罗河病毒抗体均阴性。脑电图（EEG）显示左侧颞叶痫性放电，给予左乙拉西坦治疗，患者出院后遗留有认知障碍，仍需要人照料。
Hismedicalhistoryincludedleftrenalcellcarcinoma,whichhadbeenresected1yearearlier,hepatitisC,anddiabetesmellitus.Hedeniedsmoking,alcoholabuse,oruseofanyillicitdrugs.Hewasaretiredairlinemechanicwithremoteexposuretotrichloroethaneandformaldehyde.HevisitedHondurasafewmonthspriortopresentation.Hismedicationsincludedaspirin,levetiracetam,glipizide,crestor,andinsulin.
患者既往有左肾细胞癌，1年前已行手术切除术，有丙型肝炎、糖尿病史。否认吸烟、饮酒及毒品接触史。患者是一名退休的航空机械师，很久以前接触三氯乙烯和甲醛。发病前几个月曾到过洪都拉斯。使用药物有阿司匹林肠溶片、左乙拉西坦、格列吡嗪、可定（瑞舒伐他汀）、胰岛素。
Hisgeneralexaminationwasnormal.Onneurologicalexamination,hewasalert,orientedtoselfandtimebutnottoplace,showedperseveration,andfollowedsimple儿童白癜风怎么引起的原因北京什么医院看白癜风最好
