Mania alternates with lethargy

Introduction Due to the influence of disease factors such as rabies in children, there is an alternation of mania and lethargy, and violent convulsions occur during the attack. Rabies is a zoonotic acute infectious disease caused by rabies virus. Because rabies patients have a prominent clinical manifestation of fear of drinking water, this disease has also been called "hydrophobia", but sick animals do not have this feature. The main clinical manifestations are peculiar arrogance, fear and anxiety, fear of wind and water, runny nose and pharyngeal muscle spasm, which eventually lead to paralysis and life-threatening.

Cause

(1) Causes of the disease

The rabies virus belongs to the rhabdoviridae family and the lyssavirus. The virus is shaped like a bullet, with a diameter of 75-80 nm and a length of 175-200 nm. The inner layer is a core shell with a 40 nm core, and the outer layer is a dense envelope with many filamentous protrusions on the surface and the distal end of the protrusion is braided. The entire virus surface has a honeycomb-like hexagonal structure. The genome of the virus is a negative-stranded single-stranded RNA with a molecular weight of 4.6 x 106. The viral genome is 11932 nucleotides in length, of which about 91% of the nucleotides are involved in encoding five known structural proteins, namely glycoprotein (GP), envelope matrix protein (M2P), and matrix matrix protein (M1P). Nuclear protein (NP) and transcriptase protein (LP). Genomic RNA binds to 180 NP molecules to form ribose nucleoprotein (RNP), which protects RNA from degradation and provides a suitable structural basis for genome replication and transcription.

(two) pathogenesis

Rabies virus has a strong affinity for nerve tissue, mainly through nerve retrograde, centripetal to the central transmission, generally does not enter the blood.

The pathogenesis of rabies can be divided into the following three stages:

Extraneural small-scale breeding period

After invading the skin or mucous membrane from the bite site, the virus firstly multiplies in the striated muscle cells of the local wound, and invades the nearby peripheral nerve by binding to the acetylcholine receptor of the neuromuscular junction. From local wounds to invasive peripheral nerves are not shorter than 72h.

2. Invading the central nervous system from peripheral nerves

The virus spreads to the heart along the axons of the peripheral nerves at a rate of about 5 cm/d. After reaching the dorsal root ganglia, it begins to multiply and then invades the spinal cord, which then spreads throughout the central nervous system. Mainly invade neurons in the brain stem and cerebellum. However, it can also be terminated in a certain part during the diffusion process to form a special clinical manifestation.

3. Diffusion period from central nervous system to various organs

That is, the virus spreads eccentrically from the central nervous system to the peripheral nerves, invading various tissues and organs, especially the parotid gland, the tongue taste buds, and the olfactory nerve epithelium. Due to the damage of the vagus nerve nucleus, swallowing nerve nucleus and hypoglossal nucleus, respiratory muscles and swallowing tendon can occur. Clinically, patients have symptoms such as water-induced dyspnea, difficulty in breathing, and difficulty in swallowing. The sympathetic nerve is stimulated to secrete saliva. Increased sweat; vagus ganglia, sympathetic ganglia and damage to the heart ganglion can cause cardiovascular system dysfunction and even sudden death.

At present, it is believed that the local presence of the virus is not the only factor that causes the difference in clinical manifestations. The humoral immunity and cell-mediated immunity have a protective effect in the early stage. However, when the virus enters a large number of nerve cells, the immune-mediated damage and the onset also have a certain relationship. The immunosuppressed mice were delayed after vaccination with rabies virus, and the death was accelerated after passive input of immune serum or immune cells. In human rabies, the lymphocytes that are positive for rabies virus cell proliferation are mostly arrogant and die faster. The autoimmune response to myelin basic protein (MBP) is also arrogant, and the disease progresses rapidly. Immunological damage mediated by antibodies, complement and cytotoxic T cells can be seen in brain tissue.

an examination

Related inspection

EEG examination, cranial nerve examination, brain CT examination, brain MRI examination

The overall course of rabies is 3 to 5 days, rarely more than 10 days. Very rare cases of "paralysis", the latter with high fever, progressive paralysis, and eventually died of exhaustion, the entire course of about 8 to 9 days.

In the case of episodes, the diagnosis can be preliminarily established according to the past history of rabies or suspected rabies or cat, wolf, fox and other animal bites. If you can understand the bite and the health of the animal, then Diagnosing this disease is more valuable. If it is not certain whether the biting dog or cat is suffering from rabies, the animal should be kept in a cage. If the animal does not develop within 7 to 10 days, the animal can generally be excluded from rabies. Patients with typical clinical symptoms such as excitement, arrogance, fear of water, fear of wind, throat muscle spasm, massive salivation, convulsions, etc., can make a clinical diagnosis of rabies. Pay special attention to the symptoms of "three fears" (fear of water, light, wind), if necessary, use fan wind, water and light test, madness symptoms are not obvious should pay attention to pharyngeal muscle edema and hair erection . Such as prenatal immunological antigen, antibody detection positive, post-mortem brain tissue animal inoculation and neuronal cytoplasmic found in the corpus callosum can be diagnosed.

Differential diagnosis

Differential diagnosis of mania and lethargy:

1, mania: frenzied, hand and foot harassment, is a kind of syndrome of sorrow.

2. Manic state during puerperium: Manic state during puerperium: 1 to 2 weeks after birth. It is characterized by lack of sleep, excitement, multilingualism, active movement, singing, high mood, good boasting of yourself, staying up all night, energetic, memory enhanced, and feeling good about yourself. After the manic state is calm, it can develop into a state of depression, so it is also called a state of depression.

3. Drowsiness: Exercise and speech inhibition of conscious disturbances are called lethargy or coma.

4, snoring: the original annotation of the word sputum is "heart disease also", also known as hysteria, is a more common mental illness. At present, patients with snoring are considered to be susceptible to suggestiveness, exaggeration, emotional use and a high degree of egocentricity. They are often caused by mental factors or bad cues. It can present a variety of clinical symptoms, such as impaired sensory and motor function, dysfunction of internal organs and autonomic nerves, and mental disorders. This type of symptom has no basis for organic damage, it can be caused by hints, or it can be changed or disappeared by suggestion. Hysteria is a type of neurosis that is more common in clinical practice, but the incidence has decreased in recent years. In the psychological counseling clinic of general hospitals, the disease is also rare, accounting for only 0.3% of all consultation cases.

5, neurosis: neurosis, also known as neurosis, psychosis, is a group of non-psychiatric functional disorders. The common features are: a group of psychogenic disorders, personality factors, psychosocial factors are the main factors of disease, but non-stress disorders, is a group of dysfunction, the nature of the disorder is functional non-organic; Symptoms of both physical aspects; have a certain personality trait foundation but non-personality disorder; each subtype has its characteristic clinical phase; neurosis is reversible, external stress is aggravated when it is stressed, and symptoms are alleviated or disappeared; social function is relatively good, Self-control is sufficient.

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