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麻疹的临床表现与诊断

Authors
Jorge L Barinaga, MD, MS
Paul R Skolnik, MD, FACP, FIDSA
Section Editors
Martin S Hirsch, MD
Sheldon L Kaplan, MD
Deputy Editor
Elinor L Baron, MD, DTMH
Translators
马一平, 主治医师

引言

麻疹病毒(measles virus/rubeola)隶属于副粘液病毒科麻疹病毒属。麻疹病毒感染可以引起多种临床综合征，包括[1]：

  • 免疫功能正常患者中的典型麻疹感染
  • 预先即存在抗麻疹抗体(但保护力不完全)的患者中的轻型麻疹
  • 接受了灭活病毒疫苗免疫的患者中的非典型麻疹
  • 麻疹感染后的神经系统综合征，包括急性播散性脑脊髓炎(acute disseminated encephalomyelitis, ADEM)和亚急性硬化性全脑炎(subacute sclerosing panencephalitis, SSPE)
  • 重型麻疹
  • 包括继发感染、巨细胞性肺炎和麻疹包涵体脑炎(measles inclusion body encephalitis, MIBE)在内的麻疹并发症

尽管社区疫苗接种覆盖率很高，但麻疹暴发仍可以在疫苗接种不充分的儿童中发生[2,3]。典型麻疹的临床表现及诊断、变异型麻疹的表现及不常见的神经系统并发症将总结在此。麻疹的流行病学、传播、治疗及预防将单独讨论。 (参见“Measles: Epidemiology and transmission”)

临床表现

感染分期 — 典型麻疹感染可被细分为以下临床阶段：潜伏期、前驱期、出疹期和恢复期[4]。

  • 潜伏期—潜伏期始于麻疹病毒通过呼吸道黏膜或结膜侵入机体后。病毒在原发病灶复制，扩散至局部淋巴组织，随后病毒随着血流播散至其他网状内皮组织区域。麻疹的潜伏期通常为10日，范围一般为8-10日[5]。感染个体在潜伏期的特征是没有症状，但已报道有些患者在潜伏期时会经历短暂的呼吸系统症状、发热或麻疹样皮疹[6,7]。

    病毒血症所致麻疹病毒播散，以及相关的内皮细胞、上皮细胞、单核细胞和巨噬细胞感染，也许能解释麻疹感染时可出现的多种临床表现和并发症。二次病毒血症发生于第1次病毒血症后数日，与预示着前驱期开始的症状同时出现。
  • 前驱期—前驱期指的是出现了以下症状：通常包括发热、不适和厌食，随后出现结膜炎、鼻卡他和咳嗽。结膜炎的严重程度可变，也可能伴有流泪或畏光[6]。呼吸系统症状是由病毒感染上皮细胞导致黏膜炎症所引起。通常会出现发热；热型可能有差异。已描述了多种热型；可以发生达40℃的高热。前驱期通常持续2-3日，但也可能持续长达8日之久[5]。

    患者可能会出现被称为柯氏斑的黏膜疹；柯氏斑为1-3mm的白色、浅灰色或淡蓝色的隆起，具有红斑状基底，通常见于正对磨牙的颊黏膜，但其可蔓延至覆盖颊黏膜和唇黏膜及(图片 1)硬腭和软腭[8]。它们被描述为“红底上的盐粒”[7]。随后柯氏斑可能会融合，且通常持续12-72小时[4]。

    因为柯氏斑被认为是麻疹感染具有诊断意义的特征表现，且出现于特征性皮疹发生前约48小时，故而对于疑似麻疹患者仔细检查其是否有柯氏斑十分重要。然而，并不是所有麻疹患者均会出现该黏膜疹。

    罕见情况下，重型麻疹患者可出现泛发性淋巴结肿大和脾肿大[7]。
  • 出疹期—麻疹皮疹是一种压之退色的斑丘疹，始于面部，其播散形式为从颅侧至尾侧、离心式播散，逐渐累及颈部、上躯干、下躯干和四肢(图片 2A-B)。病变可能会融合，特别在某些区域内，如皮疹始发的面部(图片 2B)。皮疹亦可能会有一些瘀点；严重病例中可能会表现为出血性瘀点[9-11]。一般来说，皮疹融合的范围和程度与儿童疾病的严重程度相关。手掌和足底很少受累。皮疹从颅侧至尾侧进展是麻疹的特征性表现，但并不是诊断性表现[6]。

    出疹期的其他特征性发现包括淋巴结肿大、高热(皮疹出现后2-3日达到峰值)、包括咽炎在内显著的呼吸系统体征，以及非化脓性结膜炎。皮疹出现时，柯氏斑通常会开始坏死脱落。

    通常，皮疹出现48小时内临床改善会跟着发生。3-4日后，皮疹逐渐变暗至褐色并开始消退，随后有细小的皮肤脱屑。皮疹通常持续6-7日。
  • 恢复期及免疫力—麻疹感染后咳嗽可能会持续1-2周。皮疹第3-4日后出现发热，提示为麻疹相关并发症(参见下文‘并发症’)。

    麻疹感染后的免疫力被认为是终身性的，但也有极少数麻疹再感染的报道[12,13]。例如，20世纪60年代中期开展的麻疹监测项目就发现过一例16岁的麻疹女性患者，其有8岁时发生过麻疹的既往史。记录到抗麻疹IgG抗体升高，而不是IgM抗体升高，这提示存在回忆应答[12]。(参见下文‘轻型麻疹’)

    由于T细胞应答受抑，麻疹感染可以导致暂时性免疫抑制 [8]。皮疹出现之前可能会出现免疫失能，并可能会在麻疹感染后持续数周时间[8,14]。关于近期麻疹感染情况下结核病再激活的报道证实了这一点[8,15]。

                        

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Literature review current through: 2017-06 . | This topic last updated: 2017-05-17.
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