1、中南大学儿科教研室中南大学儿科教研室麻疹专题麻疹专题概述概述(overview)(overview)临床特征为：发热、上呼吸道炎症、结合临床特征为：发热、上呼吸道炎症、结合膜炎、膜炎、Koplik斑斑与与全身性斑丘疹全身性斑丘疹(clinical features:fever,upper respiratory inflammation,conjunctivitis,Kopliks spots and generalized maculopapular rash)2病原病原(ETIOLOGY)麻疹病毒麻疹病毒(measles virus)n属副粘液病毒，无亚型，仅一种抗原型属副粘液病毒，无亚型
2、，仅一种抗原型(RNA-containing virus of the Paramyxovirus family,only one serotype)3病原病原(ETIOLOGY)麻疹病毒麻疹病毒(measles virus)n麻疹病毒不耐热，对日光和消毒剂均敏麻疹病毒不耐热，对日光和消毒剂均敏感，但在低温中能长期保存感，但在低温中能长期保存(Measles virus are rapidly inactivated by heat,light,and all kinds of desinfectant,but can be stored indefinitely at low tempera
3、ture)。4病原病原(ETIOLOGY)麻疹病毒麻疹病毒(measles virus)n存在于患者前驱期和出疹期的眼结膜、存在于患者前驱期和出疹期的眼结膜、鼻、咽、气管等分泌物中鼻、咽、气管等分泌物中(During the prodromal period and eruption period,it is found in sections of conjunctiva,nose ,pharynx ,trachea and so on)。5麻疹的发病机制麻疹的发病机制 鼻、咽鼻、咽 短期繁殖短期繁殖病毒病毒 局部粘膜局部粘膜 血流血流 远处器官单核远处器官单核 眼结膜眼结膜 （第一次）（第
4、一次）巨噬细胞系统巨噬细胞系统 潜伏期潜伏期大量繁殖大量繁殖 局部症状局部症状 血流血流 （第二次）（第二次）前驱期前驱期 全身症状全身症状 6病理病理(PATHOGEY)全身淋巴组织增生，有多核巨细胞形成全身淋巴组织增生，有多核巨细胞形成 (Hyperplasia of all lymphoid tissue usually occurs,multinucleated giant cells may be found)7病理病理(PATHOGEY)n多核巨细胞多核巨细胞(multinucleated(multinucleated giant cells)giant cells)：多个巨：多个
5、巨噬细胞融合形成的具有核内外包涵体的巨细胞噬细胞融合形成的具有核内外包涵体的巨细胞n网状内皮巨细胞也称华网状内皮巨细胞也称华-佛细胞佛细胞（reticuloendothelial giant cells or Warthin-reticuloendothelial giant cells or Warthin-Finkeldey cells)Finkeldey cells)：存在于全身淋巴组织和肝、脾：存在于全身淋巴组织和肝、脾等脏器中等脏器中n上皮巨细胞（上皮巨细胞（epithelial giant cellsepithelial giant cells）：主要位于皮）：主要位于皮肤、眼结合
6、膜、呼吸道和消化道粘膜等处肤、眼结合膜、呼吸道和消化道粘膜等处 8病理病理(PATHOGEY)n皮肤、眼结合膜、鼻咽部、支气管、肠道粘膜等处皮肤、眼结合膜、鼻咽部、支气管、肠道粘膜等处可见单核细胞增生可见单核细胞增生与与围绕在毛细血管周围的多核巨围绕在毛细血管周围的多核巨细胞，淋巴样组织肥大细胞，淋巴样组织肥大(Prolifieration of mononuclear cells is found in the skin,in the conjunctivae and in the mucous membranes of the nasopharynx,bronchi,and intesti
7、nal tract,multinucleated giant cells occur around the capillaries.Hyperplasia of lymphoid tissue occurs.)9病理病理(PATHOGEY)颊粘膜下层的微小分泌腺发炎，其病变内有浆液渗颊粘膜下层的微小分泌腺发炎，其病变内有浆液渗出出与与内皮细胞增殖形成内皮细胞增殖形成KoplikKoplik斑斑 (An inflammatory reaction occurs in the fine secretor of(An inflammatory reaction occurs in the fine
8、secretor of the buccal mucosa,where serous exudate and the buccal mucosa,where serous exudate and proliferation of endothelial cells result inproliferation of endothelial cells result in KopliksKopliks spots)spots)10病理病理(PATHOGEY)n麻疹引起的间质性肺炎为麻疹引起的间质性肺炎为HechtHecht巨细胞肺炎巨细胞肺炎 (Interstitial(Interstitial
9、 pneumonitis resultingpneumonitis resulting from measles virus takes the from measles virus takes the form of Hecht giant cell pneumonia)form of Hecht giant cell pneumonia)11病理病理(PATHOGEY)n麻疹皮疹的病理改变：真皮毛细血管内皮增生、麻疹皮疹的病理改变：真皮毛细血管内皮增生、血浆渗出、红细胞相对增多形成淡红色斑丘疹血浆渗出、红细胞相对增多形成淡红色斑丘疹(Maculopapular rash consists
10、of proliferation of(Maculopapular rash consists of proliferation of capillarycapillary endothelial cells in skin,serous exudate endothelial cells in skin,serous exudate and relative increase of red cells)and relative increase of red cells)n疹退后，表皮细胞坏死、角化形成脱屑。疹退后，表皮细胞坏死、角化形成脱屑。n皮疹处红细胞裂解，疹退后形成棕色色素沉着。皮疹
11、处红细胞裂解，疹退后形成棕色色素沉着。12典型麻疹典型麻疹(Typical measles)(Typical measles)潜伏期潜伏期(Incubation stage)一般为一般为1014天天(亦可短至亦可短至1周周)，此，此期可有轻度体温上升期可有轻度体温上升(It lasts usually 1014 days after contact,maybe as short as 1 week.The temperature may increased slightly)。临床表现临床表现13典型麻疹典型麻疹前驱期前驱期(Prodromal stage)指从发热至出疹指从发热至出疹,一般为
12、一般为3-43-4天天(from fever to rash appearance,usually lasts 3-4 days)临床表现临床表现14典型麻疹典型麻疹 主要表现：发热、上呼吸道炎症、眼结主要表现：发热、上呼吸道炎症、眼结合膜炎、合膜炎、Stimson线线(fever,upper respiratory inflammation,conjunctivitis)麻疹粘膜斑麻疹粘膜斑(Kopliks spots)前驱期前驱期(Prodromal stage)临床表现临床表现15Kopliks spotsKopliks spots(麻疹粘膜斑麻疹粘膜斑)时间：时间：发疹前发疹前24 4
13、8小时出现小时出现(24-48 hours before the appearance of the rash)；位置：位置：开始对着下臼齿的颊粘膜上；以后开始对着下臼齿的颊粘膜上；以后累累与与整个颊部并蔓延至唇部粘膜整个颊部并蔓延至唇部粘膜(initially opposite the lower molars but may spread the rest of the buccal and lip mucosa)。临床表现临床表现16Kopliks spotsKopliks spots(麻疹粘膜斑麻疹粘膜斑)形态：形态：直径约直径约1的灰白色小点，外有红晕的灰白色小点，外有红晕(gray
14、ish white dots with 1mm in diameter,usually as small as grains of sand,that reddish areolae)；发展：发展：1天内很快增多，皮疹出现后逐渐消天内很快增多，皮疹出现后逐渐消失失(They spread rapidly within one day and disappear gradually after the appearance of the rash)。临床表现临床表现1718典型麻疹典型麻疹出疹期出疹期(eruption stage)在发热在发热3-53-5天后出现天后出现,持续持续3-53-5天
15、天 出疹顺序出疹顺序:耳后、发际耳后、发际额、面部额、面部颈颈躯干躯干四肢四肢,达手掌、足底达手掌、足底 (initially occurring behind the ears and hairline and spreading down from the forehead and face to neck,the trunk and the extremities).临床表现临床表现19典型麻疹典型麻疹出疹期出疹期(eruption stage)(eruption stage)皮疹性质皮疹性质:红色斑丘疹，疹间皮肤正常红色斑丘疹，疹间皮肤正常(red maculupapular rash
16、,(red maculupapular rash,there is normal skin there is normal skin among rashes.)among rashes.)临床表现临床表现2021典型麻疹典型麻疹 恢复期恢复期(convalescent period)(convalescent period)皮疹按出疹先后顺序消退皮疹按出疹先后顺序消退,伴有糠麸样脱伴有糠麸样脱屑屑与与棕色色素沉着棕色色素沉着,经经7 71010天消失天消失(The(The rash fades downward in the rash fades downward in the same s
17、equence in which it same sequence in which it appeared.As the rash fades,appeared.As the rash fades,branny desquamation and branny desquamation and brownish discoloration occur brownish discoloration occur and then disappear within 7-10 and then disappear within 7-10 days)days)临床表现临床表现22 并发症并发症(comp
18、lications)(complications)肺炎肺炎(pneumonia)(pneumonia)是麻疹常见的并发症，多见于出疹期，是麻疹常见的并发症，多见于出疹期，继发细菌或其它病毒感染继发细菌或其它病毒感染n喉、气管、支气管炎喉、气管、支气管炎(laryngitis,trachitis,(laryngitis,trachitis,bronchitis)bronchitis)n心肌炎心肌炎(myocarditis)(myocarditis)23并发症并发症(complications)(complications)麻疹脑炎麻疹脑炎与与亚急性硬化性全脑炎（亚急性硬化性全脑炎（measles
19、 measles encephalitis and subacute sclerosing encephalitis and subacute sclerosing panencephalitis panencephalitis 简称简称SSPE)SSPE)结核病恶化结核病恶化(tuberculosis exacerbating)(tuberculosis exacerbating)营养障碍与维生素营养障碍与维生素A A缺乏症缺乏症(malnutrition(malnutrition and vitamin A deficiency)and vitamin A deficiency)24诊诊
20、断断(DIAGNOSIS)麻疹接触史麻疹接触史(exposure to measles(exposure to measles previously)previously)典型临床表现典型临床表现(typical clinical(typical clinical manifestations)manifestations)25诊诊 断断(DIAGNOSIS)前驱期鼻咽部找多核巨细胞前驱期鼻咽部找多核巨细胞与与尿中尿中检测包涵体细胞检测包涵体细胞(During the(During the prodromal stage,multinucleated prodromal stage,multi
21、nucleated giant cells are found in giant cells are found in nasopharynx,intrancuclear and nasopharynx,intrancuclear and intracytoplasmic inclusion bodies intracytoplasmic inclusion bodies cells are found in urine)cells are found in urine)26诊诊 断断(DIAGNOSIS)ELISAELISA法检测麻疹抗体法检测麻疹抗体(Measles virus(Measl
22、es virus antibodies become detectable by ELISA antibodies become detectable by ELISA when the rash ppears;testing of acute when the rash ppears;testing of acute and convalescent sera shows the and convalescent sera shows the diagnostic seroconversion or fourfold diagnostic seroconversion or fourfold
23、 increase in titer)increase in titer)27鉴别诊断鉴别诊断病原病原全身症状和其他全身症状和其他特征特征皮疹特点皮疹特点发热与皮疹发热与皮疹的关系的关系麻疹麻疹(rubeola)麻疹麻疹病毒病毒卡他症状卡他症状结膜炎、发热结膜炎、发热Koplik斑斑红色斑丘疹，特红色斑丘疹，特别的出疹顺序，别的出疹顺序，退疹后有色素沉退疹后有色素沉着几细小脱屑着几细小脱屑发热发热34天，天，出疹时体温出疹时体温更高更高风疹风疹(rubella)风疹风疹病毒病毒耳后、颈后、枕耳后、颈后、枕后淋巴结肿大后淋巴结肿大退疹后无色素沉退疹后无色素沉着及脱屑着及脱屑发热半天或发热半天或一
24、天后出疹一天后出疹幼儿急疹幼儿急疹exanthema subitum 人疱人疱疹病疹病毒毒6型型一般情况好，耳一般情况好，耳后、颈后、枕后后、颈后、枕后淋巴结可肿大淋巴结可肿大颈及躯干部多见，颈及躯干部多见，一天出齐，次日一天出齐，次日消退消退高热高热35天，天，热退疹出热退疹出猩红热猩红热(scarlet fever)乙型乙型溶血溶血性链性链球菌球菌高热，中毒症状高热，中毒症状重，咽峡炎、杨重，咽峡炎、杨梅舌、环口苍白梅舌、环口苍白圈、扁桃体炎圈、扁桃体炎皮肤弥漫充血，皮肤弥漫充血，密集针尖大小丘密集针尖大小丘疹，疹，1周后全身大周后全身大片脱皮片脱皮发热发热12天天出疹，出疹出疹，出疹时高
25、热时高热28麻疹的流行病学麻疹的流行病学与与预防预防 流行病学流行病学(epidemiology)(epidemiology)传染源：传染源：急性期患者和亚临床型急性期患者和亚临床型带病毒者带病毒者 预防预防(prevention)(prevention)控制传染源：控制传染源：隔离患者：隔离患者：出疹后天，并发出疹后天，并发肺炎者肺炎者1010天。天。接触过麻疹的易感者：接触过麻疹的易感者：隔离检疫隔离检疫3 3周周29麻疹的流行病学麻疹的流行病学与与预防预防流行病学流行病学n 传播途径：传播途径：主要是呼吸道飞沫主要是呼吸道飞沫传播。传播。预防预防n 切断传播途径：切断传播途径：实行实行“
26、三门三门”，病，病人住所、衣物按规人住所、衣物按规定消毒。定消毒。30麻疹的流行病学麻疹的流行病学与与预防预防流行病学流行病学预防预防n保护易感人群：保护易感人群：主动免疫主动免疫(active(active immunization)immunization)，被动免疫被动免疫(passive(passive immunization)immunization)。易感性易感性:人类对麻疹病毒普遍易人类对麻疹病毒普遍易感。感。易感者：易感者：未曾患过麻疹或未接种未曾患过麻疹或未接种过麻疹疫苗者。过麻疹疫苗者。31治治 疗疗(TREATMENT)无特异抗病毒治疗，只有支持治疗和无特异抗病毒治疗，
27、只有支持治疗和对症治疗。对症治疗。(There is no specific antiviral therapy;treatment is entirely supportive and symptomatic treatment)32治治 疗疗一般治疗一般治疗 给予易消化的富有营养的食物，给予易消化的富有营养的食物，补充充足水分；保持皮肤、粘膜清洁补充充足水分；保持皮肤、粘膜清洁33治治 疗疗一般治疗一般治疗 卧床休息，房内保持适当的温卧床休息，房内保持适当的温度和湿度，有畏光症状时房内光线要柔和度和湿度，有畏光症状时房内光线要柔和 (bed rest,keeping comfortably
28、 humidification and warm of the room;patients with photophobia should be protected from exposure to strong light)。34治治 疗疗n对症治疗对症治疗 高热时可用小量退热剂。慎用退热药，烦高热时可用小量退热剂。慎用退热药，烦躁者镇静。剧咳时镇咳祛痰。继发细菌感染可给抗生素，躁者镇静。剧咳时镇咳祛痰。继发细菌感染可给抗生素，补充维生素补充维生素A。35麻疹的新进展麻疹的新进展 麻疹的发病年龄呈两极分化趋势婴儿麻疹麻疹的发病年龄呈两极分化趋势婴儿麻疹增多，主要发生在增多，主要发生在8 8个
29、月以前个月以前,多为非典型病多为非典型病例；大年龄患者增多。例；大年龄患者增多。麻疹的不典型病例增多。麻疹的不典型病例增多。发病高峰季节后移至发病高峰季节后移至3-53-5月份月份36麻疹的并发症的变化：麻疹的并发症的变化：心肌炎明显增多，且年龄越小，发病心肌炎明显增多，且年龄越小，发病率越高。率越高。二次麻疹发生率二次麻疹发生率:在在1%1%左右，其中左右，其中60%60%发生在第一次麻疹发生在第一次麻疹二年以内。二年以内。虽然麻疹病例增多，但病死率却很低。虽然麻疹病例增多，但病死率却很低。麻疹的新进展麻疹的新进展37 麻疹前驱期最有诊断价值的表现麻疹前驱期最有诊断价值的表现()A 发热发热3-5天天 B 有卡他症状有卡他症状 C Kopliks spots D 可见少数斑丘疹可见少数斑丘疹E 有麻疹接触史有麻疹接触史麻疹提问麻疹提问1 13839
