NEJMCase36---An18-Year-OldWomanwithFever,Pharyngitis,andDoubleVisio
18岁女性发热、咽炎、复视一例
PresentationofCase
Dr.NicholasA.Morris(Neurology):An18-year-oldwomanwasadmittedtothishospitalbecauseoffever,pharyngitis,facialswelling,anddiplopia.
尼古拉斯·莫里斯医生（神经科）：一名18岁女性因发烧、咽炎、面部肿胀和复视入院。
Thepatienthadbeenwelluntil2weeksbeforethecurrentadmission,whenaheadacheandsorethroatdeveloped,withoutafever.Onevaluationatherphysiciansoffice,arapidtestforstreptococcalpharyngitiswasnegative,andshereturnedhome.Duringthenext2days,throatpainpersistedandoralintakedecreased.Shewasadmittedtotheobservationunitofanotherhospitalbecauseofdehydration,weakness,andfevers,withatemperatureashighas39.4C.Achestradiographwasnormal.
病人一直很好，直到本次入院前2周，出现头痛和咽喉痛，没有发烧。在医生办公室的评估中，链球菌咽炎的快速测试呈阴性，之后她回家了。在接下来的2天里，咽喉疼痛持续存在，经口摄入量减少。她因脱水、虚弱和发医院的观察室，体温高达39.4℃，胸片显示正常。
Thepatientreportedlyhadawhite-cellcountoflessthanpercubicmillimeter,positivetestsforIgGandIgMantibodiestoEpsteinBarrvirus(EBV)specificviralcapsidantigenandantibodiestoEBVnuclearantigen,andnegativetestsforheterophileantibodies,influenzaAandBviruses,andIgMandIgGantibodiestocytomegalovirus(CMV).ApharyngealculturegrewgroupCstreptococcus.Culturesofthebloodandurineweresterile.Adiagnosisofinfectiousmononucleosiswithpossiblebacterialsuperinfectionwasmade.Intravenousfluidswereadministered,andherconditionimproved.Onday2,treatmentwitherythromycinwasbegunandshewasdischargedhome.
据报道，该患者白细胞计数小于个/立方毫米，EB病毒（EBV）特异性病毒衣壳抗原IgG和IgM抗体及EBV核抗原抗体检测阳性，嗜异性抗体、甲型和乙型流感病毒、巨细胞病毒（CMV）IgM和IgG抗体检测阴性。咽部培养长出C群链球菌。血液和尿液的培养均无菌。诊断为感染性单核细胞增多症，可能有细菌重叠感染。静脉输液，病情好转。第2天，开始使用红霉素治疗，出院回家。
Ninedaysbeforethecurrentadmission,trismus,painonopeningthemouth,andswellingontherightsideofthefaceandjawdeveloped.Thepatientreturnedtotheemergencydepartmentofthesamehospital;parotitiswasdiagnosed,andibuprofenwasadministered.Painpersistedontherightsideofthejawandwasassociatedwithtemperaturesashighas38.3Candswellinganderythemaoftherightparotidglandandface.
在这次入院的九天前，出现了牙关紧闭，张口疼痛，以及右侧面部和下巴肿胀。医院的急诊科;诊断为腮腺炎，服用布洛芬。右颌持续疼痛，体温高达38.3摄氏度，右腮腺和面部，肿胀有红斑。
Sixdaysbeforethecurrentadmission,thepatientwasseenatasecondhospital;prednisoneandnarcoticanalgesicagentswereadministered,andmassageoftheparotidglandwasperformed.Shereturnedhome.Feverspersisted,andedemaoftherightlateralsideofthefaceandneckworsened.Threedayslater,shewasseenbyherphysicianandwasadmittedtothesecondhospital.Computedtomography(CT)oftheheadandneckreportedlyrevealednoevidenceofretropharyngealorperitonsillarabscesses.Trimethoprim–sulfamethoxazole,clindamycin,andintravenousfluidswereadministered.
在本次入院前6天，医院就诊，应用强的松和麻醉性镇痛药，并对腮腺进行按摩。之后她回家了。持续高烧，右侧面部和颈部水肿加剧。三天后，她去看了医生，医院。头部和颈部的计算机断层扫描(CT)报告显示没有证据显示咽后或扁桃体周围脓肿。使用复方新诺明、克林霉素和静脉输液。
Twodaysbeforethecurrentadmission,swellingoftherighteyelidsandhorizontaldiplopiadeveloped.Onevaluation,therewasdecreasedabductionoftherighteye.Imagingstudieswereobtained.
本次入院前两天，出现右眼睑肿胀、水平复视。经评估，右眼外展度下降。进行了影像学检查。
Dr.JasonM.Johnson:Magneticresonanceimaging(MRI)oftheheadandneck,performedwithandwithouttheadministrationofcontrastmaterial,revealedamultiloculated,rim-enhancingfluidcollectionintherightparotidglandandinflammationofthemasticatorspace.Therewaslinearenhancementofthepachymeningesintherighttemporalregion,afindingthatraisedconcernaboutmeningitis.Diffusion-weightedimagesobtainedattheleveloftheparotidglandshowedfindingsconsistentwithanabscess.Therewasanirregularityoftherightcavernoussinus,withoutdefinitethrombosis.Asubperiostealabscessintherightorbitwasalsoidentified.
JasonM.Johnson医生：头部和颈部的磁共振成像（MRI），在使用和不使用造影剂的情况下，显示在右腮腺有一个多腔、边缘增强的液体聚集，以及咀嚼肌间隙的炎症。右侧颞区硬脑膜呈线性增强，这一发现引起了对脑膜炎的
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