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患儿女,10岁,因反复发热1月余,时有头痛、头晕、恶心就诊。病后第3周曾因高热、头痛、头晕加重住某院,诊断为病毒性脑炎,予以降颅压、抗病毒治疗,症状缓解出院。出院后患儿头痛复又加剧,出现短暂性意识模糊,持续约3min,自行缓解,缓解后乏力、嗜睡,遂入我院。查体:体温38℃,除肝大肋下2cm外,余未发现阳性体征。辅助检查:血白细胞3.0×109/L,中性0.6,淋巴0.31。红细胞沉降率50mm/h。补体C3440mg/L,抗核抗体1:140,抗ds-DNA抗体及抗Sm抗体(+)。尿常规:蛋白(+),隐血(++)。脑脊液常规检查正常。头颅CT示轻度脑萎缩。最后诊断:系统性红斑狼疮(SLE)。
Children, 10 years old, more than 1 month due to repeated fever, headache, dizziness, nausea treatment. After the first 3 weeks of illness due to high fever, headache, dizziness aggravated a hospital, diagnosed as viral encephalitis, to be reduced intracranial pressure, antiviral therapy, relieve symptoms discharged. After discharge, the headache and exacerbation of children exacerbated, transient transient confusion, continued for about 3min, self-remission, relieve fatigue, lethargy, and then into our hospital. Physical examination: body temperature 38 ℃, in addition to liver ribs 2cm, I found no positive signs. Auxiliary examination: white blood cells 3.0 × 109 / L, neutral 0.6, lymph 0.31. Erythrocyte sedimentation rate 50mm / h. Complement C 3440 mg / L, antinuclear antibody 1: 140, anti-ds-DNA antibody and anti-Sm antibody (+). Urine: protein (+), occult blood (++). Cerebrospinal fluid routine examination was normal. Head CT showed mild brain atrophy. The final diagnosis: systemic lupus erythematosus (SLE).