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患儿男,5个月,以失音伴四肢瘫痪12天入院。曾在县医院按“病毒性脑炎”收住院,给予激素、抗生素、能量合剂、脱水剂等,3天后无效转我院。病后神志清醒、无热、不咳、无呕吐及呛奶现象,大小便正常。病前4～5天有腹泻病史。查体:体温36.7℃,心率100次/分,呼吸31次/分。发育营养良好,神志清,表情自然,逗时能笑,哭时有泪,但哭笑均无声音。头颅外观及眼、耳、鼻均无异常,无口歪眼斜,口腔、咽反射正常。舌居中。呼吸平稳,心、肺、腹无异常。四肢呈完全性弛缓性瘫痪,各肌群肌力为“0”级,膝、跟腱及肱二、三头肌反射均未叩出。实验室检查:血、尿、粪常规正常。脑脊液无色,潘氏反应阳性,细胞36个,单核52%,多核48%,糖3.66mmol/L,蛋白1.06g/L,氯化物204.6mmol/L。
Children male, 5 months, with aphonia with limb paralysis 12 days admitted. Once in the county hospital by “viral encephalitis” admitted to hospital, give hormones, antibiotics, energy mixture, dehydration agent, 3 days invalid transfer to our hospital. After the illness conscious, no heat, no cough, no vomiting and choking milk phenomenon, normal urine. 4 to 5 days before the disease history of diarrhea. Physical examination: body temperature 36.7 ℃, heart rate 100 beats / min, breathing 31 beats / min. Development of good nutrition, clear-mined, natural expression, funny laugh, tears when crying, but laughing and laughing no sound. Head appearance and eyes, ears, nose and no abnormalities, no crooked eye oblique mouth, mouth, pharyngeal reflex normal. Central tongue. Breathing stable, heart, lung, abdomen without exception. Completely flaccid limbs were paralyzed, muscle strength of each muscle group “0” level, knee, Achilles tendon and biceps, triceps reflex were not knocked out. Laboratory tests: blood, urine, normal feces. Cerebrospinal fluid was colorless and Pan’s reaction was positive. The number of cells was 36, mononuclear 52%, multinucleated 48%, sugar 3.66mmol / L, protein 1.06g / L and chloride 204.6mmol / L.