病例报告：伪装为创伤性脊髓损伤的麻痹型狂犬病：创伤外科中的诊断陷阱

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中文摘要

狂犬病是一种致死性人畜共患脑炎。其麻痹型约占病例的20%，常类似急性脊髓损伤（SCI）。当同时存在外伤史时，诊断锚定可能错误地将神经功能恶化归因于损伤，从而延误正确诊断。我们描述一例26岁男性，在3米坠落10天后出现进行性、上升性下肢瘫痪。在一家二级医院，他在未行脊柱MRI的情况下被临床诊断为创伤性脊髓损伤。转院后重新评估发现4个月前有狐狸咬伤史，并具有恐水变异型特征（吞咽时水“进入大脑”的感觉）。脑脊液宏基因组下一代测序（mNGS）在48小时内检出狂犬病病毒，显示与涵盖N和L基因的中国分离株100%序列同一性。该发现随后由四川省疾病预防控制中心（CDC）使用外周血标准参考检测予以确认。患者随后死于自主神经和呼吸衰竭。本病例强调近期创伤如何掩盖致死性感染病因。未行神经影像学而作出的SCI临床诊断应视为暂定诊断，mNGS可提供无偏、快速的手段来解决诊断困难的神经系统表现。

英文摘要

Rabies is a uniformly fatal zoonotic encephalitis. Its paralytic form, which accounts for approximately 20% of cases, frequently resembles acute spinal cord injury (SCI). When there is a coincident history of trauma, diagnostic anchoring may wrongly attribute neurological decline to the injury, thereby delaying the correct diagnosis. We describe the case of a 26-year-old man who developed progressive, ascending paralysis of the lower limbs 10 days after a 3-m fall. At a secondary hospital, he was clinically diagnosed with traumatic SCI without spinal MRI. On transfer, reassessment revealed a fox bite 4 months earlier and features of the hydrophobia variant (a sensation of water "entering the brain" during swallowing). Cerebrospinal fluid metagenomic next-generation sequencing (mNGS) detected Rabies lyssavirus within 48 h, showing 100% sequence identity to Chinese isolates spanning the N and L genes. This finding was subsequently confirmed by the Sichuan Provincial Center for Disease Control and Prevention (CDC) using standard reference testing on peripheral blood. The patient subsequently died of autonomic and respiratory failure. This case highlights how recent trauma can obscure a fatal infectious cause. A clinical diagnosis of SCI made without neuroimaging should be regarded as provisional, and mNGS can provide an unbiased, rapid means of resolving diagnostically challenging neurological presentations.