新型隐球菌脑膜炎45例临床分析

目的 探讨新型隐球菌脑膜炎（CNM）患者的临床特点,为诊断和治疗提供经验与参考。 方法 回顾性分析2010年1月—2019年6月海南省人民医院收治的45例CNM患者的临床表现及治疗情况。 结果 4.44%（2例）有明确鸽子接触史,22.22%（10例）合并有艾滋病,28.89%（13例）合并有肺结核、肝病等其他基础疾病。主要临床症状为头痛（36/45,80%）,发热（31/45,68.89%）,恶心、呕吐（15/45,33.33%）,复视、视力下降（3/45,6.67%）,意识障碍（4/45,8.89%）,抽搐（2/45,4.44%）,听力下降（1/45,2.22%）,脑膜刺激征阳性（11/45,24.44%）。80%(36例)出现高颅压,20例脑脊液压力大于300 mmH₂O。脑脊液检查显示颅内压升高,脑脊液蛋白、糖、氯化物呈现一高二低现象;20例患者脑脊液培养阳性,分离菌株对氟康唑、5-氟胞嘧啶(5-FC)、两性霉素B(AmB)和伏立康唑的敏感性较高;45例患者中,18例给予AmB联合5-FC治疗,12例接受AmB联合氟康唑治疗,4例接受氟康唑+5-FC治疗,8例单用AmB,3例单用氟康唑治疗,治愈24例,好转2例,有效率57.78%。 结论 CNM患者主要以颅内高压为特点,患者出现发热、头痛、脑膜刺激征阳性,应及时行腰穿,反复行脑脊液涂片及培养明确诊断,隐球菌对多种抗真菌药敏感,临床可个体化采用AmB、氟康唑（或）5-FC的联合方案治疗。

A clinical analysis of 45 cases of Cryptococcus neoformans meningitis

Objective To explore the clinical characteristics of patients with Cryptococcus neoformans meningitis (CNM), so as to provide guidance for diagnosis and treatment. Methods Retrospective analysis of the clinical manifestations and treatment of 45 patients with CNM admitted to Hainan Provincial People's Hospital were conducted from January 2010 to June 2019. Results 4.44%(2 cases) had a clear history of pigeon contact, 22.22%(10 cases) were combined with AIDS, and 28.89%(13 cases) were combined with other basic diseases such as pulmonary tuberculosis and liver disease. The clinical features including headache (36/45, 80%), fever(31/45, 68.89%), nausea and vomiting(15/45,33.33%), diplopia and vision loss (3/45,6.67%), consciousness disorders (4/45,8.89%), convulsions (2/45,4.44%), hearing loss (1/45,2.22%), and positive meningeal signs (11/45,24.44%). 80%(36 cases) had high intracranial pressure, and 20 cases had cerebrospinal fluid pressure greater than 300 mmH₂O. Cerebrospinal fluid examination showed increased intracranial pressure, and increased protein, decreased sugar and chloride. Cerebrospinal fluid culture was positive in 20 patients, and isolates were more sensitive to fluconazole, 5-fluorocytosine (5-FC), amphotericin B (AmB), and voriconazole. Of the 45 patients, 18 were treated with AmB combined with 5-FC, 12 were treated with AmB combined with fluconazole, 4 were treated with fluconazole + 5-FC, 8 were treated with AmB alone, and 3 were treated with fluconazole alone, 24 cases were cured, 2 cases improved, the effective rate was 57.78%. Conclusion CNM patients are mainly characterized by intracranial hypertension. Patients with fever, headache, and positive meningeal irritation should be treated with lumbar puncture, repeated CSF smears, and cultured for a clear diagnosis. Cryptococcus is sensitive to a variety of antifungal drugs, and can be treated clinically with a combination of AmB, fluconazole (or) 5-FC according to individualization.