Disseminated intracranial tuberculoma mimicking neurocysticercosis

Intracranial tuberculoma and neurocysticercosis (NCC) are the most frequent granulomatous infections in the central nervous system. Here we report a 41-year-old man with disseminated intracranial tuberculoma mimicking NCC. The patient complained of relapsing vertigo and vomiting consistent with Bruns syndrome. Serum antibodies against cysticercosis were positive. Magnetic resonance imaging (MRI) of the brain showed multiple disseminated ring-enhanced lesions. An initial diagnosis of NCC was made based on clinical signs and MRI. However, during antiparasitic treatment, the patient exhibited fever, meningitis signs, and positive cerebrospinal fluid findings for tuberculosis. The diagnosis was therefore corrected as tuberculoma. After three months of antituberculous treatment, the patient recovered clinically and on MRI. Our results highlight the importance of differential diagnosis of these two diseases in the early stage.     

Intradural extramedullary tuberculoma of the thoracic spine: paradoxical response to antituberculous therapy

Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare complication of tuberculosis, which can occur as a paradoxical response to antituberculous therapy. A 46-year-old woman with tuberculosis meningitis developed an acute sensory disturbance and paraplegia eight weeks after the antituberculous treatment was started. MRI revealed a cystic lesion at the Th 2 and 3 vertebrae levels, and continuous dural thickening. Laminectomy was performed; soft granulomas were unexpectedly observed inside the dura matter. After the operation, the patient experienced progressive improvement in motor strength. IETSC should be known as rare but possible complication of tuberculous meningitis.     

The complication with tuberculosis of the central nervous system in patients with miliary tuberculosis

The complication with tuberculosis of the central nervous system (CNS) were studied in 16 patients with miliary tuberculosis who were admitted to our hospital during a period of two years from April, 1997 to March, 1999, and were examined by head MRI. Twelve cases (75%) were diagnosed as having tuberculosis of CNS. Six cases had tuberculosis of CNS which was found during the screening of miliary tuberculosis cases, and all had only cerebral tuberculoma. Meningeal irritative symptoms led to the discovery of tuberculosis of CNS in the remaining six cases, in which cerebral tuberculoma was complicated with tuberculous meningitis. Of these cases of meningitis, three cases showing disturbance of consciousness died, but no cases of death was found in cases by the screening. The length of time from the onset of symptoms to the diagnosis of tuberculosis was long in many of the cases complicated with tuberculosis of CNS compared with the cases without such a complication. In the cases of miliary tuberculosis, the rate of complication with tuberculosis of CNS is high, and the possibility of patients developing serious symptoms suddenly even when they were asymptomatic at the time of diagnosis and the paradoxical expansion that becomes intensified after initiation of treatment have been reported. Therefore, it is necessary to make a close checkup of CNS when the diagnosis of miliary tuberculosis has been made.     

Effect of nucleic acid amplification for Mycobacterium tuberculosis on clinical decision making in suspected extrapulmonary tuberculosis

BACKGROUND: Laboratory-based studies have suggested the nucleic acid amplification test (NAAT) for Mycobacterium tuberculosis may be useful in diagnosing extrapulmonary tuberculosis. We sought to determine how clinicians in one hospital used results of the NAAT in clinical decision making in cases of suspected extrapulmonary tuberculosis. METHODS: We performed a retrospective analysis of all patients who underwent the NAAT on at least one nonsputum sample, excluding cerebrospinal fluid, from 1999 to 2001 in one large urban hospital. For these patients, we reviewed the hospital course, with particular attention to date of the NAAT and its influence on days treated with antituberculous medications and days to final diagnosis. RESULTS: Thirty-five patients with suspected tuberculosis who had undergone the NAAT on extrapulmonary specimens were identified. From three patients, NAAT results were nondiagnostic because of inhibitors, and they were excluded from the analysis, leaving 32 patients. Tuberculosis was ultimately diagnosed in 14 of these 32 patients. NAAT findings were positive in specimens from 12 of 14 patients with extrapulmonary tuberculosis and in 0 of 18 cases in which tuberculosis was excluded (sensitivity, 86%; specificity, 100%; positive predictive value, 100%; negative predictive value, 90%). In only 2 of 19 patients treated with antituberculous medications was the NAAT result used to determine the onset or discontinuation of therapy. In no instance was a negative NAAT result used by clinicians as definitive evidence that a patient did not have extrapulmonary tuberculosis; in all but one case, patients were continued on antituberculous therapy until final culture results were available. CONCLUSIONS: The NAAT proved to be a sensitive and specific test for detection of M tuberculosis in extrapulmonary specimens but did not weigh heavily in clinical decision making at our hospital. Judicious use of these tests may improve the accuracy and speed of diagnosis of extrapulmonary tuberculosis, while helping to eliminate unnecessary antituberculous treatment in patients without tuberculosis.     

Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients. 1. Diagnosis and treatment of mycobacterial diseases in a community general hospital

94 patients with tuberculosis were identified in a 236-bed community general hospital without a dedicated tuberculosis ward from June 1986 to February 1998. 69 patients had bacteriological proof of tuberculosis, and the remaining 25 had clinical evidence thereof. The mean age of all patients was 63.0 years (range: 23-89 years), and the male to female ratio was 2:1. 70 of these cases were admitted. During this same period of time, the total number of inpatients admitted to the internal medicine ward reached around 11,000. Excluding 6 cases who were referred to other hospitals with a tuberculosis ward, the mean duration of hospital stay of the remaining 64 cases was 51.6 days. Among all 94 cases, 62 had pulmonary tuberculosis and the other 32 had extrapulmonary manifestations. The latter group was comprised of 11 with miliary dissemination, 8 pleuritis, 4 osteomyelitis, 2 peritonitis, 2 urinary tract disease, 1 pericarditis, 1 intestinal disease, 1 meningitis, 1 intracranial tuberculoma and 1 genital disease. 3 cases of miliary tuberculosis with dissemination died with antemortem diagnoses of fever of unknown origin, pneumonia, and lung cancer with brain metastasis. These 3 cases illustrate the importance of heightened suspicion of tuberculosis among our patient population. Referral of patients with positive sputum smears to hospitals with a tuberculosis ward has occasionally been difficult because of inaccessibility. Critical comorbid diseases such as chronic renal failure requiring hemodialysis and malignancies are additional limiting factors to transfer to such facilities. Therefore, because of the prevalence and extent of this disease, its myriad clinical presentations, challenges associated with establishing an early diagnosis, and need to prevent spread to family, other patients, and staff, dedicated beds for care of tuberculosis in general hospitals are mandatory.     

The nodular form of local hepatic tuberculosis. A review

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of tuberculoma or tuberculous liver abscess without clinical evidence of tuberculosis elsewhere. Since 1950, 21 cases of isolated tuberculoma or tuberculous abscess of the liver have been reported in the world literature. We report an additional two cases, one tuberculoma and one with multiple tuberculous abscesses. The case reports illustrate the difficulty in reaching the correct diagnosis, unsuspected in nearly all cases and most often confused with carcinoma of the liver. The correct diagnosis was made by histology, identification of acid-fast organisms by smear, and by cultures of Mycobacterium tuberculosis, but required laparotomy in 19 of the 23 cases. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the vast majority of patients respond well to antituberculous chemotherapy.     

Neuroradiologic manifestations of central nervous system tuberculosis in 122 adults

PURPOSE: Central nervous system (CNS) tuberculosis remains a public health problem, particularly in developing countries. The aim of this study is to characterize neuroradiologic findings of various intracranial lesions. METHODS: We retrospectively reviewed data of 122 patients with CNS tuberculosis, without immunosuppression. CT scan was performed in all patients, whereas 17 patients had CT scan and MRI. RESULTS: We included 74 women (61%) and 48 men (39%) with a mean age of 37 years (17 -88y). 18 patients (14,7%) had a history of tuberculosis. Tuberculous meningitis was the most frequent clinical presentation (119 cases). Mycobacterium tuberculosis was isolated in cerebrospinal fluid of 18 patients (15%). Several types of lesions were identified : hydrocephalus (35 cases), tuberculomas (29 cases), leptomeningitis (26 cases), infarction (15 cases), abcesses (2 cases). Hydrocephalus was associated to other lesions in 26 cases. Communication hydrocephalus was present in 28 cases. Multiple tuberculomas were seen in 23 cases (80%), with miliary aspects in some cases. In 3 cases, tuberculoma was present without meningitis. Patients with leptomeningitis showed thick meningeal contrast enhancement involving all basal cisterns. Infarction resulted from arterial englobement or embols, and involved the area of middle cerebral artery (12 cases). CONCLUSION: Central nervous system tuberculosis has different appearences, mostly hydrocephalus and tuberculomas. MR with contrast is necessary for diagnosis and for follow-up during treatment.     

胸膜结核瘤83例临床和病理及影像学对照研究

目的 探讨胸膜结核瘤的临床、病理和影像学特征.方法 回顾性分析上海市肺科医院2005年6月至2008年6月经病理和(或)细菌学证实的83例胸膜结核瘤患者的临床、实验室检查、病理和影像学等资料.结果 83例中男50例、女33例,年龄7～85岁,平均37.8岁.患者以咳嗽、发热和胸痛为常见症状,无症状者(25例)也不少见;部分患者有阳性体征,如叩诊浊音和呼吸音减低等.83例中合并肺结核36例,80例有明确的结核性胸膜炎病史,3例无明确病史;胸膜炎治疗不及时者45例,抗结核治疗方案不规范者42例,未应用糖皮质激素者48例;59例行CT引导下经皮穿刺活检,24例行胸腔镜手术治疗,其中经病理证实为结核性病变者62例.病理所见:肉芽肿性炎症、凝固性坏死或干酪样坏死、淋巴细胞、类上皮细胞、朗汉斯巨细胞、炎症细胞、脓细胞、组织细胞和瘢痕组织等;15例穿刺物抗酸杆菌染色阳性,21例穿刺物MTB培养阳性.X线胸片示:病变呈单发者68例,多发者15例,以右下肺居多(46例),类圆形影最常见(63例).胸部CT示:病灶密度均匀20例,不均匀40例,伴钙化9例,病灶中心密度较低6例.胸部CT强化扫描示:病灶密度均匀18例,不均匀65例,伴钙化9例,病灶中心密度较低34例,边缘强化者28例.结论 胸膜结核瘤是结核性胸膜炎发生、发展与转归的一个重要过程,掌握其临床、病理和影像学特征,对诊断和鉴别诊断具有重要的价值.     

成人血行播散性肺结核202例临床及影像分析

目的通过对血行播散性肺结核临床资料的分析,提高对该病的认识。方法回顾性分析1998—2008年收治的成人血行播散性肺结核202例的临床资料、影像学特点、误诊情况及治疗反应。结果（1）中青年患者占80.2%, 老年患者占19.8%。（2）痰涂片查抗酸杆菌（AFB)阳性率为20.7%;31例AFB阴性患者中35.5%纤维支气管镜检抗酸杆菌阳性。（3）12.9%X线胸片早期表现为肺间质磨玻璃样改变,51.5%表现为大小、密度、分布均匀的粟粒结节。（4）胸部高分辨CT显示55.0%急性血行播散型表现双肺弥漫分布的大小、密度均匀的粟粒结节;另48例亚急性和慢性血行播散性肺结核表现以上中肺野为主的3～7mm大小、密度及分布不均匀的结节。46.8%的肺野内可见斑片、结节、纤维条索状影;43.1%伴纵隔和/或肺门淋巴结肿大。（5）20例活组织检查60%病理阳性。 （6）44.6%合并肺外结核,常见于脑膜、浆膜腔、淋巴结、脑、肝、脾、骨等。（7）42.1%入院前被误诊为其他疾病。（8）除8例外其余患者抗结核治疗后体温在3d到12周内降至正常。（9）79.7%在抗结核治疗2个月后胸片显示病灶不同程度吸收。结论痰涂片、HRCT、纤维支气管镜及器官组织活检是早期诊断的关键。     

Delayed diagnosis of tuberculosis in patients with human immunodeficiency virus infection

PURPOSE: To determine the frequency with which the diagnosis of tuberculosis is delayed in patients with concomitant human immunodeficiency virus (HIV) infection, and to identify reasons for such delays. PATIENTS AND METHODS: We reviewed medical records of 52 consecutive HIV-infected patients with culture-proven tuberculosis seen at a 1,900-bed general hospital serving a predominantly indigent population in Los Angeles, where the prevalences of HIV infection and tuberculosis are high. The late-treatment (LT) group consisted of 25 patients in whom tuberculosis was untreated prior to death (n = 6) or treated more than 22 days after presentation (n = 19). The early-treatment (ET) group comprised 27 patients in whom antituberculous therapy was begun less than 16 days after presentation. RESULTS: Symptoms, physical and laboratory findings, chest roentgenographic abnormalities suggestive of tuberculosis (hilar adenopathy, pleural effusion, miliary pattern, cavitation, predominant upper lobe infiltrate), and frequencies of concomitant nontuberculous disease were similar in LT and ET groups. Delayed diagnosis of tuberculosis was attributable to errors in management in 21 (84%) of 25 LT group patients. The most common error was failure to obtain at least three sputum samples for acid-fast smear and mycobacterial culture in patients with clinical and chest roentgenographic findings compatible with tuberculosis (15 cases). Acid-fast sputum smears were positive in 25 (61%) of 41 cases of pulmonary tuberculosis. Acid-fast smears of stool were positive in eight (42%) of 19 cases. Blood cultures yielded Mycobacterium tuberculosis in 18 (38%) of 48 cases. CONCLUSIONS: Delayed therapy of tuberculosis in HIV-infected patients at our medical center was common and was not due to atypical manifestations of tuberculosis. In most cases, delays could have been avoided if adequate numbers of sputum samples for acid-fast smear and mycobacterial culture had been obtained, and if empiric antituberculous therapy had been given to symptomatic patients in whom chest roentgenographic findings were suggestive of mycobacterial disease.     

A study of case findings in pulmonary tuberculosis patients

The incidence of tuberculosis patients increased again recently and many outbreaks of pulmonary tuberculosis (PTB) patients were reported. The purpose of this study is to investigate the present situation of the delay in case finding of PTB patients. 1) Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients, who were detected by their symptomatic visits, were enrolled in to this study. 50 percentile patient's delay was 21.0 days, and 50 percentile doctor's delay was 7.2 days. 50 percentile total delay was 42.0 days, which was longer than about 28 days obtained by summing up the 50 percentile patient's delay and doctor's delay. The number of cases detected within 28 days was only 39 cases (33.1%). Doctor's delay was mainly attributable to the performing the examination. Regarding the relationship between the period of total delay and sputum smear positive rate, the positive rate was less than 50% when total delay was less than 4 weeks, and came to more than 60% when the delay exceeded 4 weeks. 2) Of 236 PTB patients admitted to our hospital for treatment in 1997, 49 patients had been treated at medical institutions for other diseases. The majority of the cases were diagnosed as PTB in the routine examination, but early case findings was not made, with 9.5 weeks on an average and 50 percentile total delay was 5.5 weeks. The duration of doctor's delay in undergoing examination directly related to PTB diagnosis was accountable for doctor's delay. 3) The case finding of far-advanced cavitary PTB (bI3) patients was studied. Eighty-four patients were detected by symptomatic visits, 10 patients were detected during medical treatments of other disease, and 1 patients was detected by accident. The duration of patient's delay was 5.5 months on an average, while doctor's delay was 0.3 month on an average. The bI3 patients included many social and economical weak people. The body status on admission of bI3 patients were very severe. Twenty percentile of bI3 patients died of PTB, and 14 cases of 19 dead cases died within 1 month from admission. 4) The duration of case finding of tracheobronchial tuberculosis patients was studied. 50 percentile patient's delay was 14 days, while 50 percentile doctor's delay was 145 days. The delay in examination was considered accountable for doctor's delay, with 12 cases (57%) which were treated as bronchial asthma and 6 cases (29%) in which the sputum examination for tuberculosis bacilli was not performed after the detection of chest abnormal shadows on chest X-rays. 5) The present situation of case findings in Japan was studied. Patient's delay did not improve in recent years, while doctor's delay was improve in 2000, after Declaration of State of Emergency concerning tuberculosis. 6) As the countermeasures against patient's delay, it appears necessary to continue enlightenment on PTB, and selective detection by health examination for high risk groups is necessary. As the countermeasures against doctor's delay, it appears important to recommend to all doctors to pay attention to the patients with cough and sputum and undergo sputum examination.     

Gastrointestinal tuberculosis: 17 cases collected in 4 hospitals in the northeastern suburb of Paris

Gastrointestinal tuberculosis is a rare form of extrapulmonary tuberculosis and its diagnosis can be difficult. AIMS: To analyze the diagnostic and therapeutic characteristics of gastrointestinal tuberculosis. METHODS: Retrospective study from 17 cases collected in 4 hospitals in Seine Saint-Denis between 1987 and 2002. RESULTS: Seventeen cases and 19 localizations were collected: small intestine (N = 7), ileocecum (N = 6), colon (N = 4) and gastroduodenum (N = 2). Two patients had two localizations. Mean age was 43.9 years. Subjects from immigrant populations (76.5%) were preferentially affected. Twenty-three percent of patients (13 tested) were infected by human immunodeficiency virus. Weight-loss and general weakness (88%), abdominal pain (88%), fever (59%), nausea/vomiting (53%) were the predominant symptoms. The delay in diagnosis was 82 days (range: 7-180) and time before specific treatment 31.6 days (range: 7-90). Histological evidence of caseating granuloma was found in six patients. Mycobacterium tuberculosis was detected in six. Digestive imaging was abnormal in 15 patients. Mesenteric lymph nodes were the most common associated site of tuberculosis (N = 8, 47%). Mean duration of treatment was 8.2 months (range: 6-12). Thirteen patients were cured, three died and one was lost to follow up. CONCLUSION: Gastrointestinal tuberculosis is not an uncommon diagnosis in the north-eastern Parisian area, especially among immigrant populations and immunodeficient patients. The most frequent localizations are the small intestine and ileocecum. Diagnosis can be made by pathology and/or bacteriology on endoscopic and/or surgical biopsy samples.     

结核性脑膜炎53例临床分析

目的探讨影响结核性脑膜炎患者预后的相关因素。方法对2002-2004年收治的53例结核性脑膜炎病人的临床资料进行回顾性分析。结果痊愈29例,后遗症19例,死亡5例;高龄,抗结核开始晚,及并发脑神经损害和/或颅内结核瘤者,预后差。结论结核性脑膜炎的预后与早期诊断,合理治疗,年龄及有无并发症等诸多因素相关。     

结核性脑膜炎100例临床分析

目的探讨成人结核性脑膜炎的临床特点、脑脊液改变、影像学特点、诊治方法及其转归。方法回顾性分析1982年1月至2003年12月间在北京协和医院确诊或临床诊断为结核性脑膜炎的100例住院患者的临床资料。结果100例结核性脑膜炎患者中,男性49例,女性51例;年龄（31±11）岁。70％为慢性病程（11．1±9．2）周。13例确诊病例,脑脊液结核杆菌培养阳性,或开颅脑活检病理证实为结核性肉芽肿或粟粒样结核;87例为临床诊断病例。临床表现以发热（97％）,头痛（92％）、意识障碍（71％）和脑膜刺激征多见（77％）,44例伴颅神经损害,以动眼神经和外展神经受损为主。35例X线胸片有活动性肺结核表现,肺外活动性结核12例,陈旧性肺结核18例。腰穿示颅内压增高者占86％,脑脊液呈非化脓性改变,白细胞增高以淋巴细胞为主,蛋白质明显增高,葡萄糖显著下降。52例患者头颅影像学有异常发现,脑室扩张、交通性脑积水和脑梗死最常见。全部病例均接受抗结核治疗,9例行侧脑室外引流术。81例患者病情好转,4例因合并开放性肺结核转结核病院治疗,8例自动出院,死亡7例。结论慢性脑膜炎若伴发肺结核或肺外结核者应高度疑诊结核性,鉴别诊断和诊断性抗结核治疗有效有助诊断。脑脊液涂片和（或）培养抗酸杆菌／结核分枝杆菌阳性,以及脑活检为诊断的金标准。早期诊断、早期治疗是改善本病预后的关键。     

Imaging features of intrasellar tuberculoma: two cases

Hypophyseal tuberculoma is extremely rare. It may be confused with other more common sellar tumors such as adenomas. Characteristic, but not specific, radiological features are in the majority of cases: intense enhancement on contrast CT and thickening of the pituitary stalk better visible on MRI. We describe imaging findings in two patients with pituitary tuberculosis. In these cases an accurate non-invasive diagnosis was found to be important as antituberculous chemotherapy is curative.     

Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy: Literature review and a case report

Summary Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases an associated tuberculous meningitis was reported. The majority of these patients were children or young adults, who had inoperable intracranial tuberculomas located in high risk regions that developed a few weeks or months after the start of an appropriate chemotherapy. Fifty-three percent of the patients recovered completely, 37% improved with mild neurological defects and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. A recent experience with these potentially curable tumors of the central nervous system is reported. The literature is reviewed, and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analyzed. In conclusion, patients who are suspected to have a CNS-tuberculosis should receive a prolonged (12–30 months) course of effective antituberculous therapy. The evidence of new intracranial tuberculomas or the expansion of older existing lesions does not indicate the need to change the antituberculous drug program. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis, such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not ensured and there is no response to therapy within 8 weeks, a stereotactic biopsy on a suspected tuberculoma could be performed. If the largest lesion is not located in high risk deep regions of the brain, it could be totally removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.     

Intestinal tuberculosis: Experience at a canadian teaching institution

Thirteen cases of inflammatory bowel disease suspected to be intestinal tuberculosis are analyzed. In nine, the diagnosis was established from such criteria as caseation necrosis, positive acid-fast stains or cultures of the diseased tissue. In four others, enteric tuberculosis remained a diagnostic possibility as judged by the following criteria: coexistence of the bowel lesion with established tuberculosis elsewhere, a clear response to antituberculous chemotherapy, or typical features on roentgenographic, surgical or histologie examination.     

Acute toxic encephalopathy in patients with tuberculosis

A hundred and thirty five patients admitted to Moscow Tuberculosis Hospital No. 7 for disseminated and progressive forms of tuberculosis were examined. Among neurological disorders in tuberculosis, acute toxic encephalopathy (ATE) should be placed in the first place in terms of their severity, problems of diagnosis and treatment. In patients with acutely progressive forms of tuberculosis, the development of ATE is brought about by two factors: 1) significant tuberculous toxemia concurrent, in 37% of cases, with severe alcoholic intoxication that leads to generalized toxic and allergic vasculitis and as a result DIC syndrome; 2) cerebral hypoxia with dyscirculatory disorders due to progressive cardiopulmonary failure. The status of patients with tuberculosis and ATE is generally critical or extremely critical. These are actually resuscitative patients. Most patients have disseminated bilateral lung lesions with multiple decay cavities, with massive bacterial isolation found at sputum bacterioscopy. With this, mycobacterial resistance to at least one antituberculous drug was found in 83% of cases. Primary multidrug resistance was detected in 29.6% of patients. The diagnosis of ATE in patients with tuberculosis is difficult and requires that tuberculous meningitis shall be excluded. Acute progression, no spinal fluid changes, significant signs of cooagulopathy and thrombcytopathy with multiorgan failure and progressive DIC syndrome may diagnose ATE in patients with acutely progressive tuberculosis. The specific features of treatment in patients with tuberculosis and ATE are intensive antituberculous therapy with predominantly parenteral administration of drugs and intensive therapy for the DIC syndrome. Despite the treatment, 48 (35.6%) patients died from progressive tuberculosis and ATE, in 40 (29.6%), therapeutic efficiency was low due to multidrug myobacterial resistance.     

Acute respiratory failure caused by tuberculosis requiring mechanical ventilation

The patients with active tuberculosis in whom respiratory failure requiring mechanical ventilation developed were studied retrospectively. Nine patients (M 8, F 1) were identified at the National Tokyo Hospital during 5 years from January, 1993 to December, 1997. Seven of 9 patients were single men, and the duration of symptoms before admission was over 1 month in all patients, while the time from first visit to diagnosis was less than 7 days. All patients were identified as malnourished, and 7 patients suffered from another underlying diseases. The patients were classified into two groups. Six of 9 patients had pulmonary tuberculosis and the other three had miliary disease. The proportion of cases requiring mechanical ventilation was 0.3% and 8.6%, respectively, in pulmonary tuberculosis and miliary tuberculosis. At the start of mechanical ventilation, PaO2/FIO2 was lower than 200 in all 9 patients, and 6 patients were probably ARDS. Steroids (methylprednisolone 250-1000 mg/day) were used in all 9 patients. Despite the use of mechanical ventilation and antituberculous therapy, 8 out of 9 patients died. Only one patient with miliary tuberculosis survived. The establishment of the therapy for acute respiratory failure is needed so as to improve prognosis of such cases. At the same time, the delay in consulting a doctor led to acute respiratory failure in most cases, so it is also important to encourage tuberculosis patients to visit a doctor as soon as possible, after the appearance of symptoms.     

不典型表现的结核性脑膜炎62例临床分析

目的　总结不典表现的结核性脑膜炎 (结脑)的诊断与治疗。方法 回顾性分析 62例不典型结脑患者的临床资料。结果 本组病例在临床上没有典型的结脑症状，表现意识障碍 17例(27.4%)、头晕、低热 47例 (75.8%)、乏力、精神萎靡 13例 (21.0%)；肢体麻木 21例 (33.9%)、瘫痪5例 (8.1%)、颅神经损害 18例 (29.0%)和尿潴留 10例；(16.1%)、癫痫样发作 4例 (6.5%)。胸部影像学检查阳性 37例 (59.7%)、头颅CT阳性 13例 (21%)。脑脊液检查 :糖降低 30例 (48.4%)、氯化物降低 32例 (51.6%)、蛋白升高 36例 (58.1%)、腺苷酸脱氨酶 (ADA)阳性 58例 (93.5%)、结核抗体 (PPD IgG)阳性 48例 (77.4%)、涂片抗酸杆菌阳性 2例 (3.2%)。 61例经抗结核治疗痊愈，1例死亡。结论 不典型结脑临床表现缺乏特异性，脑脊液改变不典型，但脑脊液中结核抗体阳性对于诊断中枢神经系统结核病有参考意义，且腺苷酸脱氨酶是一个敏感及特异性强的指标，实验实及影像学检查对确诊该病有重要意义。规范抗结核治疗配合鞘内注射效果佳。