肝性脊髓病3例

<正>例1:男,62岁,因间歇性腹胀伴进行性双下肢无力7年入院,既往先后4次在我院就诊,2009年在肝胆外科行"脾脏部分栓塞术"。本次入院查体:神志清楚,肝病面容,可见肝掌、蜘蛛痣,肌力II级,呈痉挛性步态,巴宾斯基征阳性,扑翼样震颤阳性,腹平软,移动性浊音阴性,脾肋下未触及。胸腰段MRI提示L2平面下缘可疑脊髓等T1长T2信号,腹部B超检查提示肝硬化,脾大。双下肢超声检查提示双下肢动脉未见狭窄及     

219例妊娠梅毒患者与配偶的梅毒血清学临床研究

目的了解妊娠梅毒患者与配偶的感染状况,为制定降低梅毒发病率相关政策提供依据。方法对219例妊娠梅毒患者的配偶进行甲苯胺红不加热血清试验(TRUST)、梅毒螺旋体明胶颗粒凝集试验(TPPA)检测,结果均阴性者,3个月后复查TRUST和TPPA。对妊娠梅毒患者与配偶的检测结果进行统计分析。结果 219例妊娠梅毒患者,TRUST滴度范围为1∶1~1∶256,TRUST滴度≥1∶16者45例,TRUST滴度1∶16者174例。1例合并HIV(+)。3例为二期梅毒,其中2例夫妻同患二期梅毒,另1例配偶TRUST滴度为1∶16,无临床症状。53例配偶TRUST和TPPA均阳性。配偶TRUST滴度≥1∶16者18例,TRUST滴度1∶16者42例。7例配偶TRUST阴性,TPPA阳性,其中1例6周后复查TRUST转为阳性。妊娠梅毒患者TRUST滴度1∶16组的174名配偶,24.1%(42/174)为梅毒感染者;妊娠梅毒患者TRUST≥1∶16组的45名配偶,40.0%(18/45)为梅毒感染者,两组梅毒感染率差异有统计学意义(χ2=4.522,P0.05)。结论此次调查对象大多数为潜伏梅毒,开展妊娠梅毒的普查,对妊娠梅毒的配偶进行追踪检测,是降低梅毒发病率的有效方法。TPPA比TRUST更适合梅毒高危人群的筛查试验;TRUST滴度≥1∶16的妊娠梅毒的配偶,梅毒感染率高于滴度1∶16的妊娠梅毒配偶。     

HIV阴性的妊娠梅毒规范驱梅治疗后TRUST血清学转归及影响因素

目的对进行规范治疗的妊娠梅毒患者进行梅毒血清学随访,探讨妊娠梅毒TRUST血清学转归的影响因素。方法通过对妊娠女性进行梅毒筛查,发现妊娠梅毒并进行分期,记录妊娠梅毒患者病史,规范治疗。治疗结束后对其进行至少2年的TRUST血清学随访,记录治疗结束后半年、1年和2年时TRUST状况和滴度。结果配偶TRUST阳性妊娠梅毒患者的TRUST远期(2年)阴转率高于配偶TRUST阴性患者,差异有统计学意义(P<0.01);晚期潜伏梅毒的TRUST转阴率明显低于早期梅毒,差异有统计学意义(P<0.01);不良妊娠史、发现及治疗的时间和妊娠梅毒患者的血清学转阴间可能没有关系(P>0.05);TRUST滴度≤1∶8患者转阴率明显低于滴度>1∶8患者,差异有统计学意义(P<0.01)。结论经规范的驱梅治疗后,TRUST滴度高、配偶梅毒血清学阳性、早期梅毒的妊娠梅毒患者血清TRUST相对容易转阴。     

妊娠梅毒规范驱梅治疗后血清TRUST转归的研究

目的探讨妊娠梅毒患者进行规范治疗后对妊娠梅毒血清TRUST转归的影响。方法通过对妊娠女性进行梅毒筛查,发现妊娠梅毒并进行分期,记录其病史,规范治疗。治疗结束后对其进行至少2年的TRUST血清学随访,分析治疗结束后6个月、1年和2年时TRUST状况和滴度。结果配偶TRUST阳性妊娠梅毒患者的TRUST远期（2年）阴转率明显高于配偶TRUST阴性患者（P〈0．01）;而TRUST血清学滴度大于1：8的妊娠梅毒患者相对更容易出现血清学阴转（P〈0．01）。结论经规范的驱梅治疗后,TRUST滴度高、配偶梅毒血清学阳性、早期梅毒的妊娠梅毒患者血清TRUST转阴率较高。     

ELISA和TRUST检测梅毒螺旋体方法比较分析

目的 比较ELISA(酶联免疫吸附试验)、TRUST(甲苯胺红不加热血清试验)法诊断梅毒螺旋体感染的方法学差异.方法 用目前国内最常用的诊断梅毒螺旋体感染的TRUST试剂及ELISA试剂检测722例标本,同时与TPPA(梅毒螺旋体明胶凝集试验)的检测结果进行比较,从而得到各试验的假阴性率和假阳性率.结果 对722份样本的检测中,ELISA和TPPA的阳性符合率为98.26％,假阴性率和假阳性率分别为0.46％和1.91％,2种方法差异无统计学意义(P ＞0.05); TRUST和TPPA的阳性符合率为84.39％,假阴性率和假阳性率分别为21.08％和5.10％;ELISA和TURST检出率差异有统计学意义(P＜0.01).结论 ELISA测定梅毒螺旋体的方法在日常大量标本检验时优于TRUST.     

171例梅毒血清学检测阳性及追踪结果分析

目的:研究不同检测方法对梅毒血清学检测的影响,找出最好的筛查方法,减少因输血引起的梅毒传染,协助梅毒诊断。方法:171例分为3组,TP-ELISA及TRUST试验均为阳性的为第1组,仅TP-ELISA阳性的为第2组;仅TRUST阳性的为第3组。对第2、3组3个月后再进行TP-ELISA及TRUST复查,观察有无梅毒血清学变化。结果:171例其中TP-ELISA首次确认阳性163例,TRUST首次确认阳性167例,两者同时阳性159例,TP-ELISA阴性,而TRUST阳性的8例(4.6%);TRUST阴性,而TP-ELISA阳性4例(2.3%);血清学检测有显著性差异(χ2=46 134.421 1,χ23.84,P0.05);8例TRUST阳性者3个月后有2例TP-ELISA阳性,血清学检查差异有统计学意义(χ2=5.25,χ23.84,P0.05)。结论:部分学者认为的TP-ELISA检测优于RPR、TRUST实验不科学,梅毒检测的最佳方案应为一次TP-ELISA和一次梅毒非特异性抗体检测。     

TPPA和TRUST两种检查方法在梅毒血清学检查中的应用

目的探讨分别采用明胶颗粒凝集试验(TPPA)和甲苯胺红不加热血清试验(TRUST)两种检查方法在梅毒血清学检查中的应用。方法选择我院2005年1月—2009年12月26例梅毒血清标本作为研究对象,根据梅毒的诊断标准[2]:其中Ⅰ期梅毒10例,Ⅱ期梅毒9例,Ⅲ期梅毒4例,潜伏梅毒3例;另选10例经临床确定为类风湿性关节炎、乙型肝炎、SLE、肺结核的作为对照组;以及10例健康体检者作为研究对象。46例标本采用明胶颗粒凝集试验(TPPA)和甲苯胺红不加热血清试验(TRUST)两种检查方法同时进行检测,操作严格按照各厂家要求进行。观察比较两种检查方法的检测阳性率及敏感性和特异性。结果 TRUST法对梅毒的检测阳性率为80.77%(21/26),TPPA法对梅毒的检测阳性率为96.15%(25/26),TPPA检测法对梅毒检测的阳性率明显高于TRUST检测法(P0.05)。TPPA检测梅毒的敏感性和特异性明显高于TRUST检查法(P0.05)。且检测Ⅲ期梅毒及潜伏梅毒的阳性率分别均高TRUST检测的阳性率,两组比较差异具有显著性。结论 TPPA的敏感性和特异性优于TRUST检测法是临床常用的梅毒确诊试验,但其不适合大量标本的筛查,更适合用于TRUST测定阳性后的确诊试验,建议临床检验医师应予以注意。     

1152例梅毒孕妇及所产新生儿的梅毒血清学试验结果分析

目的探讨梅毒孕妇及所产新生儿的梅毒血清学试验在先天梅毒早期诊断的价值。方法收集2013—2017年海南省预防与控制梅毒母婴传播项目中的1 152例梅毒孕妇及其所产的1 152例新生儿标本,进行梅毒甲苯胺红不加热血清试验(TRUST)和梅毒螺旋体明胶凝聚试验(TPPA)及梅毒螺旋体免疫球蛋白M(IgM)抗体试验(TP-IgM)检测。结果 1 152例孕妇中TRUST和TPPA的阳性率分别为78.82%(908例)和100.00%;1 152例新生儿中TRUST和TPPA的阳性率分别为47.14%(543例)和97.14%(1 119例);新生儿确诊先天梅毒37例(3.21%),TP-IgM阳性有34例,新生儿TRUST滴度大于或等于母亲TRUST滴度的4倍有10例(7例TP-IgM阳性,3例TP-IgM阴性)。结论 TP-IgM检测为先天梅毒诊断的必要的梅毒血清学检查,再联合TRUST和TPPA检测可提高诊断先天梅毒的准确率,新生儿梅毒TRUST滴度≥1∶64,可作为先天梅毒诊断的重要依据。     

CLIA法联合TPPA法在临床梅毒血清学筛查中的应用评价

目的探讨化学发光免疫分析(CLIA)法联合梅毒螺旋体明胶颗粒凝集试验(TPPA),在临床梅毒血清学筛查中的应用价值。方法用CLIA进行特异性梅毒螺旋体抗体初筛试验,阳性标本再经TPPA和梅毒甲苯胺红不加热血清试验(TRUST)复检。CLIA与TPPA结果不一致者用蛋白印迹法(WB)验证。结果 599例CLIA初筛阳性标本用TPPA法复检阳性568例、阴性31例;TRUST法复检阳性189例、阴性410例。31例TPPA阴性标本经WB试验验证结果为18例阴性、13例阳性。结论 CLIA法联合TPPA法初筛梅毒作为梅毒筛查的流程是可行的,值得推广。     

应用TP-IgM-WB法诊断早期先天梅毒

目的研究新生儿中胎传梅毒感染的血清梅毒螺旋体蛋白印迹试验(TP-IgM-WB)水平,探讨其临床意义.方法对58例梅毒孕妇所产60例(2例双胞胎)新生儿血清,应用梅毒螺旋体蛋白印迹试验(TP-IgM-WB)检测,并与TRUST、明胶颗粒凝集试验(TPPA)方法平行测定.结果60例新生儿TP-IgM-WB法检出阳性27例,占45%(27/60),TRUST和TTPA阳性各59例.结论确诊27例新生儿为早期先天梅毒婴儿,为临床提供了明确的诊治依据,对防治梅毒有重要意义.     

神经梅毒的临床特征及诊治分析

目的探讨神经梅毒的临床、神经影像学和实验室检查特征及其治疗和预后,以提高对该病的诊治水平。方法对本院收治的符合神经梅毒诊断标准的18例神经梅毒患者的临床资料、实验室检查、MRI结果及诊治过程进行回顾性分析。结果临床以间质型梅毒,尤其以脑膜血管梅毒常见,临床表现缺乏特异性;血清梅毒螺旋体凝集试验特异性较高,而脑脊液的阳性率低于血清;头部MRI以梅毒树胶肿表现典型;治疗上除梅毒树胶肿需手术切除外,余类型首选青霉素治疗,有效率93％（14115例）。结论神经梅毒的临床表现及神经影像学无特异性,易误诊,血清或（和）脑脊液梅毒抗体阳性即可确诊,青霉素仍为有效的首选治疗药物。     

Clinical characteristics,diagnosis, and predictors of neurosyphilis patients with human immunodeficiency virus co-infection: A retrospective study at infectious diseases hospitals in two cities of China

This study aimed to compare between the clinical and laboratory characteristics of neurosyphilis and those of syphilis in human immunodeficiency virus (HIV) positive and explore the risk factors associated with the occurrence of neurosyphilis in the HIV infected.In-patients diagnosed with HIV and syphilis co-infection who underwent a lumbar puncture and completed cerebrospinal fluid (CSF) examination were divided into neurosyphilis group and syphilis group. The demographic characteristics, symptoms and signs, and laboratory tests of the 2 groups were comparatively analyzed. Logistic regression analysis was used to explore the risk factors associated with the occurrence of neurosyphilis.Among 81 patients, 33 patients were assigned to the neurosyphilis group, and 48 to the syphilis group. There were no significant differences in the age, gender, marital status, acquired immunodeficiency syndrome course, opportunistic infections, serum HIV viral load, and history of syphilis treatment. The difference in HIV transmission route between the 2 groups was statistically significant (P = .010), and the patients from the neurosyphilis group were mainly infected via heterosexual contact. The proportion of serum toludine red unheated serum test (TRUST) titer ≥1:16 in the neurosyphilis group were 78.8%, which was significantly higher compared to the syphilis group (48.9%). The level of CSF white blood cell count, CSF protein, and CSF HIV viral load in the neurosyphilis group were significantly higher than those of the syphilis group. The proportion of patients with neurological symptoms and signs in the neurosyphilis group was significantly higher compared to the syphilis group (P < .001). Multivariate logistic regression analysis showed that heterosexual contact transmission route, not received antiretroviral therapy, lower CD4 cell count and higher serum TRUST titer, untreated with syphilis, and neurological symptoms and signs were risk factors associated with the occurrence of neurosyphilis.The serum TRUST titer, CSF white blood cell count, CSF protein level, CSF HIV viral load, and the percentage of neurological symptoms and signs in the neurosyphilis group were higher. Heterosexual transmission route, not received antiretroviral therapy, and untreated with syphilis prompted the possibility of neurosyphilis occurrence.     

梅毒血清学试验阳性患者1O例临床分析

目的探讨合并神经系统病变梅毒患者的临床表现、诊断和治疗方法。方法分析10例梅毒血清学试验阳性的梅毒患者的临床特点、血清学及脑脊液检查、影像学表现、诊断、分型及治疗结果等。结果10例患者中据脑脊液结果确诊神经梅毒8例、疑诊1例、非神经梅毒1例。8例神经梅毒确诊病例中脊髓痨型3例、梅毒性脑膜炎2例、麻痹性痴呆1例,树胶肿性神经梅毒1例,脑血管梅毒1例。头颅及脊髓MRI检查异常无明显特异性。青霉素治疗10例,有效9例,失访1例。治疗后脑脊液蛋白、白细胞、压力、脑脊液非螺旋体抗原滴度有不同程度下降。10例患者均未发生赫氏反应。结论神经梅毒临床表现多样,脑脊液检查是诊断的关键。     

Serum TRSUT Titer ≥1:16 Is a Predictor for Neurosyphilis Among HIV-Infected Patients With Concurrent Syphilis and No Neurological Symptoms

Investigating the predictors for lumbar puncture to diagnose the asymptomatic neurosyphilis among HIV and syphilis co-infected patients in Shanghai, China.Respectively, screening the medical records from August 1, 2009 to June 30, 2015. Those HIV-infected patients with concurrent syphilis who had received lumbar puncture were selected and their clinical and demographic data were recorded. Participants comprised symptomatic and asymptomatic patients. The latter ones could be further divided into 3 groups: late syphilis, early syphilis with anti-syphilis treatment failure, and early syphilis with serum toludine red unheated serum test (TRUST) ≥1:32. Both syphilis stage and anti-syphilis treatment effect were defined by common criteria, and syphilis of unknown duration was considered as late syphilis. Asymptomatic neurosyphilis was defined as neurosyphilis without neurological symptoms such as headache, cognitive dysfunction, motor deficits, auditory or ophthalmic abnormalities, and stroke. Neurosyphilis was defined as reactive cerebrospinal fluid (CSF) TRUST and/or CSF white blood cell >20 cells/μL without other reasons. Mann–Whitney test and Fisher''s exact test were used for analyzing the difference between neurosyphilis and non-neurosyphilis group. Logistic regression test was performed to analyze the risk factors for neurosyphilis.In total, 170 participants were collected, and the rate of neurosyphilis was 32.35%. Among all the 105 participants without neurological symptoms, 80 patients were with late syphilis and 25 were with early syphilis. Among the early syphilis patients, 23 had a TRUST ≥1:32 and the other 2 experienced an anti-syphilis treatment failure. The differences of clinical and demographic variables between neurosyphilis and non-neurosyphilis group were not statistically significant except the serum TRUST titer (P < 0.01). From HIV/syphilis co-infected patients with or without neurological symptom, those who had neurological symptoms, CD4 <350 per μL and serological TRUST titer ≥1:16 were 4.9-fold (95% confidence interval [CI]: 2.37–10.31), 4.3-fold (95% CI: 1.17–15.78), and 4.1-fold (95% CI: 1.58–10.76), respectively, more likely to be diagnosed with neurosyphilis. Asymptomatic patients whose serum TRUST titer ≥1:16 were 8.48-fold (95% CI: 1.08–66.63) more likely to have asymptomatic neurosyphilis.Among asymptomatic HIV-infected patients with late syphilis or early syphilis experienced an anti-syphilis treatment failure, those who have a serum TRUST titer ≥1:16 are suggested to perform lumbar puncture in order to avoid delayed diagnosis and the occurrence of severe sequelae of syphilis.     

Syphilitic posterior uveitis: correlative findings and significance.

Twenty-one patients with syphilitic posterior uveitis were investigated retrospectively to study the disease spectrum, associations with neurosyphilis, and therapeutic implications. Ophthalmologic manifestations of syphilitic posterior uveitis are differentiated into acute and chronic uveitides. The several distinct acute uveitic syndromes are usually florid and are associated with early syphilis, with VDRL-positive syphilitic meningitis, and frequently with human immunodeficiency virus coinfection. The chronic posterior uveitides are often insidious, a manifestation of late syphilis, and associated commonly with subclinical neurosyphilis. All patients with acute cases and 54% of patients with chronic cases in our study received penicillin therapy appropriate for neurosyphilis. The frequent association of syphilitic posterior uveitis with neurosyphilis and the analogous spirochetal sequestration beyond the blood-brain and the blood-ocular barriers suggest that all patients with syphilitic posterior uveitis, irrespective of ocular disease intensity, should undergo evaluation of cerebrospinal fluid and be treated with penicillin regimens appropriate for neurosyphilis.     

未经治疗梅毒患者脑脊液检测的意义

目的　观察艾滋病病毒 (HIV)阴性、未经治疗、且无神经损害临床表现的梅毒患者的脑脊液常规及梅毒抗体的检测情况 ,并探讨这些指标的诊断意义。方法　对 36例未经治疗且无神经系统临床表现的梅毒 (其中二期16例 ,隐性 2 0例 )患者脑脊液进行脑脊液常规、梅毒暗视野检查、聚合酶链反应 (PCR)及脑脊液梅毒抗体试验、梅毒血清快速反应素试验 [(RPR)、IgM、梅毒参比试验 (VDRL)、荧光密螺旋体抗体 (TPPA)、梅毒螺旋体明胶颗粒凝集试验 (FTA Abs) ]检测。结果　在所检测的 36例梅毒患者脑脊液中 ,常规检测发现 2 4例 (6 6 6 7% )蛋白升高 ,11例 (30 6 % )葡萄糖升高 ,未发现红细胞和白细胞 ;有 19例 (5 2 78% )梅毒患者脑脊液存在≥ 1种梅毒抗体。其中 6例 (16 7% )VDRL阳性 ,13例 (36 39% )FTA Abs阳性 ,14例 (38 33% )TPHA阳性 ,RPR、IgM、TP PCR及梅毒暗视野检查均阴性 ;二期和隐性梅毒各项指标检测结果之间差异无显著的统计学意义 (P >0 0 5 ) ;而脑脊液VDRL、FTA Abs、TPPA三种检测结果之间差异有显著的统计学意义 (P <0 0 5 )。结论　未经治疗的梅毒患者其脑脊液存在异常 ,这些异常的结果表明部分未经治疗的梅毒患者存在无症状神经梅毒。     

梅毒血清复发患者脑脊液IFN-γ等指标检测结果分析

目的探讨梅毒血清复发与神经梅毒之间的关系,同时从细胞免疫学角度对梅毒血清复发的发生机制进行研究。方法对20例符合梅毒血清复发诊断的患者行腰穿抽取脑脊液,进行常规、生化、血浆快速反应素试验（RPR）及梅毒螺旋体明胶凝集试验（TPPA）检测;采用双抗体夹心酶联免疫吸附试验（ABC-ELISA）分别检测血清复发组、RPR阴转组（20例）和正常人群组（20例）血清中γ-干扰素（IFN-γ）的含量,以及血清复发组脑脊液中IFN-γ的含量。结果在20例血清复发患者中,有5例神经梅毒（25.0%）。血清复发组患者血清IFN-γ水平明显低于正常对照组、RPR阴转组,差异均有统计学意义（P〈0.01,P〈0.01）。结论神经系统受累可能是梅毒血清复发的原因之一;梅毒血清复发患者的细胞免疫功能受到抑制。     

Une thrombose veineuse cérébrale révélant une neurosyphilis

IntroductionSyphilis is a bacterial infection which is increasing in France. Neurosyphilis is a rare manifestation of syphilis, mainly involving the meninges and the blood vessels. It is a rare cause of cerebral vascular stroke. Venous thrombosis of syphilitic origin is rarely described.ObservationWe reported a case of a fifty-year-old patient hospitalized for bilateral non-painful decreased visual acuity with headache. The CT scan showed cerebral venous thrombosis from the right lateral sinus to the jugular gulf. Patient presented a bilateral papillar oedema on the ocular fundus. Lumbar puncture showed lymphocytic meningitis with blood and CSF serology suggestive of neurosyphilis. The patient received antibiotic therapy with penicillin G for 14 days with curative anticoagulation for six months. The evolution was favorable.ConclusionCerebral venous thrombosis in neurosyphilis is a poorly described entity. This case report confirms the status of great simulator of syphilis. In the context of its worldwide recrudescence, syphilis must be evoked in front of an unexplained neurological disorder.     

脑脊液免疫球蛋白作为神经梅毒诊断和愈后判断指标的研究

目的探讨脑脊液免疫球蛋白对神经梅毒的诊断和愈合判断的价值。方法回顾36例多次住院神经梅毒临床和实验室检查等资料,采用SPSS 17.0进行统计分析。结果36例神经梅毒患者中无症状神经梅毒13例,麻痹性痴呆11例,脑膜血管梅毒5例,脊髓痨5例,脑膜神经梅毒2例。初次检查脑脊液免疫球蛋白(Ig)IgG、白细胞、IgM、IgA和蛋白升高分别为35例(97.2%)、30例(83.3%)、29例(80.6%)、26例(72.2%)、25例(69.4%)。血清甲苯胺红不加热试验(TRUST),脑脊液TRUST、IgA、IgG、IgM、白细胞、蛋白皆较治疗前降低,差异有统计学意义(P<0.05)。结论脑脊液中的免疫球蛋白可以作为神经梅毒的诊断和愈后判断的新指标。     

Cerebral syphilitic gumma in HIV-infected patients: case report and review

Neurosyphilis presenting as a cerebral gumma is an uncommon event. To date there are seven cases of cerebral gumma reported in human immunodeficiency virus (HIV)-infected patients. We describe a HIV-infected patient with neurosyphilis presenting as an expanding central nervous system lesion and unremarkable cerebrospinal fluid analysis. This case report illustrates the clinical and therapeutic aspects of syphilitic gumma in HIV-infected patients.