经导管心包内尿激酶与激素灌洗治疗结核性心包炎

目的 总结心包腔内灌注尿激酶与地塞米松结合心包引流治疗结核性心包炎的经验。方法 我院1998—2004年收治的有心包填塞症状的结核性心包炎患者12例，经心包穿刺置管行心包引流，并给予尿激酶与激素冲洗心包。结果 12例患者引流通畅，引流时间2—5天。随访6—24月未发生缩窄性心包炎。结论 经导管引流并使用尿激酶与激素冲洗心包治疗结核性心包炎能防止或减少缩窄性心包炎的发生。     

结核性脑膜炎患者死亡与初始异烟肼耐药的相关性

目的研究结核性脑膜炎患者死亡与初始异烟肼耐药是否相关。方法回顾性队列研究方法,分析1995年1月至2005年1月京山县人民医院的结核性脑膜炎患者死亡的所有因素,评估死亡与初始异烟肼耐药是否相关。结果 121例患者临床诊断为结核性脑膜炎(结核杆菌培养阳性),其中8例(7%)患者初始药敏显示为异烟肼耐药。在全部患者中,初始异烟肼耐药与死亡之间未经校正的相关性无统计学意义(OR=5.06,95%CI为1.14~22.53)。其中,94例脑脊液结核杆菌培养阳性,初始异烟肼耐药与死亡具显著相关性(未校正OR=12.6,95%CI为1.40~113.31)。校正年龄、性别、HIV感染因素后,二者相关性进一步增高(OR=13.18,95%CI为1.46~119.25)。结论脑脊液结核杆菌培养阳性的结核性脑膜炎患者死亡与初始异烟肼耐药相关;脑脊液结核杆菌培养阳性的结核性脑膜炎患者的常规化疗方案存在高风险和低疗效。     

结核性脑膜炎高热患者亚低温治疗期的循证护理

目的探讨结核性脑膜炎高热患者亚低温治疗期的循证护理方法。方法通过分析并提出结核性脑膜炎高热患者亚低温治疗期的主要护理问题、获取最佳循证支持、指导护理实践、进行效果评价。结果采用有效的循证干预,患者体温维持在36～37.5℃,在防治压疮、促进排痰、高热降温、预防胃肠功能紊乱等方面护理效果好。结论循证护理能较好地解决结核性脑膜炎高热患者亚低温治疗期的护理问题,是一种有效、安全的护理方法。     

结核性脑膜炎高热患者亚低温治疗期的循证护理

目的 探讨结核性脑膜炎高热患者亚低温治疗期的循证护理方法.方法 通过分析并提出结核性脑膜炎高热患者亚低温治疗期的主要护理问题、获取最佳循证支持、指导护理实践、进行效果评价.结果 采用有效的循证干预,患者体温维持在36～37.5 ℃,在防治压疮、促进排痰、高热降温、预防胃肠功能紊乱等方面护理效果好.结论 循证护理能较好地解决结核性脑膜炎高热患者亚低温治疗期的护理问题,是一种有效、安全的护理方法.     

不同方案治疗结核性脑膜炎27例疗效观察

血行播散型肺结核（简称Ⅱ型）中，发生结核性脑膜炎（简称结脑）者并不少见，脑功能衰竭是死亡的主要原因之一。为了改善患者的症状和延长寿命。近年来在运用抗痨药的前提下，采用不同剂量中枢兴奋剂，糖皮质激素（简称激素）或激素与中枢兴奋剂联合应用均取得一定疗效，本文分析不同方案治疗27例结脑的临床疗效。     

结核性脑膜炎54例临床分析

目的：探讨结核性脑膜炎的诊断及治疗,方法：对近10a收住的54例结核脑膜炎患者进行回顾性调查研究。结果：其中28例入院时即确诊,26例误诊,误诊率为48%,通过全程抗痨化疗并结合糖皮质激素以及有效的对症支持能早期诊断及有效抗痨治者,结论：密切观察病情变化,全面检查有利于早期诊断,而早期诊断、尽快抗痨化疗、合理的糖皮质激素应用及强有力的对症支持治疗对结核性脑膜炎患者尤为重要,可有效降低病死率及致残率。     

经导管心包内尿激酶与激素灌洗治疗结核性心包炎12例

目的 通过心包腔内灌注尿激酶与地塞米松结合心包引流治疗结核性心包炎，总结治疗结核性心包炎的治疗经验。方法 1998-2004年我院收治的有心包填塞症状的结核性心包炎患者12例，经心包穿刺置管行心包引流，并给予尿激酶与激素冲洗心包。结果 12例患者引流通畅彻底，引流时间2～5d，随访6～24个月未发生缩窄性心包炎。结论 经皮导管引流并使用尿激酶冲洗心包治疗结核性心包炎是安全有效的，并能防止或减少缩窄性心包炎的发生。     

糖皮质激素冲击治疗Ⅲ期结核性脑膜炎疗效观察

目的探讨糖皮质激素冲击治疗晚期结核性脑膜炎的有效性和安全性。方法将50例Ⅲ期结核性脑膜炎患者随机分为两组，在抗痨治疗的基础上，治疗组（25例）给予甲基强的松龙500mg/d静脉滴注冲击治疗5d后，迅速减至80mg/d后逐渐减量，对照组（25例）z给予地塞米松15mg/d治疗，症状明显好转后减量，两组激素使用疗程均最多10周。结果治疗组意识障碍恢复时间、体温恢复时间等均优于对照组（P〈0．05）；疗程12周时的治愈率、好转率及后遗症比较，治疗组均优于对照组（P〈0．05），不良反应间差异无统计学意义。结论大剂量甲基强的松龙冲击治疗Ⅲ期结核性脑膜炎疗效显著且不良反应无明显增加。     

长期应用激素诱发肺结核临床分析

目的探讨长期使用糖皮质激素诱发肺结核的临床特点、诊断和预后。方法采用回顾性病例调查的方法,对24例长期使用激素并发肺结核的患者进行临床分析。结果与普通肺结核相比,长期应用激素相关肺结核临床表现以中高热、乏力多见,干咳和胸痛少见;病情重,合并其他病原体感染、继发性肺结核、结核性胸膜炎及合并肺外结核多见;X线上多表现为均匀一致的片絮状阴影;合并肺门或纵隔淋巴结肿大少见;病灶分布范围较广,以非肺结核好发部位发病率高,多分布在双侧肺、中肺野及下肺野。结论长期使用激素易诱发肺结核或导致原来肺结核恶化,对长期使用激素的患者应提高警惕,必要时给予预防性抗结核治疗。     

结核性脑膜炎50例临床诊治探讨及分析

对结核性脑膜炎诊治情况展开综合探析。筛选2007年1月~2015年12月于我院就诊50例结核性脑膜炎患者,对患者进行及早诊断,以选择合适的治疗方法,主要选取一线的抗结核类药剂(吡嗪酰胺、异烟肼)进行救治。患者经诊断及治疗之后,好转23例(46.0%),未愈11例(22.0%),后遗症9例(18.0%),死亡7例(14.0%)。临床治疗结核性脑膜炎前,需先诊断患者的病情,针对其实际病情选择治疗方法,此次研究以一线的抗结核类药剂(吡嗪酰胺、异烟肼等)丢结核性脑膜炎患者进行救治,能够有效控制患者的病情,提升临床疗效,值得推广。     

Tuberculous meningitis in adults--experience from Turkey

Background: The annual incidence of tuberculous meningitis (TM) is unknown. TM is a disease that still often results in residual sequelae, and has a mortality rate ranging between 15 and 51%. Experience of countries such as Turkey where drug‐resistant tuberculosis and TM are prevalent is important. Methods: Clinical and laboratory findings of 42 patients with TM, followed between 1991 and 2002, were evaluated retrospectively. Results: Twenty‐eight female and 14 male patients were included in this study. The mean age of the patients was 33.9 ± 13.2 years (range, 16–60 years). Fourteen had a history of pulmonary tuberculosis; 12 reported close contact with a person with active pulmonary tuberculosis; three were diagnosed with active pulmonary tuberculosis; two, with HIV infection; two, with Pott's disease; and one, with systemic lupus erythematosus. On admission, 17 patients were diagnosed with stage I; 15, with stage II; and 10, with stage III disease. Hemiparesis (35.7%), cranial nerve palsy (30.9%), and altered consciousness (26.9%) were the most common neurological deficits. Prolonged duration of pre‐existing symptoms and female gender were found as significant risk factors in those who develop neurological sequelae (p < 0.01 and p < 0.05, respectively). Cranial computerised tomography revealed various pathological findings in all but five patients. Sulcus effacement was the most common radiological finding. Enlargement of ventricles, focal cerebral oedema/shunt, calcification of meninges, tubercle, and infarction were other common abnormal radiological findings. Conclusions: Prolonged duration of pre‐existing symptoms and female gender are predictors of neurological sequelae of TM. Early identification of such patients and prompt initiation of anti‐tuberculosis therapy may improve their outcome.     

Patients in whom active tuberculosis was diagnosed after admission to a Japanese university hospital from 2005 through 2007

To identify problems in early diagnosis of tuberculosis and to design countermeasures against the disease, we examined the status of active tuberculosis among patients admitted to a university hospital that did not have an isolation ward for tuberculosis. Between 2005 and 2007, we analyzed demographic characteristics, disease type, chest radiologic findings, and the process leading to diagnosis. Active tuberculosis was diagnosed after admission in 55 patients (34 males and 21 females): pulmonary tuberculosis, 26; tuberculous pleuritis, 13; tuberculous meningitis, 6; miliary tuberculosis, 4; tuberculous pericarditis, 3; lymph-node tuberculosis, 2; and tracheal and bronchial tuberculosis, 1. Although radiographic examinations provided abundant information, chest radiography showed normal findings in 7 patients (12.7%). Computed tomographic scanning was useful for detailed evaluation of abnormalities. Twenty patients (36.4%) were given diagnoses at departments other than ours (Department of Pulmonary Medicine). Numbers of days between hospital admission and diagnosis of tuberculosis (50th percentile/80th percentile) were 8.0/37.8 for miliary tuberculosis, 8.0/8.0 for tracheal and bronchial tuberculosis, 7.5/17.8 for tuberculous pleuritis, 7.0/8.8 for tuberculous pericarditis, 6.0/15.6 for pulmonary tuberculosis, 3.5/4.4 for lymph-node tuberculosis, and 1/1 for tuberculous meningitis. Early diagnosis of tuberculosis requires adherence to the following precautions. Tuberculosis should be suspected in any patient with respiratory symptoms. Sputum tests for acid-fast bacteria should be performed at least three times initially. If findings on chest X-ray films are equivocal, high-resolution computed tomography should be performed to confirm details of shadows and to detect minimal pulmonary shadows or cavitary lesions. Physicians from all specialties should be repeatedly informed about the risk of tuberculosis and should include tuberculosis in the differential diagnosis in patients suspected to have pulmonary diseases.     

脑脊液腺苷脱氨酶测定对结核性脑膜炎的诊断意义

目的探讨脑脊液腺昔脱氨酶(ADA)活性测定对结核性脑膜炎诊断的临床意义。方法对确诊的50例结核性脑膜炎、46例病毒性脑膜炎、42例化脓性脑膜炎及40例非脑炎患者采用LX20全自动生化分析仪检测脑脊液ADA活性。结果结核性脑膜炎患者组脑脊液ADA活性明显高于其它非结核性脑膜炎患者,平均为(12.69±5.08)U/L,最高达27.33U/L。病毒性脑膜炎、化脓性脑膜炎和其它非脑膜炎患者脑脊液ADA分别为(3.26±1.03)U/L(、4.52±2.11)U/L、(2.99±1.22)U/L,最高9.04U/L,与结核性脑膜炎患者相比差别有统计学意义(P<0.01)。结核性脑膜炎组43例患者治疗6周后脑脊液中ADA活性比刚入院时明显降低,差别有统计学意义(P<0.01)。结论脑脊液腺苷脱氨酶可作为诊断结核性脑膜炎的重要参考指标。     

结核性脑膜炎实验室检查方法的评价

为了评价结核性脑膜炎（结脑）的实验室检查方法，对２０例结脑和２８例非结脑患儿的脑脊液分别进行了ＰＣＲ、抗结核抗体、涂片找结核杆菌及腺苷脱氨酶活性测定。测定结果在结脑组和非结脑组均存在明显差别（Ｐ＜０.０１），对结脑诊断的敏感性和特异性分别是８５％和８９.３％、５５％和８５.７％，５％和１００％，８５％和８２.１％，其中以ＰＣＲ检查的敏感性和特异性最高，提示ＰＣＲ是快速诊断结脑的可靠方法。     

Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis

Tuberculous meningitis is primarily a disease of the meninges of brain and spinal cord along with adjacent brain parenchyma. The characteristic pathological changes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Tuberculous meningitis has a strong predilection for basal parts of the brain. Exudates, if dominantly present in the interpeduncular, suprasellar and Sylvian cisterns, result in optochiasmatic arachnoiditis and tuberculoma. Optochiasmatic arachnoiditis and tuberculoma are devastating forms of tuberculous meningitis and often associated with profound vision loss. This clinical entity more frequently affects young adults. In a recent study, on the multivariate logistic regression analysis, female sex, younger age and raised cerebrospinal fluid protein content were identified as predictors for developing optochiasmatic arachnoiditis. Frequently, optochiasmatic tuberculoma and optochiasmatic arachnoiditis develop paradoxically while a patient is being treated with anti-TB drugs. MRI reveals confluent enhancing lesions that are present in the interpeduncular fossa, pontine cistern, and the perimesencephalic and suprasellar cisterns. Management of tuberculous optochiasmatic arachnoiditis and optochiasmatic arachnoiditis tuberculoma has been variable. Treatment of optochiasmatic arachnoiditis continues to be a challenge and the response is generally unsatisfactory. In isolated case reports and in small series, corticosteroids, methyl prednisolone, thalidomide and hyaluronidase have been used with variable success. The benefit from neurosurgery is controversial and deterioration may follow the initial temporary improvement. Management of paradoxical optochiasmatic arachnoiditis is also controversial. Some patients regain vision following treatment with anti-TB drugs and continued usage of corticosteroids. Neurosurgery may be considered in the patients with either treatment failure or when diagnosis is in doubt. In conclusion, presence of optochiasmatic arachnoiditis or tuberculoma has important therapeutic and prognostic implications for patients of tuberculous meningitis.     

Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis

Tuberculous meningitis is primarily a disease of the meninges of brain and spinal cord along with adjacent brain parenchyma. The characteristic pathological changes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Tuberculous meningitis has a strong predilection for basal parts of the brain. Exudates, if dominantly present in the interpeduncular, suprasellar and Sylvian cisterns, result in optochiasmatic arachnoiditis and tuberculoma. Optochiasmatic arachnoiditis and tuberculoma are devastating forms of tuberculous meningitis and often associated with profound vision loss. This clinical entity more frequently affects young adults. In a recent study, on the multivariate logistic regression analysis, female sex, younger age and raised cerebrospinal fluid protein content were identified as predictors for developing optochiasmatic arachnoiditis. Frequently, optochiasmatic tuberculoma and optochiasmatic arachnoiditis develop paradoxically while a patient is being treated with anti-TB drugs. MRI reveals confluent enhancing lesions that are present in the interpeduncular fossa, pontine cistern, and the perimesencephalic and suprasellar cisterns. Management of tuberculous optochiasmatic arachnoiditis and optochiasmatic arachnoiditis tuberculoma has been variable. Treatment of optochiasmatic arachnoiditis continues to be a challenge and the response is generally unsatisfactory. In isolated case reports and in small series, corticosteroids, methyl prednisolone, thalidomide and hyaluronidase have been used with variable success. The benefit from neurosurgery is controversial and deterioration may follow the initial temporary improvement. Management of paradoxical optochiasmatic arachnoiditis is also controversial. Some patients regain vision following treatment with anti-TB drugs and continued usage of corticosteroids. Neurosurgery may be considered in the patients with either treatment failure or when diagnosis is in doubt. In conclusion, presence of optochiasmatic arachnoiditis or tuberculoma has important therapeutic and prognostic implications for patients of tuberculous meningitis.     

A case of isoniazid-resistant miliary tuberculosis in which tuberculous meningitis paradoxically developed despite systemic improvement

A 63-year-old man with chronic myelomonocytic leukemia was admitted to our hospital with miliary tuberculosis. He received anti-tuberculosis drugs: isoniazid (INH), rifampicin (RFP), ethambutol (EB), and pyrazinamide (PZA). His condition clearly and immediately improved after the therapy, but he experienced a high fever of about 38°C every day from 1 month after the initiation of the therapy. Drug-induced fever and tumor fever were suspected as causes, but the etiology could not be determined. The tuberculosis was identified as an INH-resistant strain, so INH was stopped and levofloxacin (LVFX) was introduced, with streptomycin (SM), in addition to RFP, EB, and PZA. At 2 months after the initiation of the therapy (about one week after the change in the anti-tuberculosis drug regimen), his spinal fluid was examined, given his complaints of headache and vomiting. The spinal fluid analysis revealed invasion of lymphocytic inflammatory cells and high adenosine deaminase activity; the patient was thus diagnosed with tuberculous meningitis. His condition gradually improved after the changing of the anti-tuberculosis drugs. Thus, to summarize, the tuberculous meningitis had worsened paradoxically despite his systemic improvement, although it was successfully treated by the addition of LVFX and SM. We must keep in mind that a potential cause of fever during anti-tuberculosis therapy may be INH-resistant tuberculous meningitis.     

妊娠合并结核性脑膜炎的特征及护理

目的分析总结妊娠合并结核性脑膜炎患者的相关特征及护理经验。方法对2010年1 12月收治的8例妊娠合并结核性脑膜炎患者的相关资料进行回顾性分析,并就疾病特点所采取的有效护理措施进行表述。结果 6例患者好转出院继续治疗（均于出院后1周内终止妊娠）,1例经抢救后转院行引产手术,1例因经济原因自动出院。结论应大力普及妊娠期结核性脑膜炎相关知识,重视首发症状及腰椎穿刺检查结果,做到早发现,早诊断,早治疗,并采取相应的护理措施,减少并发症和致死率。     

Extrapulmonary tuberculosis: an overview

In the 1980s, after a steady decline during preceding decades, there was a resurgence in the rate of tuberculosis in the United States that coincided with the acquired immunodeficiency syndrome epidemic. Disease patterns since have changed, with a higher incidence of disseminated and extrapulmonary disease now found. Extrapulmonary sites of infection commonly include lymph nodes, pleura, and osteoarticular areas, although any organ can be involved. The diagnosis of extrapulmonary tuberculosis can be elusive, necessitating a high index of suspicion. Physicians should obtain a thorough history focusing on risk behaviors for human immunodeficiency virus (HIV) infection and tuberculosis. Antituberculous therapy can minimize morbidity and mortality but may need to be initiated empirically. A negative smear for acid-fast bacillus, a lack of granulomas on histopathology, and failure to culture Mycobacterium tuberculosis do not exclude the diagnosis. Novel diagnostic modalities such as adenosine deaminase levels and polymerase chain reaction can be useful in certain forms of extrapulmonary tuberculosis. In general, the same regimens are used to treat pulmonary and extrapulmonary tuberculosis, and responses to antituberculous therapy are similar in patients with HIV infection and in those without. Treatment duration may need to be extended for central nervous system and skeletal tuberculosis, depending on drug resistance, and in patients who have a delayed or incomplete response. Adjunctive corticosteroids may be beneficial in patients with tuberculous meningitis, tuberculous pericarditis, or miliary tuberculosis with refractory hypoxemia.     

快速进展型结核性心包炎的临床治疗

目的探讨不同治疗方案对于快速进展为缩窄性心包炎的结核性心包炎（快速进展型结核性心包炎）治疗效果、并发症、死亡率、患者预后的影响,以期对结核性心包炎的治疗获得更好的效果。 方法回顾性分析2014年6月至2019年5月成都市第三人民医院心脏大血管外科对38例快速进展型结核性心包炎的治疗方式、外科手术干预时机、手术方式及疗效、并发症、死亡率和随访情况等,治疗方式包括药物治疗、心包穿刺引流术、心包开窗术、心包剥脱术等。同期观察对慢性缩窄性心包炎行外科手术治疗患者115例。 结果对于快速进展型结核性心包炎采用不同的治疗方案,随访1~5年。所有患者均采用抗结核药物治疗,其中单纯药物治疗5例,全部进展为缩窄性心包炎;早期行心包穿刺引流术12例,治愈1例,其余11例进展为慢性缩窄性心包炎;早期行心包开窗术10例,进展为慢性缩窄性心包炎1例,治愈9例;早期行心包剥脱术11例,无进展为慢性缩窄性心包炎病例。全组无围术期死亡病例。与同期行慢性缩窄性心包炎外科手术治疗患者相比,快速进展型结核性心包炎外科手术治疗患者低心排综合征发生率较低（4.8% vs 24.3%,P＜0.05）,患者心功能改善情况较好（100.0% vs 80.7%,P＜0.05）,术后5年随访生存率较高（100% vs 78%,P＜0.05）。 结论快速进展型结核性心包炎单纯采用药物治疗和心包穿刺术治疗,有很高比例的患者会进展为缩窄性心包炎,从而严重影响患者的预后。早期外科干预能显著降低快速进展型结核性心包炎进展为缩窄性心包炎的概率,从而改善患者总体预后,改善患者生存质量,减轻社会负担。