HIV感染与非HIV感染患者新型隐球菌脑膜炎临床特点比较

新型隐球菌广泛分布在自然界中,可引起人类感染,大多经呼吸道吸入,在肺部引起轻度炎症,或隐性传染,亦可由破损皮肤及肠道传人.当机体免疫功能下降时可向全身播散,主要侵犯中枢神经系统.新型隐球菌感染的风险因素包括HIV感染、肝硬化、糖尿病、实体器官移植、恶性肿瘤、类风湿性疾病、皮质激素的使用和慢性肾脏疾病等¨].在未知或没有免疫抑制的人群中,也会发生隐球菌感染[2].在HIV感染高流行区,新型隐球菌性脑膜炎发病率高,且预后差.艾滋病患者并发隐球菌脑膜炎的病死率为9％ ～ 55％,非HIV感染者病死率为15％ ～44％[3].新型隐球菌脑膜炎的诊断和治疗对临床医师来说仍是一个挑战.本研究比较分析我院非HIV感染与HIV感染患者新型隐球菌脑膜炎的临床特点,为提高疾病的诊治水平积累经验.     

肾移植患者合并新型隐球菌脑膜炎一例

肾移植患者合并新型隐球菌脑膜炎，在诊治上非常困难，我们治愈1例。报告如下。患者为男性，63岁，因慢性肾小球肾炎尿毒症于1991年4月行同种异体肾移植，手术顺利。术后用环抱素A（CsA）8mg·kg－1/d、硫唑嘌呤（Aza）100mg/d及泼尼松（常规用量）行免疫抑制治疗。CsA用量根据血药浓度调整。肾功能正常，术后35天出院。定期随访。术后第748天出现急性排斥，经泼尼松龙冲击治疗逆转。术后第804天出现低热，再次入院，经抗感染及试验性抗结核治疗均无效，体温达38．7℃：以上，用复达欣未能控制，头痛加重，出现恶心呕吐、颈项强直等脑膜…     

隐球菌脑膜炎16例的临床特点及误诊分析

目的:探讨新型隐球菌脑膜炎(CNM)的临床特点及对误诊原因,提高诊治水平。方法:对16例CNM患者的临床资料进行回顾性分析。结果:新型隐球菌脑膜炎以颅高压征象多见,意识障碍、精神异常、抽搐、视力及听力的损害也较常见。16例患者中亚急性或慢性起病14例(87.5%)。近期使用皮质类固醇和(或)免疫抑制剂7例(43.75%),患者具有系统性红斑狼疮、肾病综合征、白血病、糖尿病等基础疾病9例(56.25%)。首次涂片即发现隐球菌8例(50%),重复送检发现隐球菌4例(25%),反复涂片阴性2例(12.5%),隐球菌培养后确诊。曾被误诊为其他疾病10例(62.5%)。结论:新型隐球菌颅内感染大多数以亚急性或慢性起病,目前CNM的基础疾病谱更加广泛,因临床表现缺乏特异性,易于误诊。     

27例隐球菌性脑膜炎患者的临床分析

目的探讨隐球菌性脑膜炎的临床特征,以提高该病的诊治水平及预后。 方法回顾性分析复旦大学附属华山医院收治的27例诊断为隐球菌性脑膜炎患者的临床资料。 结果88.89%（24例）隐球菌性脑膜炎患者以头痛为首发症状;脑脊液糖（1.81 ± 0.69 mmol/L）降低尤为显著;若并发颅神经损害,多累及视神经和听神经;头颅CT或MR可见脑缺血病灶（37.04%）及软脑膜不同程度强化灶（59.26%）;所有患者均有不同程度的颅内压增高,病原学脑脊液墨汁染色阳性患者22例（占81.48%）,隐球菌培养阳性患者20例（占74.07%）,荚膜多糖抗原检测（乳胶凝集试验）阳性占100%;两性霉素B（AmpB）联合5-氟胞嘧啶（5-FC）治愈好转率100%（17/17）,AmpB + 5-FC +氟康唑治疗的4例患者中好转3例。 结论隐球菌性脑膜炎早期误诊率较高,脑脊液墨汁染色、隐球菌乳胶凝集试验及培养有助于确诊;两性霉素B联合5-氟胞嘧啶仍是目前经典的抗真菌治疗方案,两性霉素B与伊曲康唑联合治疗方案有待大样本的临床验证;早期控制真菌及颅高压是改善预后关键,必要时可尽早外科干预。     

肺结核合并新型隐球菌性脑膜炎2例

病例1患者男,30岁,无基础疾病,无家禽喂养或接触史。患者20多天前出现头痛,进行性加重,以额颞部为甚,伴头晕眼痛、发热,体温最高达38．5℃,伴恶心,无呕吐,双下肢无力。查体：脑膜刺激征（＋）;胸部CT：两肺多发感染性病变,结核可能;头颅CT：未见明显异常,痰找结核分支杆菌（＋）,脑脊髓液检查：脑脊髓液压力420mmH2O（1mm H2O=0．0098kPa）,     

播散性新型隐球菌感染误诊为肺癌一例

患者男,45岁,农民,因阵发性头痛、呕吐,伴咳嗽1个月余,于2011年2月11日入院.患者在1个月前“感冒”后出现头痛,阵发性,不剧,伴轻度眩晕感及眼睛复视.呕吐剧烈,每次5～10 min,3～5次/d,食后即吐,无明显恶心感,呕吐时伴眼球及脸部其他部位充血,入院前加剧.患者偶有发热,口腔温度最高达38℃,轻微咳嗽,无咳痰、咳血,无胸闷、胸痛,无畏寒,无腹痛、腹泻.外院ct检查示左肺下叶占位性病变,以“左肺癌脑转移?”转来浙江省丽水市人民医院以明确诊断及治疗.     

89例新型隐球菌性脑膜炎的临床分析

目的：分析两性霉素B和（或）氟康唑联合氟胞嘧啶治疗新型隐球菌性脑膜炎（CNM）的疗效。方法回顾性分析89例住院CNM患者的临床资料及治疗情况。结果患者首发症状多表现为头痛（89/89,100.0%）和呕吐（62/89,69.7%）。发热、头痛、呕吐和脑膜刺激征为该病主要临床表现。CNM确诊前怀疑为结核性脑膜炎19例,占21.3%;怀疑为巨细胞病毒脑炎8例,占8.9%。经两性霉素B和（或）氟康唑联合氟胞嘧啶抗真菌治疗后,66例好转、治愈,20例自动出院,3例死亡。结论 CNM易出现误诊,两性霉素B和（或）氟康唑联合氟胞嘧啶抗真菌治疗疗效显著。     

隐球菌性脑膜炎病原治疗的护理

对84例隐球菌性脑膜炎患者采用两性霉素B行病原治疗，强调其护理重点是给药护理、特殊护理、情感支持、人文关怀、健康教育、出院指导等，结果65例患者治愈无复发，12例好转，7例死亡。提示预防隐球菌性脑膜炎感染的关键是落实一级预防措施。     

艾滋病合并隐球菌脑膜炎患者的护理

总结6例艾滋病合并隐球菌脑膜炎患者的护理经验，提出注意使用两性霉素B的药物护理、鞘内注药的护理，实施对症治疗的护理，并做好营养治疗及心理护理。     

隐球菌性脑膜炎患者的临床观察及护理

对6例隐球菌性脑膜炎患者采用两性霉素B进行病原治疗及鞘内注射药物、降低颅内压、纠正水电解质紊乱等治疗，治疗期间严密观察病情，加强全面细致的基础护理和心理疏导，并做好相关的药物护理。结果 6例患者住院2～4个月均痊愈出院，无1例发生并发症。提示针对患者不同病情，及时予以精心护理及健康指导有助于患者康复。     

Longitudinal study of cryptococcosis in adult solid-organ transplant recipients

While studies in kidney recipients have found meningitis to be the most common clinical manifestation of cryptococcosis (Cry), it is unclear if the clinical presentation of Cry differs among various solid-organ transplant (SOT) recipients and whether the serum cryptococcal antigen (SCA) might predict the site of infection. We report the clinical manifestations and the correlation with a positive SCA among 55 consecutive SOT recipients diagnosed with Cry at the University of Pittsburgh Medical Center. These included: heart (n=13), lung (n=4), liver (n=28), kidney (n=9) and small bowel (n=1) recipients. While there were no significant differences in the manifestations of Cry in heart and lung recipients, kidney recipients had disseminated disease as the most common presentation (P=0.02). In contrast, pneumonia (P=0.003) and meningitis (P=0.02) were more frequent than disseminated disease in liver recipients. Positive SCA was higher in patients with disseminated disease and meningitis than in patients with isolated pneumonia (P=0.0001). Significant differences in the manifestations of Cry were observed among types of SOT populations. A positive SCA may be predictive of dissemination and meningitis, but it may not be sensitive for pulmonary disease.     

肝移植术后原发性肺隐球菌病3例临床分析

目的探讨原位肝移植术后原发性肺隐球菌病(PPC)的诊断和治疗。方法收集武警总医院2005年4月～2009年12月1302例原位肝移植术后3例并发PPC患者的临床资料,结合相关文献进行复习。结果 3例患者分别在肝移植术后6、13、31个月并发PPC;肺穿刺活组织病理学检查确诊1例,临床诊断2例(乳胶凝集试验阳性及CT检查肺部阴影);均采用单药治疗,氟康唑治疗1例,伊曲康唑治疗2例,均未出现药物相关不良反应。结论 PPC多发生在肝移植术后中、远期,缺乏特征性临床表现和影像学特征,肺穿刺活组织学检查是PPC的确诊手段,唑类抗真菌药对PPC有效且无明显不良反应。     

Heel pain and HIV-associated lipodystrophy: a report of two cases

Plantar fasciitis is diagnosed based on a pathognomonic clinical presentation and physical examination including plantar heel pain with the initial few steps after a period of inactivity. People living with HIV/AIDS, who are taking anti-retroviral medications, often have an associated redistribution of body fat (lipodystrophy). Lipoatrophy of the extremities may involve the heel fat-pad in this population and result in the signs and symptoms of plantar fasciitis. Two cases of plantar heel pain in HIV-associated lipodystrophy are presented to discuss the possible clinical association between the two conditions. Although conservative therapies have limited evidence, they are commonly used and have been seen, clinically, to result in a resolution of symptoms. In the presented cases, the individuals benefited from soft tissue therapy, modalities, activity modification and education on proper footwear. Clinicians should be aware that the association between these two conditions may be a significant cause of morbidity in a population of patients with HIV.     

胸腔镜手术治疗肺隐球菌病11例报告

目的探讨肺隐球菌病的临床特点及胸腔镜手术的疗效. 方法回顾分析1996年1月～2002年12月我院11例肺隐球菌病的临床资料,其中胸腔镜肺楔形切除术8例,胸腔镜辅助改良后外侧小切口肺叶切除术2例,肺楔形切除术1例. 结果术前误诊10例.孤立性病变8例,双肺多发性病变3例.完全切除病灶8例,肺活检术3例.术后除2例伤口皮下积液外无其它并发症.术后随访12～72个月,(38.6±10.8)个月,无脓胸、支气管胸膜瘘发生,无肺隐球菌病复发. 结论肺隐球菌病多无基础疾病及症状,以孤立性病变多见.术前难以明确诊断,胸腔镜手术能彻底切除病灶,创伤小,恢复快.     

Utility of urine and serum lateral flow assays to determine the prevalence and predictors of cryptococcal antigenemia in HIV-positive outpatients beginning antiretroviral therapy in Mwanza,Tanzania

Background

Detection of subclinical cryptococcal disease using cryptococcal antigen screening among HIV-positive individuals presents a potential opportunity for prevention of both clinical disease and death if patients with detectable cryptococcal antigen are identified and treated pre-emptively. Recently developed point-of-care cryptococcal antigen tests may be useful for screening, particularly in resource-limiting settings, but few studies have assessed their utility.

Methodology

The objectives of this study were to determine the prevalence and factors associated with cryptococcal antigenemia in HIV-positive patients with CD4⁺ T-cell counts ≤200 cells/µL who were initiating ART, and also to evaluate the utility of the point-of-care urine lateral flow assay (LFA) cryptococcal antigen test using two different diluents, compared to gold standard serum antigen testing, as a screening tool. Urine and serum of outpatients initiating antiretroviral therapy at two hospitals in Mwanza were tested for cryptococcal antigen, and demographic and clinical characteristics were obtained using structured questionnaires and patients’ files. Patients with asymptomatic cryptococcal antigenemia received oral fluconazole in accordance with World Health Organization recommendations.

Results

Among 140 patients screened, 10 (7.1%) had asymptomatic cryptococcal antigenemia with a positive serum cryptococcal antigen. Four of these ten patients had CD4 counts between 100 and 200 cells/µL. The prevalence of cryptococcal antigen detected in urine using a standard (older) and a test (newer) diluent were 44 (31.4%) and 19 (13.6%), with Kappa coefficients compared to serum of 0.28 and 0.51 (p<0.001 for both). Compared to the new LFA diluent for urine cryptococcal antigen, the standard diluent had higher sensitivity (100% versus 80%) but lower specificity (74% versus 92%) using serum cryptococcal antigen as a gold standard.

Conclusions

Our findings suggest that HIV-positive outpatients with CD4 counts <200 cells/µL, rather than 100, should be screened for asymptomatic cryptococcal antigenemia given its association with mortality if untreated. Agreement of the urine LFA with the serum LFA was not sufficient to recommend routine screening with urine LFA.     

肺移植治疗终末期肺病18例报告

陈静瑜郑明峰朱艳红胡春晓何毅军王永功周敏陆国础陆明华【摘要】目的探讨国内开展临床肺移植的可行性以及目前存在的主要问题。方法2002年9月至2005年4月共完成临床肺移植18例,其中肺气肿9例、肺纤维化5例、矽肺1例、支气管肺扩张1例、肺淋巴管平滑肌瘤病1例及室间隔缺损合并艾森曼格综合征1例。受者术前均为重症呼吸衰竭,长期靠呼吸机依赖3例。手术方式为:单肺移植15例(左肺移植9例,右肺移植6例),其中2例受者的供肺为同一供者同期的左、右单肺,有1例为左侧供肺植入右胸腔,1例为体外循环下室间隔缺损修补后行右肺移植;非体外循环下序贯式双侧单肺移植3例。结果术后短期内死亡3例,1例于术后15d死于急性排斥,1例于术后30d死于感染后多脏器功能衰竭,1例术后36d死于肺梗死。其余15例均痊愈出院,肺功能明显改善,生存1年以上3例,生存2年以上2例,中位生存时间10个月。结论肺移植是治疗各种终末期肺病的有效的手段;但术后的缺血再灌注损伤、排斥反应和感染仍是肺移植短期死亡的主要原因。     

肺隐球菌病累及中枢神经系统1例

正患者女,43岁,10余天前无明显诱因出现头痛,伴呕吐、发热;既往体健。查体未见明显异常。实验室检查:甲胎蛋白1.78ng/ml,癌胚抗原0.98 ng/ml,糖类抗原19-9为7.70U/ml,糖类抗原12-5为42.80U/ml。头部MRI:双侧大脑半球灰白质交界区见多发长T1、稍长T2结节,双侧基底节区见囊状长T1、长T2结节,于弥散加权成像(diffusion weighted imaging,DWI)(b=1 000s/mm2)中呈低信号(图1A),表观弥散系数(apparent diffusion coefficient,     

Multiple osseous involvements in a case of disseminated cryptococcosis

Osseous involvement occurs in 5–10% of patients with disseminated cryptococcosis. We are reporting an unusual case of disseminated cryptococcosis involving the sternum and lumbar vertebra with the formation of psoas abscess with pulmonary tuberculosis. The patient presented with fever for 3 months. A diagnosis of pulmonary tuberculosis was made on thoracic contrast-enhanced computerized tomography and she was put on antituberculosis treatment. She was immunocompetent with negative human immunodeficiency virus. She conceived subsequently and had complaints of backache and swelling over the sternum. Magnetic resonance imaging showed destruction of L5 vertebra with psoas abscess. Vertebral cryptococcosis may mimic tuberculosis and malignancy. She had a bad obstetric history and experienced five, first-trimester spontaneous abortions in each successive year since 2001. This pregnancy again resulted in spontaneous abortion. Cryptococcus neoformans was isolated from two different sites: pus-involving the sternum and ultrasound-guided psoas abscess aspirate. Serum latex agglutination test for cryptococcal capsular polysaccharide antigen was positive. The diagnosis of cryptococcosis was delayed because the patient was diagnosed as a case of pulmonary tuberculosis, wherein clinical signs, symptoms and radiological findings in both the conditions are similar. Amphotericin B was started but she developed varicella infection and expired due to cardiac failure.     

免疫功能正常者肺部隐球菌病四例并文献复习

隐球菌病是由新型隐球菌引起的亚急性或慢性深部真菌病,主要侵犯中枢神经系统和肺部组织,常发生于恶性肿瘤、白血病或应用大剂量糖皮质激素或化疗等免疫功能低下的患者,免疫功能正常人群发生隐球菌感染的临床报道相对较少,其临床表现及胸部影像学常常不典型,容易引起误诊和漏诊.我们回顾了浙江省金华市人民医院经病理确诊的免疫功能正常者患肺部隐球菌病4例,并结合文献复习进行分析.