AIDS合并结核性脑膜炎患者的死亡风险因素分析

目的　探讨AIDS合并结核性脑膜炎患者死亡的风险因素,以帮助临床医生尽快制定预防及干预策略,从而降低死亡率。方法　回顾性分析2009年 1月—2017年12月北京地坛医院125例AIDS合并结核性脑膜炎入院治疗患者的临床资料。结果　125例患者中有50例（40.00％）于12个月随访期内死亡。低蛋白血症、中枢神经系统病变诊断不明、非AIDS指征性疾病是AIDS合并结核性脑膜炎患者随访期生存率明显下降、死亡风险增加的影响因素。结论　低蛋白血症、中枢神经系统病变诊断不明、非AIDS指征性疾病是导致AIDS合并结核性脑膜炎患者死亡的风险因素。因此,具备这些风险因素的患者,在入院早期应当给予重视及积极的重症监护治疗。     

AIDS并发结核性脑膜炎临床特点分析

目的探讨AIDS并发结核性脑膜炎（结脑）患者的临床特点,提高对本病的认识。方法对我院收治的22例AIDS合并结脑患者的临床资料进行回顾性分析。结果22例AIDS并发结脑患者的CD4＋T淋巴细胞计数较低,平均为37．2／mm3,其中〈50／mm3的18例,占81．8％。患者同时合并多种机会性感染,病死率较高。结论AIDS合并结脑临床表现复杂,诊断、治疗较困难,预后差,预防、早期诊断、合理及时的治疗是关键。     

Multidrug-resistant tuberculous meningitis in an HIV-positive patient: a challenging disease

We report two cases of disseminated multidrug-resistant tuberculosis with meningitis in HIV-positive patients, who were both recent emigrants from sub-Saharan Africa. Our two cases highlight new challenges in the care of HIV and tuberculosis coinfection including early diagnosis and treatment of multidrug-resistant tuberculosis that is spreading.     

Predictors of outcome in patients with tuberculous meningitis.

OBJECTIVE: To assess predictors of mortality and neurological sequelae in patients with tuberculous meningitis (TBM). METHODS: Patients with TBM treated at 12 university hospitals in Turkey between 1985 and 1997 were evaluated using a standardised protocol applied retrospectively. Variables associated with hospital mortality as well as with the presence of neurological sequelae at 6 months were determined using logistic regression models. RESULTS: Four hundred and thirty-four patients between the ages of 13 and 83 years (mean 33 years) were evaluated. Sixty-eight per cent of these patients presented with Medical Research Council Stage II or III. One hundred and one patients (23.3%) died and 67 (27%) of evaluable survivors had neurological sequelae. In multi-variable analysis, convulsion (OR 3.3, 95%CI 1.2-9.0, P = 0.02), comatose mental status (OR 6.0, 95%CI 3.6-10.2, P = 0.01), and delayed or interrupted treatment (OR 5.1, 95%CI 2.4-11.2, P = 0.01) were shown to be predictors for mortality. The presence of extra-meningeal tuberculosis (OR 2.1, 95%CI 1.1-4.2, P = 0.035), cranial nerve palsy (OR 2.6, 95%CI 1.4-4.2, P = 0.01), hemiparesia/focal weakness (OR 9.3, 95%CI 3.8-22.6, P = 0.01), hemiplegia/multiple neurological deficit (OR 7.1, 95%CI 2.14-23.38, P = 0.01) and drowsiness (OR 4.2, 95%CI 2.04-8.82, P = 0.01) were independent predictors of neurological sequelae at 6 months following hospital discharge. CONCLUSION: The results of this study emphasise the importance of prompt and uninterrupted anti-tuberculosis therapy for tuberculous meningitis. The presence of seizures or coma on admission to hospital are important predictors for mortality, while the presence of focal neurological signs is a predictor for persistent neurological sequelae in survivors.     

结核性与隐球菌性脑膜炎的鉴别诊断

目的　探讨结核性脑膜炎（结脑）和隐球菌性脑膜炎（隐脑） 的临床和脑脊液鉴别要点。方法　回顾性调查并比较１９８３ 年２ 月～１９９７ 年１２ 月收治的５３ 例结脑和５５ 例隐脑患者的临床表现和特效治疗前的脑脊液（ＣＳＦ） 结果。结果　９％ 的结脑和４９％ 的隐脑以头痛为首发症状,结脑和隐脑发生视力改变、听力下降、肢体瘫痪的比例分别为３％ 和３６ ％ ,２％ 和１６ ％ ,１９％ 和０ ;视神经乳头水肿的发生率分别为１５％ 和６６％ ,且隐脑患者多为中、重度水肿。发生脑疝的比例分别为１１ ％ 和２９％ 。９０％ 的隐脑和１１％ 的结脑患者ＣＳＦ压力＞４００ ｍｍ Ｈ２Ｏ。３６％ 的隐脑患者ＣＳＦ中蛋白质含量正常,有升高者大部分为轻度升高,＞２ ｇ／Ｌ者仅占９％ ,而结脑均有蛋白质含量升高,且４５％ 的患者＞２ ｇ／Ｌ。结论　患者具有下列特征时考虑隐脑可能性大：起病时以头痛为主而不伴发热,听力损害出现早,中、重度视神经乳头水肿,ＣＳＦ压力显著升高,蛋白含量正常等。而感染中毒症状突出,ＣＳＦ中蛋白含量明显升高,特别是＞２ ｇ／Ｌ时,结脑的可能性较大。     

艾滋病合并结核性脑膜炎32例临床分析

目的 探讨艾滋病合并结核性脑膜炎(TBM)的临床特征、诊断和治疗,提高艾滋病合并TBM的认识。 方法 回顾性总结1999年1月-2009年12月收治的32例艾滋病合并TBM的临床资料。 结果发热30例、头痛29例、意识障碍18例、抽搐12例,脑膜刺激征25例,咳嗽27例,咳痰25例。不同程度存在艾滋病相关表现。常合并肺结核（75%）及其他肺外结核（12.5%）。所有病例CD4＜200/mm³。脑脊液压力升高,白细胞升高,蛋白质升高,糖降低,氯化物降低,ADA 升高。结论 艾滋病合并TBM临床表现复杂,无特异性,病情重,致残率高,死亡率高。治疗上抗结核治疗+激素,适时联合HARRT治疗可降低病死率,提高生活质量,延长生命。     

Cryptococcal meningitis in patients with AIDS

The Cryptococcus has become a major cause of meningitis in patients infected with the human immunodeficiency virus (HIV), and the expression of cryptococcal infection in this population of patients is quite unique. Often the infection is devoid of inflammatory response and is associated with very high antigen and fungal titers. Response to amphotericin therapy is erratic, and relapse is common. We have asked Dr. William E. Dismukes, principal investigator of the NIAID Mycoses Study Group, to discuss the following clinical questions: When and how does cryptococcal infection in HIV-infected patients present? How does it differ in HIV-infected and non-HIV-infected individuals? How is the diagnosis established? What is the sensitivity of the CSF cryptococcal antigen test? Is the serum antigen test of any value? What is the best way to treat patients--the recommended drugs, dosages, and duration of therapy? Is maintenance therapy necessary, and finally, what drugs are available for it? [Please note that an AIDS training program is now available for members of the Infectious Diseases Society of America and that details of this program appear in the Notices section of this Journal issue (pages 859-60).]     

结核性脑膜炎11例误诊分析

我科 1991年～ 1997年共收治结核性脑膜炎 (结脑 ) 3 0例 ,其中误诊 11例。现将误诊原因分析如下。临床资料1.一般资料 :11例患者 ,男性 6例 ,女性 5例 ,年龄 16～ 4 6岁。患者均有发热 ,伴不同程度的头痛、呕吐。随病程发展 ,逐渐出现中枢神经系统损害 ,脑膜刺激征 9例 ( 81.8% ) ,意识障碍10例 ( 90 .9% ) ,颅神经损害 3例 ( 2 7.3 % ) ,锥体束征 5例 ( 4 5 .5 % ) ,偏瘫 2例 ( 18.2 % ) ,截瘫尿潴留 1例 ( 9.1% )。2 .误诊情况 :因发热误诊为感染性疾病 6例 ( 5 4 .5 % ) ,分别为上呼吸道感染、尿路感染、肺部感染和伤寒。因意识障碍误诊…     

隐球菌性脑膜炎与结核性脑膜炎的临床对比分析

目的比较隐球菌性脑膜炎（隐脑）与结核性脑膜炎（结脑）临床表现、实验室检查的差异,探讨两种脑膜炎的鉴别诊断规律。方法对19例隐脑和19例结脑患者的一般情况、临床表现、实验室检查进行回顾性分析。结果与结脑组相比较,隐脑组患者体温、颅压增高较明显,跟底病变及听力下降等脑神经受损症状出现早且多,但颈项强直不及结脑组患者明显。隐脑组患者脑脊液（CSF）中氯化物含量降低不及结脑组患者明显,但葡萄糖含量降低较结脑组患者显著。结论根据患者的临床表现特点及CSF检查结果的不同,可以对结核性脑膜炎及隐球菌性脑膜炎进行初步的临床诊断,避免两类脑膜炎的误诊。     

Tuberculous meningitis with acellular cerebrospinal fluid in AIDS patients.

OBJECTIVE: To describe the clinical manifestations of tuberculous meningitis in HIV-positive patients with acellular cerebrospinal fluid (CSF). DESIGN: Retrospective analysis of case reports. METHODS: Four HIV-positive patients with acellular CSF and tuberculous meningitis are reported. RESULTS: Clinical presentation did not indicate meningeal infection in three of the four cases, and CSF tests were unusual in all cases. Two patients were diagnosed only after death. CONCLUSIONS: Acellular CSF may obstruct the diagnosis of tuberculous meningitis in AIDS patients.     

结核性脑膜炎129例的临床与病理

目的 探讨结核性脑膜炎（结脑）的诊断。方法 对１９５２￣１９９４年经尸检证实的１２９例结脑进行回顾性分析。结果 生前误诊６４例，误诊率为４９．６％，其中３４例误诊为其他脑病疾病，余３０例误诊为重症肺结核、重症肺炎、胃癌、风湿性心脏病、肺心病及白血病。临床上以脑膜炎和脑外结核表现为主，脑脊液改变压力升高，细胞计数与蛋白含量增高，糖与氯化物降低。脑ＣＴ显示脑实质粟粒性结节影，颅底面、脑脚间池和大脑裂呈     

Cryptococcal meningitis: outcome in patients with AIDS and patients with neoplastic disease.

A retrospective analysis of 41 patients with cryptococcal meningitis and AIDS or neoplastic disease was done. Patients with AIDS were younger and predominantly male; they had a shorter duration of prior illness, higher initial serum cryptococcal antigen titers, and lower initial cerebrospinal fluid white blood cell counts than those with neoplastic disease. The median overall survival for patients with AIDS was 9 months compared with 2 months for those with neoplastic disease (P = .004). Seventy-eight percent of patients with AIDS and 43% of those with neoplastic disease were cured or improved 6 months after diagnosis (P = .039). Toxicity from amphotericin B and flucytosine was similar for both groups. One patient with AIDS relapsed. Multivariate predictors of survival included headache (P = .007) and an AIDS diagnosis (P = .009). Examination of outcomes for other opportunistic infections associated with AIDS and other immunosuppressive illness may distinguish prognostic features for different patient populations.     

Diagnostic utility of cerebrospinal fluid studies in patients with clinically suspected tuberculous meningitis.

OBJECTIVE: To compare yields of cerebrospinal fluid (CSF) studies in the diagnosis of tuberculosis meningitis (TBM). DESIGN: Prospective laboratory study, Kenyatta National Hospital, Kenya. STUDY POPULATION: Consecutive patients with 1) headache, neck stiffness and altered consciousness for more than 14 days, 2) above features plus evidence of tuberculosis elsewhere in the body, and 3) on standard antimeningitic drugs for one week without response, were included. Those with contraindications to lumbar puncture, confirmed causes of meningitis (except TB) and on anti-tuberculosis treatment were excluded. METHODS: CSF cell counts, glucose and protein were assayed. CSF was stained on ZN, cultured on LJ and BACTEC and subjected to PCR and LCR for Mycobacterium tuberculosis DNA sequences. Positive tests for M. tuberculosis were classified as definite and the rest as probable TBM. RESULTS: Fifty-eight patients with a mean age of 33.0 years were recruited. Mean CSF cell count was 71/microl and CSF lymphocyte count up 67%. Mean CFS protein and glucose were 2.10 g/l and 2.05 mmol/l, respectively. BACTEC was positive in 20 cases, LJ 12, LCR eight, and PCR and ZN one each. Twenty-six patients had definite and 32 probable TBM. Patients with definite TBM had significantly higher CSF protein, lower CSF glucose, higher CSF cell count and lower CSF lymphocytes. CONCLUSION: TBM can be confirmed in half of clinically suspected cases. More sensitive tests for confirmation of TBM are required.     

Abdominal tuberculous abscesses in AIDS patients: percutaneous treatment.

OBJECTIVE: to analyze certain epidemiological and ultrasonographic features, and the response to percutaneous treatment, of abdominal tuberculous abscesses in patients with human acquired immunodeficiency syndrome. METHODS: we reviewed the clinical records and ultrasonographic findings in 7 patients with abdominal tuberculous abscesses who were treated in our service by ultrasonography-guided percutaneous drainage. RESULTS: in 5 patients there was a previous diagnosis of AIDS. The abscesses (two in one patient) were located mainly in the retroperitoneum and appeared mottled at ultrasonography. Seven of the abscesses were drained via catheter, whereas in the remaining case aspiration puncture was used. Mycobacterium tuberculosis was found in the drained material in 6 patients, and 1 case presented superinfection by Enterococcus faecalis. Percutaneous drainage was effective in 6 patients, and in the remaining case it was only palliative. CONCLUSIONS: the incidence of abdominal tuberculous abscesses is increasing in patients with AIDS, and in some patients it is the first symptom. Abscesses are located primarily in the retroperitoneum. They can be dealt with satisfactorily by percutaneous drainage guided by ultrasonography.     

高压氧辅助治疗结核性脑膜炎及结核性脑膜脑炎疗效研究

目的探讨高压氧辅助抗结核药物治疗结核性脑膜炎和结核性脑膜脑炎（两者统称为结脑）的临床疗效,以建立结脑治疗的新方法。方法将我科2005年02月-2008年01月间确诊的64例结脑患者随机分为2组,对照组给予全身抗结核化疗＋口服泼尼松治疗,治疗组在二者基础上给予高压氧辅助治疗。观察2组患者的体温、颅压、临床症状体征、颅内病灶吸收情况和脑脊液（CSF）等变化,并进行比较。结果治疗组患者体温、颅压降至正常,意识恢复时间及CSF中糖、蛋白质、氯化物等恢复时间均短于对照组（P〈O．05）;治疗1个月后,治疗组患者颅内病灶吸收情况及并发症改善优于对照组（P〈0．05）。结论高压氧辅助全身抗结核药物治疗结脑疗效确切,有望缩短结脑的化疗疗程。     

125例老年性结核性脑膜炎诊断及治疗分析

目的总结老年性结核性脑膜炎(结脑)的诊断方法。方法结合临床表现、脑脊液、影像学检查以及免疫学,分析125例老年性结脑临床资料。结果结合临床症状、体征、脑脊液、影像学及免疫学,125例患者临床诊断为结核性脑膜炎,给予诊断性抗结核治疗,大部分病例好转出院。结论老年性结脑发病缓慢,早期临床症状不典型,诊断困难,误诊率及死亡率高。对结脑的患者均应反复行脑脊液及头部核磁共振检查,排除其他颅内感染性病变、脑血管疾病及肿瘤性疾病,尽早做诊断性抗结核治疗。结核性脑膜炎是中枢神经系统的重症结核病。目前,随者人口老龄化,老年结核性脑膜炎患者呈逐年增多趋势,老年患者因其特殊体质关系,导致临床症状不典型、并发症多、误诊率高,治疗困难。使其病死率及后遗症发生率高。