中心静脉导管置入胸腔治疗结核性胸膜炎临床疗效分析

目的探讨中心静脉导管置入胸腔持续引流替代反复多次胸腔穿刺抽液治疗结核性胸膜炎临床应用价值。方法对我院2005年1月～2008年10月收治的结核性胸膜炎病例中经胸部X线和／或胸部超声检查确诊为中或大量胸腔积液的病例87例,随机分成2组（治疗组40例及对照组47例）,分别用中心静脉导管持续胸腔引流和反复多次的胸腔穿刺抽液治疗,对这两种治疗方法的效果、出现并发症情况、住院费用进行比较。结果两种方法相比：胸水吸收时间、胸膜反应、胸水包裹发生率、气胸发生率、住院费用、治疗后第三个月的胸膜厚度等各项指标对比其差异均有统计学意义（P〈0．05）。结论中心静脉导管置入胸腔持续胸腔引流治疗结核性胸膜炎方法简单、方便、安全、经济,患者痛苦少、效果好,值得基层医院推广。     

应用于结核性胸膜炎分子生物学检测的胸腔积液核酸提取方法初步比较分析北大核心CSCD

目的筛选鉴定有助于结核性胸膜炎分子生物学检测的胸腔积液核酸提取方法。方法收集18例结核性胸膜炎患者胸腔积液样本,分别采用6种方法提取核酸,应用微滴数字PCR技术分析样本中结核分枝杆菌特异性核酸IS6110和IS1081数量,以此评估不同胸腔积液核酸提取方法的优劣。结果对于胸腔积液原液或胸腔积液离心上清,采用柱法和磁珠法提取的核酸样本中靶标数量无明显差别。对于胸腔积液离心沉渣,采用物理破碎法提取的核酸样本中IS6110和IS1081数量显著高于化学破碎法(IS6110,Z=-3.408,P=0.001;IS1081,Z=-3.297,P=0.001)。相比于小体积(0.7 mL)胸腔积液原液直接提取,大体积(4 mL)胸腔积液离心的上清和沉渣(物理破碎)中提取的核酸样本含有更多的靶标数量(分别IS6110,Z=-3.237,P=0.001,IS1081,Z=-2.667,P=0.008;IS6110,Z=-3.157,P=0.002,IS1081,Z=-2.250,P=0.024)。结论大体积胸腔积液离心上清游离核酸提取法和离心沉渣物理破碎核酸提取法能够富集更多的结核分枝杆菌核酸,是较好的用于结核性胸膜炎分子生物学检测的核酸制备方法。     

Myasthenia Gravis Aggravated by Steroid-Induced Isolated Mediastinal Tuberculous Lymphadenitis

Background

Myasthenia gravis (MG) is occasionally aggravated by chronic infection, of which there are many kinds.

Case Report

We report herein the case of a 56-year-old woman with MG aggravated by the activation of isolated mediastinal tuberculous lymphadenitis (MTL) during corticosteroid administration. The possibility of MTL had been disregarded in the differential diagnosis of aggravation of MG weakness, because MTL without pulmonary manifestations is uncommon even in areas where tuberculosis is endemic.

Conclusions

This case suggests that chronic infections such as tuberculosis should be considered in myasthenic patients with progressive exacerbation if definite evidence for aggravating factors of MG is not obtained.     

Neurological complications in AIDS patients: the 1-year retrospective study in Chiang Mai University, Thailand

The first case of AIDS patient in the northern part of Thailand was reported in 1987 (Vithayasai et al., 1996), marking the outbreak of an epidemic. In our experience, the neurological involvement in AIDS patients seems to have changed in pattern and incidence during the last 8 years. We have conducted a retrospective study to review the incidence of AIDS-defining diseases in the patients admitted to Chiang Mai University Hospital, Thailand during the period September 2001 to August 2002. There were 155 AIDS patients admitted during this specified period, 118 of which were male and 37 female, aged between 16 and 60. The incidence of neurological complications was 50.3 per 100 person-years, in which central nervous system involvement account for 46.5 per 100 person-years and peripheral nervous system involvement account for 3.8 per 100 person-years. The incidence of cryptococcal meningitis appeared to be decreasing since 1994 whereas the incidence of cerebral toxoplasmosis appeared to be increasing. The incidence of cryptococcal meningitis, cerebral toxoplasmosis and cytomegalovirus (CMV) infection was 18.0, 14.8 and 7.0 per 100 person-years, respectively. Other common non-neurological AIDS-defining illnesses in northern Thailand include pulmonary tuberculosis (15.4 per 100 person-years), extra-pulmonary tuberculosis (9.6 per 100 person-years), and disseminated penicilliosis (12.2 per 100 person-years). In this way and summarizing, in northern Thailand, the three most common neurological involvements before the era of highly active anti-retroviral therapy are cryptococcal meningitis, cerebral toxoplasmosis and CMV infection. The incidence of cryptococcal meningitis appeared to be decreasing whereas the incidence of cerebral toxoplasmosis seemed to be increasing.     

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。     

草分子杆菌注射液对难治性结核性脑膜炎患者外周血中T淋巴细胞亚群改变的影响

目的探讨草分子杆菌注射液对难治性结核性脑膜炎患者外周血中T淋巴细胞亚群改变的影响。方法选取住院的未经抗结核治疗的难治性结核病脑膜炎患者84例,其中男59例,女25例;年龄15～78岁。随机分为2组,治疗组采用草分子杆菌注射液＋HRZE＋氟美松＋鞘内注药方案;对照组仅用HRZE＋氟美松＋鞘内注药方案治疗;用药12周。分别统计：显效、有效、无效、总有效率、2组T淋巴细胞亚群治疗前后变化、X线摄胸片显示病变吸收情况、痰菌的转阴情况、脑积液检查以及测定患者外周血T淋巴细胞亚群和NK细胞的变化。结果治疗组总有效率为97.6%,对照组为83.3%,2组比较差异无统计学意义（P〉0.05）。但显效率治疗组明显高于对照组（P〈0.01）。2组治疗前各项免疫指标比较差异无统计学意义（P〉0.05）;治疗后治疗组较对照组CD3^＋、CD4^＋细胞增加（P〈0.01）,CD4^＋/CD8^＋比值升高（P〈0.01）,CD8^＋减低但差异无统计学意义（P〉0.05）;对照组治疗前后差异无统计学意义（P〉0.05）。结论草分子杆菌注射液对难治性结脑患者外周血中T淋巴细胞亚群有免疫调节作用,疗效肯定,不良反应小,是理想的抗结核辅助用药。     

老年性脊柱结核的特点及保守治疗疗效观察

目的:探讨老年性脊柱结核的特点及单独应用抗结核药物治疗早期老年脊柱结核的疗效。方法:对2008年1月至2010年7月纳入选择标准的36例经单纯应用抗结核药物行保守治疗的老年性脊柱结核病例进行分析研究,其中男19例,女17例;年龄60～85岁,平均73.5岁。36例患者病灶均处于活跃期,血沉及CRP水平高于正常。治疗方法为联合用药(3HRZE/6-9HRE),疗程9～12个月。随诊通过观察结核症状、化验指标和放射学的影像变化以评价疗效并调整用药,通过视觉模拟评分(VAS)评价疼痛程度。结果:36例均获随访,时间8～24个月,平均15个月。其中31例患者化疗9～12个月结核病灶治愈,血沉及CRP恢复正常;4例(对利福平或异烟肼耐药)选用左氧氟沙星、对氨基水杨酸等抗结核药物化疗15个月后痊愈;1例患者结核症状加重,经手术治疗3个月后缓解,血沉及CRP恢复正常。影像学变化:治疗后X线及CT示椎体骨质硬化、融合,未见明显后凸畸形,1例手术患者植骨融合,未见内固定松动。治疗前及末次随访时Cobb角分别为(17.6±2.3)°、(18.1±2.7)°(P>0.05);MRI示椎旁脓肿吸收,椎体炎症消退。VAS评分治疗前为6.5±1.7,末次随访时为1.4±0.5(P<0.05)。7例患者出现药物不良反应,通过暂时停药并配以对症药物治疗后恢复正常。结论:对于早期老年脊柱结核病例,在严格的督导下单纯应用抗结核药物行规范的个体化保守治疗可获得满意的效果。     

老年患者结核性脑膜炎脑脊液细胞学及临床特点

目的探讨老年结核性脑膜炎患者脑脊液细胞学(CSF)变化及临床特点。方法42例病人经临床和辅助检查确诊,采用脑脊液细胞玻片离心沉淀法收集细胞,经MGG染色后在显微镜下观察。结果全部病例脑脊液细胞学均有异常,老年患者脑脊液细胞学有明显不同的特点。结论初诊时,脑脊液细胞学以淋巴细胞比例占优势较多,随病程进展出现程度不同的混合细胞反应,治疗有效者嗜中性粒细胞下降及消失较快;一部分患者一直以淋巴细胞占优势,伴有激活淋巴细胞、激活单核细胞,并持续性较长时间。脑脊液细胞学的动态变化,为判断老年结核性脑膜炎的病情转归、疗效有着重要的临床价值。     

结核性脑膜炎脑脊液细胞学的特征性表现

目的探讨脑脊液细胞学检查对结核性脑膜炎早期临床诊断的价值。方法采用玻片离心沉淀法制片收集脑脊液细胞,瑞-姬姆萨染色(MGG),光学显微镜分类计数。结果37例临床诊断为结核性脑膜炎患者的脑脊液细胞学呈以下改变:细胞学形态以斑片状聚集分布的激活型单核细胞、单核吞细胞和巨噬细胞,周围伴中性粒细胞和淋巴细胞,中性粒细胞比例为35.57±22.95%,类似于无反应性肉芽肿样改变。结论形似无反应性肉芽肿样的脑脊液细胞学改变以及中性粒细胞特征性的比率,可能是结核性脑膜炎早期诊断的特征性改变。     

Splenic Vein Occlusion Secondary to Tuberculous Lymphadenitis at the Splenic Hilum: Report of a Case

(Received for publication on Dec. 16, 1998; accepted on Nov. 11, 1999)