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结核性脑膜炎/心包炎患者能使用激素吗?——1例14岁患者的循证治疗
引用本文:谭建龙,王双,廖再波.结核性脑膜炎/心包炎患者能使用激素吗?——1例14岁患者的循证治疗[J].中国循证医学杂志,2008,8(12):1122-1125.
作者姓名:谭建龙  王双  廖再波
作者单位:四川大学华西医院老年病科,成都,610041
摘    要:目的肺及肺外结核患者是否能使用激素是目前颇有争议的临床问题,结合1例肺结核合并结核性心包炎和结核性脑膜炎患者的病情,用循证临床实践的方法,就是否使用激素进行床旁循证治疗。方法计算机检索Cochrane图书馆、OVID、MEDLINE、www.guideline.org,查找和评价高质量临床证据,并根据患者意愿为患者制定治疗方案。结果共纳入11个RCT,2个Cochrane系统评价,9个指南。证据表明:①糖皮质激素能降低结核性脑膜炎患者的死亡风险,也能降低神经系统功能缺损的风险;②泼尼松龙使结核性心包炎患者总体死亡率降低(P=0.044),同时使心包炎所致的死亡风险也显著降低(P=0.004);③激素能否使肺结核患者获益仍有争议。结合患者病情和意愿,在抗痨治疗的基础上加用地塞米松等治疗7周后,患者脑脊液基本恢复正常,心包积液消失。结论对于结核性脑膜炎和结核性心包炎患者应常规使用糖皮质激素治疗,但如何选择糖皮质激素类药物以及治疗疗程仍未达成一致。

关 键 词:结核性脑膜炎  结核性心包炎  肺结核  糖皮质激素  循证治疗

Could Corticosteroids Be Used for Pulmonary Tuberculosis Combined with Tuberculous Meningitis and Tuberculous Pericarditis:An Evidence-based Treatment for a 14-year-old Boy
TAN Jian-long,WANG Shuang,LIAO Zai-bo.Could Corticosteroids Be Used for Pulmonary Tuberculosis Combined with Tuberculous Meningitis and Tuberculous Pericarditis:An Evidence-based Treatment for a 14-year-old Boy[J].Chinese Journal of Evidence-based Medicine,2008,8(12):1122-1125.
Authors:TAN Jian-long  WANG Shuang  LIAO Zai-bo
Institution:TAN Jian-long,WANG Shuang,LIAO Zai-bo Department of Geriatrics,West China Hospital,Sichuan University,Chengdu 610041,China
Abstract:Objective To formulate an evidence-based treatment for a patient with pulmonary tuberculosis combined with tuberculous meningitis and tuberculous pericarditis.Methods According to the principles of evidence-based clinical practice,we searched The Cochrane Library(Issue 2,2008),Ovid-Reviews(1991 to 2008),MEDLINE(1950 to 2008),and http://www.guideline.org.to identify the best evidence for treating a patient with pulmonary tuberculosis combined with tuberculous meningitis and tuberculous pericarditis.Results Nine guidelines,2 systematic reviews,and 11 randomized controlled trials were included.The evidence showed that corticosteroids could help reduce the risk of death and disabling residual neurological deficiencies in patients with tuberculous meningitis.After adjusting for age and gender,the overall death rate of patients with tuberculous pericarditis was significantly reduced by prednisolone(P=0.044),as well as the risk of death from pericarditis(P=0.004).But for patients with pulmonary tuberculosis,there was still a controversy about the use of corticosteroids.Given the evidence,the patient's clinical conditions,and his preferences,dexamethasone was used for the boy in question.After 7 weeks of treatment,his cerebrospinal fluid returned to normal and pericardial effusion disappeared.Conclusion Corticosteroids should be recommended in HIV-negative people with tuberculous meningitis or/and tuberculous pericarditis.The difference in the effectiveness of various corticosteroids such as dexamethasone,prednisolone,or methylprednisolone and the optimal duration of corticosteroid therapy is still unknown.
Keywords:Tuberculous meningitis  Tuberculous pericarditis  Pulmonary tuberculosis  Corticosteroids  Evidence-based treatment
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