结核性脑膜炎100例临床分析

目的探讨成人结核性脑膜炎的临床特点、脑脊液改变、影像学特点、诊治方法及其转归。方法回顾性分析1982年1月至2003年12月间在北京协和医院确诊或临床诊断为结核性脑膜炎的100例住院患者的临床资料。结果100例结核性脑膜炎患者中,男性49例,女性51例;年龄（31±11）岁。70％为慢性病程（11．1±9．2）周。13例确诊病例,脑脊液结核杆菌培养阳性,或开颅脑活检病理证实为结核性肉芽肿或粟粒样结核;87例为临床诊断病例。临床表现以发热（97％）,头痛（92％）、意识障碍（71％）和脑膜刺激征多见（77％）,44例伴颅神经损害,以动眼神经和外展神经受损为主。35例X线胸片有活动性肺结核表现,肺外活动性结核12例,陈旧性肺结核18例。腰穿示颅内压增高者占86％,脑脊液呈非化脓性改变,白细胞增高以淋巴细胞为主,蛋白质明显增高,葡萄糖显著下降。52例患者头颅影像学有异常发现,脑室扩张、交通性脑积水和脑梗死最常见。全部病例均接受抗结核治疗,9例行侧脑室外引流术。81例患者病情好转,4例因合并开放性肺结核转结核病院治疗,8例自动出院,死亡7例。结论慢性脑膜炎若伴发肺结核或肺外结核者应高度疑诊结核性,鉴别诊断和诊断性抗结核治疗有效有助诊断。脑脊液涂片和（或）培养抗酸杆菌／结核分枝杆菌阳性,以及脑活检为诊断的金标准。早期诊断、早期治疗是改善本病预后的关键。

Tuberculous meningitis in Chinese adults: a report of 100 cases

OBJECTIVE: To investigate the clinical features, cerebrospinal fluid (CSF) changes, imaging characteristics, diagnostic methods, treatment regimens and outcomes of Chinese adult patients with tuberculous meningitis (TBM). METHODS: Clinical data of 100 cases of TBM admitted to Peking Union Medical College Hospital from January 1982 to December 2003 were investigated retrospectively. Data were collected with regard to the clinical, laboratory and demographic characteristics of the patients as well as the results of radiological investigations and data of clinical outcome. RESULTS: One hundred TBM cases were included in this study; there were 49 males and 51 females. The mean age was (31 +/- 11) years. Seventy percent of the patients was of chronic duration (11.1 +/- 9.2) weeks. Thirteen cases were definitely diagnosed through positive CSF culture and smear or brain biopsy, the remaining 87 cases were diagnosed clinically. Fever (97%), headache (92%), decreased level of consciousness (71%), meningeal irritation (77%) and impairment of cranial nerve function were the most frequent symptoms and signs. Thirty-five cases were accompanied with active pulmonary tuberculosis and 12 cases with extrapulmonary tuberculosis. Raised intracranial pressure was present in 86%. CSF was non-purulent with lymphocytic pleocytosis, marked elevation of protein concentration and significant decrease of glucose. Sixty-seven cases had imaging data; abnormalities were found in 52 with ventricular enlargement, hydrocephalus and infarction the most frequent findings. All the patients received anti-tuberculosis therapy, nine underwent neurosurgical drain due to hydrocephalus, eighty-one improved and seven died. CONCLUSIONS: TBM should be suspected when chronic meningitis was accompanied with active pulmonary or extrapulmonary tuberculosis. Differential diagnosis and trial anti-tuberculosis therapy may be of help for the diagnosis. Positive CSF smear and culture and biopsy of brain or meninges are the golden standards for the diagnosis of TBM. Early diagnosis and treatment are very important for improving the outcome.