33例结核性脑膜炎的临床分析

目的 探讨结核性脑膜炎的临床特征、诊断和预防.方法回顾分析2008年9月~2012年2月我院收治的33例结核性脑膜炎患者的临床资料.结果 33例结核性脑膜炎患者均为散发,以中青年为主,多为隐匿起病.首发头痛、发热、恶心、呕吐,部分伴咳嗽,意识障碍,肢体瘫痪,颅神经损害,病理征阳性,脑膜刺激征阳性.脑脊液检查：涂片培养各发现抗酸杆菌阳性1例.病毒学检测：排除病毒性脑炎、脑膜炎.病理检查：无癌细胞及恶性肿瘤细胞.影像学检查：X线胸片,大部分发现有肺部结核病灶,（包括继发性肺结核,血行播散性肺结核,结核性胸膜炎,胸膜增厚）,少部分有生殖、泌尿系统、骨脊柱结核病灶;头部CT大部分有异常改变,主要为脑实质低密度灶脑积水,少部分有脑表面、室管膜的多发性小钙化灶,极少数伴脑梗死,脑出血.预后：近半数15例好转,7例未愈,6例有后遗症,5例死亡.结论 结核性脑膜炎按临床诊断标准易被诊断,但大部分患者起病隐匿,慢性病程,症状变化大,体征不典型.脑脊液初期不典型,抗酸杆菌阳性率低,早期易误诊误治,大部分确诊时已为中晚期,经抗结核治疗,大部分预后良好,部分未愈,部分留有后遗症,少部分死亡.

Clinical analysis of 33 cases of tuberculous meningitis

Objective To explore the clinical features, diagnosis and prevention of tuberculous meningitis （TBM）o Methods Retrospectively analyzing the clinical data of 33 patients with TBM from September 2008 to February 2012 in our hospi- tal. Results 33 patients with TBM were distributed, mainly young and middle-aged, most of them had chronic courses of the dis- ease. Usually the patients started with a headache, fever, nausea, vomiting, partly with coffgh, disturbance of consciousness, pa- ralysis, cranial nerve damage, positive pathological character, positive meningeal stimulation. Cerebrospinal fluid（CSF） examina- tion： Thought CSF smear 1 positive case with acid-fast bacillus was found. Virology test： rule out viral encephalitis, meningitis; Pathologic examination： no cancer cells and malignant tumor cells. Imaging examination： through X-ray chest radiograph it was found that most patients had pulmonary tuberculosis kitchens （ including secondary pulmonary tuberculosis, hematogenous dissemi- nated pulmonary tuberculosis, tuberculous pleurisy and pleural thickening）, and that a small number of cases had tuberculosis kitchens in reproductive and urinary system, bone, spine. There are mostly abnormal changes in head CT, which mainly appeared parenchymal low density focals hydrocephalus, partly showed multiple small calcifications on brain surface or ependymal, happen with cerebral infarction or cerebral hemorrhage in a very few. Prognosis： 15 cases turned for the better, 7 cases did not cure, 6 ca- ses had sequela, 5 cases died. Conclusion TBM is easily diagnosed by clinical diagnosis standard, which occur concealedly for the majority, of patients, has chronic disease course, symptoms of which change widely and signs of which are not typical. CSF of the patients with TBM is not typical early, positive rate of acid-fast bacilli smear of CSF is low. It is common that TBM was not di- agnosed and remedied early, and was diagnosed in mid-late stage. By anti-tuberculosis treatment, prognosis of most patients with TBM is possibly good, and some patients will not possibly cure, some possibly have sequela, minority of them possibly pass out.