结核性脑膜炎评分系统对儿童结核性脑膜炎的诊断价值

目的 评价结核性脑膜炎(TBM)评分系统对儿童TBM与病毒性脑炎进行鉴别的价值。方法 回顾性分析2010年1月1日至2017年12月31日天津市儿童医院呼吸科收住院的确诊及临床诊断TBM的患儿102例(TBM组),以及同期病毒性脑炎患儿125例(病毒性脑炎组)。TBM评分系统采用包括临床表现、脑脊液检测结果、影像学表现、肺结核或肺外结核的其他表现进行综合评分来诊断TBM(分值越高,越支持TBM诊断;评分≥12分可以临床诊断TBM)。采用病例对照研究的方法,比较该评分系统诊断TBM的敏感度及特异度;同时比较该评分系统与结核菌素皮肤试验(TST)、γ干扰素释放试验(IGRA)及脑脊液病原学检测敏感度的差异。结果 TBM组患儿中,16例(15.69%,16/102)脑脊液病原学检测阳性,确诊为TBM患儿;其余86例(84.31%,86/102)TBM患儿经评分系统评估,分值为(13.25±2.22)分,明显高于病毒性脑炎组患儿的评分(3.79±2.48)分],差异有统计学意义(t=29.97,P<0.001)。86例患儿中,76例患儿TBM评分≥12分,判断为临床诊断TBM患儿;TBM诊断的敏感度为90.20%(92/102),特异度为100.00%(102/102)。脑脊液病原学检查中,抗酸杆菌染色的敏感度为15.69%(16/102),结核分枝杆菌培养的敏感度为10.78%(11/102),DNA检测的敏感度为16.47%(14/85),均明显低于TBM评分系统(χ ²值分别为113.65、128.66、100.64,P值均<0.001)。免疫学检查方法中,TST的敏感度为50.00%(51/102),特异度为99.20%(124/125);IGRA的敏感度为72.55%(74/102),特异度为99.20%(124/125);敏感度均明显低于TBM评分系统(χ ²值分别为39.31、10.48,P值均<0.001)。 结论 TBM评分系统对TBM诊断价值较好,其敏感度明显高于脑脊液抗酸染色、脑脊液结核分枝杆菌培养、脑脊液DNA检测、TST及IGRA等检测方法。

The evaluation of tuberculous meningitis scoring system in the diagnose of tuberculous meningitis in children

Objective The purpose of this study was to evaluate the value of tuberculous meningitis (TBM) scoring system in differentiating TBM from viral meningitis.Methods This was a retrospective analysis on 102 TBM children who admitted to the Department of Respiration, Children’s Hospital of Tianjin between January 1, 2010 and December 31, 2017 (defined as the TBM group) and 125 children with viral encephalitis in the same period (defined as the viral encephalitis control group). TBM was diagnosed using a comprehensive scoring system that included clinical manifestations, cerebrospinal fluid (CSF) test results, imaging findings, and other manifestations of pulmonary tuberculosis/extrapulmonary tuberculosis. The higher the score, the more TBM diagnosis was supported. TBM could be clinically diagnosed if the score was greater than or equal to 12. In this case-control study, the sensitivity and specificity of the scoring system in the diagnosis of TBM were analyzed. At the same time, the difference in test sensitivity among the scoring system and the tuberculin skin test (TST), the tests for release of interferon (IGRA) and the CSF etiology was compared.Results Among the children in the TBM group, 16 (15.69%, 16/102) of them were positive in the CSF etiology test and were confirmed as definite TBM by the scoring system. The score of the remaining 86 (84.31%, 86/102) patients with TBM was (13.25±2.22), which was higher than that of the children with viral encephalitis (3.79±2.48). The difference was statistically significant (t=29.97, P<0.001). Seventy-six of the 86 cases had a TBM score of ≥12, and thus were clinically diagnosed as TBM. The sensitivity of the TBM scoring system for the diagnosis of TBM was 90.20% (92/102) and the specificity was 100.00% (102/102). In the examination of CSF etiology, the sensitivity of anti-acid staining of Mycobacterium tuberculosis was 15.69% (16/102), the sensitivity of culture was 10.78% (11/102), and the sensitivity of DNA testing was 16.47% (14/85), which were significantly lower than that of TBM scoring system (χ ²=113.65, 128.66, 100.64, Ps<0.001). In the immunological examination, the sensitivity of TST test was 50.00% (51/102) and the specificity was 99.20% (124/125). IGRA had a sensitivity of 72.55% (74/102) and a specificity of 99.20% (124/125). The sensitivities were significantly lower than that of the TBM scoring system (χ ²=39.31, 10.48, Ps<0.001).Conclusion The TBM scoring system has a good diagnostic value for TBM, and its sensitivity is significantly higher than those of CSF acid stain, CSF culture, CSF DNA test, TST and IGRA detection methods.