结核性脑膜炎并发颅神经损伤的临床特征分析

目的 探讨结核性脑膜炎(tuberculous meningitis,TBM)并发颅神经损伤的临床特征。方法 收集2014年6月至2017年12月首都医科大学附属北京胸科医院收治的486例经临床诊断性治疗确诊为TBM的患者资料,其中414例(85.2%)未出现颅神经损伤(无颅神经损伤组),72例(14.8%)并发颅神经损伤(有颅神经损伤组)。分析两组患者临床特征和转归情况,以及并发颅神经损伤的危险因素。结果 72例有颅神经损伤组患者在发热(90.3%,65/72)、头痛(90.3%,65/72)、恶心呕吐(56.9%,41/72)、意识障碍(54.2%,39/72)、误诊率(38.9%,28/72)方面均高于无颅神经损伤组[分别为77.3%(320/414)、66.7%(276/414)、22.7%(94/414)、31.4%(130/414)、26.6%(110/414)](χ ²=6.280,P=0.012;χ ²=16.334,P=0.000;χ ²=35.840,P=0.000;χ ²=14.015,P=0.000;χ ²=5.201,P=0.023);logistic回归分析显示,TBM患者并发颅神经损伤的危险因素为有头痛的症状[OR(95%CI)=4.109(1.806~9.349),Wald χ ²=11.353,P=0.001]、有意识障碍[OR(95%CI)=2.531(1.493~4.290),Wald χ ²=11.901,P=0.001]。72例并发颅神经损伤的患者多见视神经(52.8%,38/72)、动眼神经(56.9%,41/72)损伤,两组颅神经同时受累16例(22.2%),三组颅神经同时受累3例(4.2%)。抗结核药物治疗2个月后随访,69例(95.8%)患者颅神经损伤完全恢复,1例(1.4%)患者因病情严重死亡,仅2例(2.8%)患者遗留有动眼神经和视神经损伤后遗症。 结论 TBM患者并发颅神经损伤并不少见,误诊率较高,发热、头痛、恶心呕吐、意识障碍等症状较明显,且头痛、意识障碍与出现颅神经损伤密切相关,经有效抗结核治疗转归良好。

Clinical characteristics of tuberculous meningitis complicated with cranial nerve injury

Objective To investigate the clinical features of tuberculous meningitis (TBM) complicated with cranial nerve injury.Methods A total of 486 clinical diagnosed TBM patients in Beijing Chest Hospital of Capital Medical University from June 2014 to December 2017 were collected. Of these, 414 (85.2%) cases had no cranial nerve injury (no cranial nerve injury group) and 72 (14.8%) cases with cranial nerve injury (with cranial nerve injury group). The clinical characteristics and outcomes of the two groups of patients were analyzed, as well as the risk factors for concurrent cranial nerve injury.Results Seventy-two patients with cranial nerve injury had fever (90.3%, 65/72), headache (90.3%, 65/72), nausea and vomiting (56.9%, 41/72), disturbance of consciousness (54.2%, 39/72), misdiagnosis rate (38.9%, 28/72) were higher than those without cranial nerve injury (77.3% (320/414), 66.7% (276/414), 22.7% (94/414), 31.4% (130/414), 26.6% (110/414), respectively) (χ ²=6.280, P=0.012;χ ²=16.334, P=0.000; χ ²=35.840, P=0.000; χ ²=14.015, P=0.000; χ ²=5.201, P=0.023, respectively); logistic regression analysis showed that the risk factors for cranial nerve injury in patients with TBM were symptom of headache (OR (95%CI)=4.109 (1.806-9.349), Wald χ ²=11.353, P=0.001), and disturbance of consciousness (OR (95%CI)=2.531 (1.493-4.290), Wald χ ²=11.901, P=0.001). Seventy-two patients with cranial nerve injury were more likely to have optic nerve (52.8%, 38/72) and oculomotor nerve (56.9%, 41/72) injury. Sixteen (22.2%) cases had two groups of cranial nerves involved and 3 (4.2%) cases had three groups of cranial nerves involved. After 2 months of anti-tuberculous drug treatment, 69 patients (95.8%) had complete recovery of cranial nerve injury, 1 patient (1.4%) died of serious illness, and only 2 patients (2.8%) left oculomotor and optic nerve sequelae. Conclusion It is not uncommon for patients with TBM to have cranial nerve injury. The rate of misdiagnosis is high. The symptoms of fever, headache, nausea and vomiting, and disturbance of consciousness are obvious. However, headache and consciousness disorder are closely related to the occurrence of cranial nerve injury. The cranial nerve injury can be recovered well after effective anti-tuberculosis treatment.