艾滋病合并隐球菌性与结核性脑膜炎多重感染的临床及影像学特征分析

 目的 探究艾滋病（aquired immunodeficiency syndrome，AIDS）合并隐球菌性脑膜炎（cryptococcal meningitis，CM）与结核性脑膜炎（tuberculous meningitis，TBM）多重感染患者的临床与MRI影像特点，为临床诊治提供参考。方法 回顾性分析上海市公共卫生临床中心2015年9月至2021年10月收治的39例艾滋病合并隐球菌性与结核性脑膜炎（AIDS/CM/TBM）患者的临床资料，并比较其与61例艾滋病合并隐球菌性脑膜炎（AIDS/CM）患者和42例艾滋病合并结核性脑膜炎（AIDS/TBM）患者的临床表现、实验室指标及头颅MRI影像特征等方面的差异。结果 AIDS/CM/TBM组患者头痛的发生率高于AIDS/TBM组，抽搐、视力障碍、意识障碍的发生率高于AIDS/CM组和AIDS/TBM组，差异均有统计学意义（P<0.05）。32例（82.0%）AIDS/CM/TBM患者CD4⁺T淋巴细胞计数≤100个/μL。AIDS/CM/TBM组白细胞计数、脑脊液蛋白水平均高于AIDS/CM组，脑脊液糖水平低于AIDS/CM组；脑脊液压力和脑脊液氯化物水平高于AIDS/TBM组，差异均有统计学意义（P<0.05）。34例（87.2%）AIDS/CM/TBM患者头颅MRI检查存在病灶，多发为主，呈脑膜炎和脑膜脑炎表现，脑叶病灶发生率高于AIDS/CM组，血管周围间隙扩大或胶样假囊的出现率低于AIDS/CM组，差异均有统计学意义（P<0.05）。多因素Logistic回归分析结果显示头痛、意识障碍及脑脊液糖≤1.85 mmol/L与AIDS/CM/TBM多重感染相关（P=0.009，0.005，0.002）。结论 AIDS/CM/TBM临床表现更重，实验室检查变化更显著，头颅MRI表现以脑膜炎和脑膜脑炎为主；头痛、意识障碍及脑脊液糖≤1.85 mmol/L对其诊断具有提示意义，有助于临床及时干预。

Analysis of clinical and imaging characteristics of cryptococcal meningitis and tuberculous meningitis co-infection in AIDS patients

Objective To investigate the clinical and MRI characteristics of cryptococcal meningitis and tuberculous meningitis co-infection in aquired immunodeficiency syndrome(AIDS)patients,and to improve its diagnostic efficacy. Methods The clinical data of 39 AIDS patients with cryptococcal meningitis and tuberculous meningitis co-infection(AIDS/CM/TBM) who were admitted to Shanghai Public Health Clinical Center from Sept 2015 to Oct 2021 were retrospectively analyzed. Their clinical manifestations,laboratory results and MRI findings were compared with 61 AIDS patients with cryptococcal meningitis(AIDS/CM)and 42 AIDS patients with tuberculous meningitis(AIDS/TBM).Results The incidence rate of headache of the AIDS/CM/TBM patients was higher than that of the AIDS/TBM patients,and the incidence rate of convulsion,visual disorders,consciousness disorders were higher than those in the AIDS/CM patients and AIDS/TBM patients(P<0.05).The CD4⁺ T cell counts of 32 (82.0%) AIDS/CM/TBM patients were ≤ 100 cells/μL. The white blood cell counts and the cerebrospinal fluid(CSF)protein levels in the AIDS/CM/TBM patients were significantly higher than those in the AIDS/CM patients,and the CSF glucose levels were significantly lower than those in the AIDS/CM patients(P<0.05).The CSF opening pressure and the CSF chloride levels in the AIDS/CM/TBM patients were significantly higher than those in the AIDS/TBM patients(P<0.05). Thirty-four (87.2%) AIDS/CM/TBM patients showed intracranial lesions in MRI examination, and the main manifestations were meningitis and meningoencephalitis.The incidence of brain lobe lesions in the AIDS/CM/TBM patients was higher than that of the AIDS/CM patients,and the incidence of dilated VirchowRobin spaces(VRS) or pseudocysts was lower than that of the AIDS/CM patients (P<0.05). Multivariate Logistic regression analysis showed that headache,consciousness disorders,and CSF glucose levels ≤ 1.85 mmol/L were correlated with the multiple infection of AIDS/CM/TBM(P=0.009,0.005, 0.002). Conclusion The clinical manifestations of AIDS/CM/TBM are more severe,the changes of laboratory examination are more significant,and the manifestations of brain MRI are meningitis and meningoencephalitis. Headache,consciousness disorders,and CSF glucose levels ≤ 1.85 mmol/L have suggestive significance for clinical diagnosis,which are helpful for timely intervention.