新型隐球菌颅内感染的临床表现及其抗原检测的临床应用

目的 探讨新型隐球菌性颅内感染的临床特点、脑脊液的相关检查和隐球菌抗原胶乳凝集系统检测的临床应用。方法应用临床病例分析统计方法，对本院78例确诊的新型隐球菌脑膜炎或脑炎患者的发病规律、临床特点和脑脊液检查进行归纳、分析，并进行脑脊液隐球菌抗原胶乳凝集系统的检测。结果78例患者中有69例（88．5％）为亚急性或慢性起病，9例（11．5％）为急性起病，64．1％以上的患者有头痛、发热；第1次腰穿隐球菌抗原胶乳凝集检查阳性者为97．4％。结论新型隐球菌颅内感染起病形式各异，临床表现、脑脊液常规、生化检查及头颅影像学检查均缺乏特异性；隐球菌抗原胶乳凝集对早期诊断新型隐球菌颅内感染有重要价值。     

新型隐球菌性脑膜炎20例临床分析

目的 总结分析新型隐球菌性脑膜炎（CM）的临床表现、实验室检查、影像学表现、治疗及预后,探讨CM的治疗效果.方法 回顾性分析我院20例CM的临床资料.结果 所有患者确诊前均被误诊为其他疾病,多数患者无基础病变（65.0%）.首发症状多表现为发热（90.0%）,头痛（95.0%）;发热、头痛、呕吐、视盘水肿和脑膜刺激征阳性为主要临床表现;19例脑脊液涂片墨汁染色阳性,1例多次涂片阴性,培养出隐球菌.氟康唑和二性霉素B联用疗效显著.结论 隐球菌性脑膜炎临床表现、脑脊液常规、生化及影像学检查缺乏特异性,脑脊液墨汁染色和细菌培养为确诊依据.氟康唑和二性霉素B联用效果好,二性霉素B鞘内注射联合5-氟胞嘧啶口服能显著提高疗效.     

新型隐球菌颅内感染101例临床特点及诊断

目的总结新型隐球菌颅内感染的临床特点及临床诊断。方法用临床病例分析统计方法,对101例确诊的新型隐球菌脑膜炎或脑炎患者的发病规律和临床特点进行归纳、分析。结果101例患者中95例(94.1%)为亚急性或慢性起病,85.0%以上的患者有头痛、发热,72例(71.3%)患者出现呕吐,另外意识障碍、精神异常、发作性抽搐、视力、听力损害也较常见。97例脑脊液涂片发现隐球菌;2例多次涂片阴性,隐球菌培养阳性;1例经脑实质穿刺活检病理确诊;1例小脑囊肿术后病理确诊。大部分病例确诊前被误诊为其他疾病。结论新型隐球菌颅内感染大多数以亚急性或慢性起病,临床表现、脑脊液常规、生化检查及头颅影像学检查均缺乏特异性。脑脊液或脑组织病原学检查发现隐球菌为诊断的金标准。     

新型隐球菌性脑膜炎26例临床观察

目的观察新型隐球菌性脑膜炎的临床特点,总结分析其临床表现、实验室检查、鉴别诊断与治疗原则,探讨新型隐球菌性脑膜炎治疗进展。方法对26例新型隐球菌性脑膜炎患者的临床资料进行回顾,总结其治疗经验。结果所有患者均表现为头痛、发热,脑脊液乳胶凝集试验阳性,其中21例脑脊液墨汁染色可见新型隐球菌生长。经两性霉素B联合氟胞嘧啶、氟康唑治疗,总有效率达76.92%(20/26);4例早期采用两性霉素B联合伏立康唑治疗的患者症状与体征明显改善。结论新型隐球菌性脑膜炎误诊率高,脑脊液乳胶凝集试验阳性有助于早期明确诊断,可减少误诊率。两性霉素B、氟胞嘧啶、氟康唑均为一线抗真菌药物,联合用药可提高疗效。     

隐球菌性脑膜炎早期诊断及疗效探讨(附30例报道)

目的提高对隐球菌性脑膜炎的认识,探讨隐球菌性脑膜炎的最佳诊断与治疗方法。方法对我科收治的30例经病原学证实的隐球菌性脑膜炎患者进行回顾性分析。结果30例隐球菌性脑膜炎患者入院前有20例被误诊,其中误诊为结核性脑膜炎14例。采用涂片墨汁染色法,脑脊液细胞学MGG染色法,阿利新兰染色法检出隐球菌的阳性率分别为66.67%,84.00%,81.82%。单一应用两性霉素B治疗12例,好转4例,恶化2例,死亡6例。应用大扶康或氟康唑静脉注射18例,其中对于较重的辅以脑脊液置换加鞘内注射两性霉素B和(或)氟美松,好转14例,恶化2例,死亡2例。结论隐球菌性脑膜炎的误诊率很高。采用多种检测方法,多次反复送检,可以提高隐球菌性脑膜炎的早期诊断率。联合用药较单一用药好,首选大扶康或氟康唑,辅以脑脊液置换,并鞘内注射,效果更好。     

新型隐球菌性脑膜炎和(或)脑炎102例诊断与治疗经验

目的总结新型隐球菌性脑膜炎和(或)脑炎临床特点,为早期诊断和有效治疗提供经验。方法与结果回顾分析102例新型隐球菌性脑膜炎和(或)脑炎患者临床特点,主要表现为缓慢进展的颅内高压症状、脑膜刺激征和脑神经损害症状,累及脑实质者可出现癫发作、偏瘫、精神障碍、共济失调等。新型隐球菌性脑膜炎和(或)脑炎误诊率较高,尤其易误诊为结核性脑膜炎,对疑似患者,反复多次脑脊液细菌涂片、乳胶凝集试验和影像学检查相结合,可提高诊断准确性。两性霉素B与氟胞嘧啶诱导治疗后联合氟康唑维持治疗是目前临床常用治疗方案,可取得较好疗效,外科手术(如侧脑室-腹腔分流术)是治疗合并脑积水的新型隐球菌性脑膜炎和(或)脑炎的有效方法。结论新型隐球菌性脑膜炎和(或)脑炎临床表现缺乏特异性,极易误诊,对于疑似患者,应反复多次行脑脊液细菌涂片,结合乳胶凝集试验和影像学检查尽早明确诊断。对于诊断明确的患者应采用联合、长期抗真菌治疗方案,必要时积极采取外科手术治疗,改善患者预后。     

19例隐球菌性脑膜炎的临床分析

目的探讨隐球菌性脑膜炎的临床特征。方法回顾性分析19例临床确诊隐球菌性脑膜炎患者的一般情况、临床表现、合并疾患、脑脊液及影像学改变、治疗及转归等的特征,探寻其中的规律。结果该组患者皆不伴有明确的免疫缺陷性疾病,多以头痛、呕吐等颅高压症状为主要表现,通过脑脊液检查能够较快确定诊断,脑实质的影像学改变很常见,两性霉素B治疗安全有效,鞘内注射及脑室穿刺等治疗方法也是可行的,早期治疗可以改善预后。结论隐球菌性脑膜炎的易感病因仍有不明之处,隐球菌性脑膜炎的临床表现多样,治疗方法仍有待规范,预后不满意。     

新型隐球菌脑膜炎的诊断探讨及文献复习

目的:探讨新型隐球菌脑膜炎(CNM)的临床特点及诊断方法。方法:对18例CNM患者的临床资料进行回顾性分析并文献复习。结果:18例患者均经病原学确诊。大部分CNM患者为亚急性起病,临床表现无特异性,误诊率高,首诊误诊率为72％,其中误诊为结核性脑膜炎的占69％。结论:脑脊液中找到新型隐球菌是诊断该病的重要依据,多种快速检测手段结合可提高早期诊断率。     

隐球菌性脑膜炎78例脑脊液细胞学改变

目的总结隐球菌性脑膜炎(CNM)的脑脊液标本细胞学检测资料,提高对隐球菌性脑膜炎的诊断。方法总结近6年(2003年1月至2008年7月)我院CNM的临床资料、脑脊液诊断情况。结果共78例患者,常规涂片墨汁染色首检阳性者48例(61.5%),26例(33.3%)重复送检时发现隐球菌,余4例(5.1%)墨汁染色始终呈阴性,靠隐球菌培养确诊。55例(70.5%)行细胞学检查的患者首次送检即直接找到隐球菌。结论脑脊液细胞学较常规涂片墨汁染色首检隐球菌阳性率更高。CNM的诊断有赖于脑脊液墨汁染色、细胞学检查、隐球菌培养等多种手段相结合以提高其阳性率。     

新型隐球菌脑膜炎的临床分析

目的 分析新型隐球菌脑膜炎的临床及脑脊液改变特点.方法 对2例新型隐球菌脑膜炎进行回顾性分析.结果 2例病人均有发热、头痛、脑膜刺激征阳性.突出特点是颅内压力显著增高,脑脊液涂片墨汁染色1例在入院后首次检查发现新型隐球菌,另1例反复多次检查才发现新型隐球菌.死亡1例,痊愈1例.结论 新型隐球菌脑膜炎除脑膜炎的表现外,突出特点是颅内压力显著增高,脑脊液墨汁染色查见新型隐球菌是确诊的依据,但需多次检查才能发现新型隐球菌,导致诊断困难,不能及时抗真菌治疗,本病预后差,病死率高.     

Quantitation of lymphocyte subsets in cerebrospinal fluid and blood during the clinical course of aseptic and bacterial meningitis.

Mononuclear cell subsets in cerebrospinal fluid (CSF) and peripheral blood (PB) were monitored during the clinical course in 23 patients with acute meningitis using 6 monoclonal antibodies. Significant differences between aseptic and bacterial meningitis mainly consisted of a higher percentage of OKT4-positive cells in PB in the acute phase of bacterial meningitis. Significant differences between CSF and PB are found in the amount of most cell subtypes at all times except the acute phase of bacterial meningitis. The OKT4/OKT8 ratio was always significantly higher in CSF and correlated with the acuity of inflammation in bacterial meningitis.     

脑脊液检测对隐球菌性脑膜炎的临床意义

目的探讨脑脊液(CSF)检测对隐球菌性脑膜炎(CM)的临床诊断、治疗及预后的意义。方法分析36例CM患者的CSF动态变化、疗效及转归。结果 CM患者在治疗前32例(88.9%)CSF压力升高、34例(94.4%)墨汁染色阳性、26例(72.2%)白细胞总数升高、33例(91.7%)蛋白质含量升高、27例(75.0%)氯化物含量降低,治疗后6例(33.3%)脑脊液压力升高、4例(22.2%)墨汁染色阳性、8例(44.4%)白细胞总数升高、10例(55.6%)蛋白质含量升高、4例(22.2%)氯化物含量降低,且上述指标均呈动态变化。36例患者中治愈17例(47.2%),好转10例(27.8%),死亡9例(死于脑疝)(25%)。结论脑脊液检查是CM临床诊断最重要的手段,在治疗过程中可作为动态观察CM疗效的指标。     

自发性低颅压综合征31例临床特征和影像学分析

目的 探讨自发性低颅压综合征（SIH）的临床特点和影像学改变.方法 回顾性分析31例SIH患者的临床及影像资料.结果 所有患者均有体位性头痛,可伴有恶心、呕吐、头晕、耳鸣、听力丧失、行走不稳、一过性视物模糊、复视、颈肩部疼痛、颈强直 CSF压力均＜70 mmH2O,蛋白升高12例,WBC增多11例,RBC增多7例 全部患者行头颅CT检查,8例见脑肿胀,脑沟变浅,脑室变窄,临床症状消失后复查均恢复正常 15例行头颅MRI检查,8例行增强检查示硬脑膜弥漫性强化,头颅CT及MRI检查见4例硬膜下积液、2例硬膜下血肿 全部患者采用内科综合疗法,1例行硬膜下血肿清除术,均痊愈.结论 SIH的临床表现多样,体位性头痛是特征性症状,腰穿CSF及头颅MRI检查具有诊断价值 本病预后良好,但少数并发硬膜下血肿.     

后颅窝开颅术后无菌性脑膜炎的临床分析

目的探讨后颅窝开颅术后无菌性脑膜炎的诊断和治疗。方法回顾性分析16例后颅窝开颅术后无菌性脑膜炎患者的临床特点和治疗方式。结果16例患者均有发热，体温37.5～40.1℃，白细胞计数（45～110）×10^6/L，脑脊液糖定量（2.2～3.9）mmol/L，细菌培养阴性；所有患者均接受地塞米松静脉注射和鞘内注射治疗；6例间断腰穿，10例腰穿置管持续引流；16例患者均治愈，其中14例院内治愈，2例自动出院，4月内自愈。结论术后3d开始发热，脑脊液白细胞数增高，糖定量正常和细菌培养阴性可以诊断为无菌性脑膜炎；激素治疗和脑脊液引流是治疗无菌性脑膜炎的主要手段。     

广州管圆线虫病致嗜酸细胞性脑膜炎九例患者临床和脑脊液细胞学特点

目的 总结北方地区出现的广州管圆线虫感染引起的嗜酸细胞性脑膜炎病例的临床特点,并探讨脑脊液细胞学对该病的诊断意义.方法 对中国医学科学院北京协和医院收治的9例在北京地区发病的患者进行临床观察和脑脊液细胞学等检查,总结分析并复习文献.结果 9例患者中男性4例,女性5例.临床表现为急性起病(9例)、发热(9例)、头痛(9例),伴恶心或呕吐(3例)、脑膜刺激征(7例)、视乳头水肿(2例)、肢体感觉异常(7例)、脑神经受累(3例)和肢体瘫痪(1例)等.临床分型:脑膜型8例,脊髓型1例.神经影像学:4例存在软脑膜弥漫强化,脑和脊髓实质点片状异常信号者4例.脑脊液检查:全部患者均有压力升高,白细胞均升高[(70～780)×106/L],蛋白均升高,5例有葡萄糖减低.脑脊液细胞学:嗜酸细胞比例均升高.1例(仅行1次腰穿)嗜酸细胞比例5%,其余8例脑脊液嗜酸细胞多次枪查在45%～90%,呈现以嗜酸细胞为主的炎症,伴激活淋巴细胞和单核细胞,偶见浆细胞,未见寄生虫虫体.结论 脑脊液嗜酸细胞比例超过50%的脑膜炎应高度怀疑广州管圆线虫病.临床结合脑脊液细胞学对诊断广州管圆线虫病有一定实用意义.     

Application of the polymerase chain reaction to monitor Mycobacterium tuberculosis DNA in the CSF of patients with tuberculous meningitis after antibiotic treatment.

The polymerase chain reaction (PCR) was used to detect Mycobacterium tuberculosis DNA in 29 CSF specimens from seven patients with tuberculous meningitis after the start of antituberculous chemotherapy. Ten of the 13 CSF specimens taken from these patients with an initial treatment of three weeks were positive for the PCR study. By contrast, only one of the other 16 CSF specimens taken from patients treated for more than three weeks was positive. This study shows that M tuberculosis DNA can exist in the CSF of a patient with tuberculous meningitis for three weeks after treatment and that PCR can still be a sensitive method to detect M tuberculosis DNA in the CSF after the start of treatment in patients with tuberculous meningitis.     

Detection of mycobacterial antigen in cerebrospinal fluid: diagnostic and prognostic significance

Inhibition enzyme-linked immunosorbent assay (ELISA) was standardised to quantitate circulating mycobacterial antigens in cerebrospinal fluid (CSF) specimens. Of the 40 patients with clinical diagnosis of tuberculous meningitis, the assay was found to be positive in 26 patients. In a control group of 42 patients with non-tuberculous neurological diseases the assay was negative. The assay showed a sensitivity of 65 and 100% specificity for tuberculous meningitis. In 8 patients with tuberculous meningitis receiving chemotherapy, multiple CSF examinations were subjected to this assay. The antigen concentration showed a gradual decrease between 3 and 4 weeks after the commencement of antituberculosis chemotherapy. There was a positive correlation between clinical recovery and antigen concentration. Detection of mycobacterial antigen in CSF specimen by inhibition ELISA has not only diagnostic utility but also could be applied to monitor antituberculosis chemotherapy in patients with tuberculous meningitis. The assay is reproducible and feasible for routine immunology laboratory. It also could be considered as a diagnostic aid when repeated bacteriological cultures are negative in CSF specimens of patients with tuberculous meningitis.     

Cerebrospinal fluid cytokines and matrix metalloproteinases in human immunodeficiency seropositive and seronegative patients of tuberculous meningitis

Background:

Some important clinical differences exist between human immunodeficiency virus (HIV)-seropositive and HIV-seronegative patients. Alterations in the cerebrospinal fluid (CSF) cytokines and matrix metalloproteinase have been noted in tuberculous meningitis. In HIV-infected patients, the immunopathogenesis is expected to be different.

Materials and Methods:

In this study, 64 patients of tuberculous meningitis (28 HIV seropositive and 36 seronegative) were included. The patients were followed up for six months. Cerebrospinal fluid (CSF) samples of tuberculous meningitis patients and 20 controls were subjected to tissue necrosis factor (TNF)-α, interleukin (IL)-1β, interferon (IFN)-γ, IL-10, matrix metalloproteinase (MMP)-2, and MMP-9 estimations. The levels were correlated with the patients’ baseline clinical characteristics, CSF parameters, neuroimaging findings, and the outcome. The outcome was assessed and modified with the Barthel index.

Results:

The CSF cytokines and MMP levels were significantly elevated in tuberculous meningitis when compared with the controls. There was no significant difference seen between HIV seropositive and seronegative tuberculous meningitis, except for the IL-1β level, which was significantly lower in the HIV-infected patients. The cytokine and MMP levels did not correlate with the baseline clinical characteristics, disease severity, cerebrospinal fluid characteristics, neuroimaging findings, and outcome.

Conclusion:

In conclusion, HIV infection did not affect a majority of the CSF cytokines and MMP levels in tuberculous meningitis except for IL-1β level. None of the estimated inflammatory parameters correlated with the outcome.     

Preliminary studies of T lymphocyte subsets in patients with neurologic diseases

With immunofluorescence assay a preliminary study of T-cell subsets in the peripheral blood (PB) and cerebrospinal fluid (CSF) of patients with multiple sclerosis (MS), viral encephalitis, Guillain-Barré syndrome (GBS), tuberculous meningitis, and other neurological diseases (OND) was carried out. The results revealed that the T4+ percentage and T4+/T8+ ratio of PB as well as CSF increased, T8+ decreased in cases of MS. The changes of CSF T subsets in cases of (GBS) were similar to those in cases of MS. There was no difference in PB T subsets between GBS and the normal controls. The T4+/T8+ ratio of PB and CSF reduced in cases of tuberculous meningitis, and such changes were also found in PB of viral encephalitis patients. Therefore, it was demonstrated that the immunoregulatory dysfunctions were present in these neurological disorders, and the characters of the changes were different between infectious and autoimmune diseases.     

不同给药途径万古霉素在脑脊液和血液中药物浓度及疗效比较

目的探讨鞘内注射万古霉素治疗革兰氏阳性菌脑膜炎的疗效和安全性。方法前瞻性将26例确诊革兰氏阳性菌脑膜炎成年患者随机分为治疗组(13例)和对照组(13例),治疗组每日静脉注射万古霉素加鞘内给药,对照组仅静脉用药。分别收集血液和脑脊液,用荧光偏振免疫法测定其中的万古霉素药物浓度。结果两组比较,在脑脊液药物浓度、用药时间方面,治疗组明显优于对照组,差异有统计学意义(P均<0.01)。在用药过程中和随访的3～12个月期间,除1例出现"红人综合征"外,两组均未见明显不良反应。结论鞘内注射万古霉素可能是一种治疗革兰氏阳性菌感染性脑膜炎的安全、有效方法,可达到数倍于最小抑菌浓度的药物浓度,并能明显缩短治疗时间,减少治疗费用。