【作者】 刘巧；

【导师】 吕晓菊；

【作者基本信息】 四川大学 ， 内科学， 2007， 硕士

【摘要】 [背景]由于器官移植的广泛开展，广谱抗菌药物的广泛应用及激素、免疫抑制剂、抗肿瘤化疗药物应用增多以及艾滋病的流行，近年中枢神经系统感染逐渐增多。结核性脑膜炎和隐球菌脑膜炎是两大类最常见的中枢神经系统感染。二者临床表现相似，早期确诊困难，极易延误治疗时机，导致病死率及致残率增加。[目的]通过比较二者的临床特征、实验室检查尤其是脑脊液检查及影像学特点，探讨早期诊断方法，从而进行针对性治疗。[方法]采用回顾性调查方法，收集华西医院2002.1—2006.12五年间确诊的327例结核性脑膜炎病人和1996年7月—2007年2月十一年间确诊的96例隐球菌性脑膜炎病人的病例资料。将临床资料分为一般情况、基础疾病、临床表现和实验室检查、尤其是脑脊液检查、影像学检查、治疗及疗效等归纳统计，建立数据库，做回顾性分析。采用SPSS10.0统计软件进行卡方检验或确切概率计算。计数资料用％表示，计量资料用均数±标准差((?)±s)表示。[结果] 327例结核性脑膜炎和96例隐球菌脑膜炎中，以30—40岁男性多见(结脑患者年龄7-83岁，均数33.19±15.67岁；隐脑患者年龄6-86岁，均数39.74±15.99岁)，均以农民多见。结核性脑膜炎327例中，94例(28.74％)合并基础疾病。96例隐球菌性脑膜炎病人中，68例(70.83％)合并有基础疾病327例结核性脑膜炎病人中，入院时发热292例(89.3％)，头痛309例(94.5％)，呕吐212例(64.83％)；96例隐球菌性脑膜炎病人中，入院有发热63例(65.6％)，头痛92例(98.9％)，呕吐64例(66.67％)。血常规检查显示，327结核性脑膜炎病人中42例贫血(12.84％)，WBC升高(＞10.0×10~9／L)63例(19.27％)；分类中性粒细胞＞70％者247例(75.54％)，淋巴细胞＞40％仅3例；96例隐球菌性脑膜炎病人中有10例贫血(占10.42)。WBC升高(＞10.0×10~9／L)有22例，占22.92％；分类中性粒细胞＞70％者70例(72.92％)，淋巴细胞＞40％0例。327例结核性脑膜炎病人中有301例脑脊液白细胞数升高(92.04％)；微量蛋白升高者303例(93％)，葡萄糖降低者205例(64.26％)，氯化物降低者267例(81.7％)。96例隐球菌性脑膜炎病人中，脑脊液白细胞数升高83例(86.47％)，微量蛋白升高者80例(83.33％)，葡萄糖降低者62例(64.58％)，脑脊液氯化物降低59例(61.5％)。327例结核性脑膜炎病人，有178例做了头颅CT检查，其中有问题的118例(66.67％)；111例做了头颅MRI检查，98例有问题(88.28％)。96例隐球菌性脑膜炎病人中，有40例做了头颅CT检查，其中24例有异常(60％)；32例做了头颅MRI检查，30例有问题(93.75％)。病原体检查隐球菌性脑膜炎96例中，涂片全部查到隐球菌。327例结核性脑膜炎病人中，10例涂片查到结核分枝杆菌或病理查到结核肉芽肿。44例脑脊液标本应用PCR技术做了TB-DNA检查，9例TB-DNA阳性。327例结核性脑膜炎中，①痊愈0例，②显效219例(66.97％)，③进步47例(14.37％)，④无效24例(7.41％)，⑤死亡6例(1.83％)，⑥自动出院30例(9.17％)，总有效率为81.65％。96例隐球菌脑膜炎患者，①痊愈3例，②显效47例，③进步6例，④无效5例，⑤死亡14例，⑥自动出院24例，总有效率为58.33％。[结论]1．结核性脑膜炎和隐球菌脑膜炎都以男性多见，以青壮年为主。结核性脑膜炎的有效率高于隐球菌脑膜炎。2．隐球菌脑膜炎有超过2／3合并基础疾病，结核性脑膜炎有1／3合并有基础疾病。3．发热是结核性脑膜炎的最主要表现，头痛是隐球菌脑膜炎的重要表现。4．白细胞计数不高，中性比例增高是二者共同特点。5．结核性脑膜炎的微量蛋白升高明显高于隐球菌脑膜炎P＜0.05，结核性脑膜炎氯化物降低明显高于隐球菌脑膜炎P＜0.05。隐球菌脑膜炎的脑脊液压力升高比结核性脑膜炎明显P＜0.05。隐球菌脑膜炎脑脊液葡萄糖降低更明显些，但P＞0.05。二者脑脊液白细胞数升高无明显差别P＞0.05。6．对于头颅病变MRI效果要优于CT，P＜0.05。7．应加强对慢性脑膜炎病人的长期随访。更多还原

【Abstract】 [Background] Along with the application of organ transplantation, the wider use of broad-spectrum antimicrobial agents, the increased application of adrenal cortical hormones, immunosuppressants,, anti-tumor chemotherapy drugs and the AIDS epidemic, infection of the central nervous system have increased gradually in recent years. Tuberculous meningitis and cryptococcal meningitis were the two most common types of central nervous system infections. The similarity of clinical manifestation, early diagnosis difficulties, delays in the timing of treatment, lead the increase of increased mortality and morbidity of these two different infections.[Objective] To compare the clinical characteristics, in particular the laboratory examination of cerebrospinal fluid examination and imaging features. Discuss early diagnostic methods, and provide evidences for rational diagonosis and therapy.[Method] Retrospectively review the data of 327 cases confirmed as tuberculous meningitis from Janruary 2002 to December 2006 and 96 cases confirmed as cryptococcus meningitis from July 1996 to February 2007. The clinical materials include the general material, underlying disease, pattern of onset, clinical manifestations, laboratory examination, especially CSF results, imaging features, therapeutics and curative effect. Then individual database was established, then analyzed retrospectively. Count information expressed in percentage, measurement data with mean±standard deviation (X±S), Using SPSS 10.0 software for the Chi-square test or the exact probability calculation.[Results] A total of 327 cases of tuberculous meningitis and 96 cases of cryptococcal meningitis were enrolled. Male patients were derminant.Aged 30-40 yeas old (the age range of TBM was from 7 to 83 yrs, the mean age was 33.19±15.67 yrs; the age range of CN was from 6 to 86 yrs, the mean age was 39.74±15.99 yrs). Farmers were dominant.In 327 Tuberculous meningitis cases, 94 (28.74%) co-existed underlying diseases. And in 96 Cryptococcal meningitis patients, 68 (70.83%) with the underlying disease.In 327 cases of tuberculous meningitis patients, 292(89.3%) with fever on admission, 309 with headache(94.5%), 212 with vomiting(64.83%). In 96 cases of cryptococcal meningitis patients, hospitalized with fever in 63 cases (65.6%), headache in 92 cases (98.9%), vomiting in 64 cases (66.67%).About blood tests, 42 out of 327 cases of tuberculous meningitis patients had anemia (12.84%), WBC increased (＞10.0×10~9/L) in 63 cases (19.27%), Categories mainly as neutrophils (＞70%) of 247 cases(75.54%), lymphocyte predominance (＞40%) only in three cases. In 96 cases of cryptococcal meningitis patients, there were 10 cases with anemia (10.42%). 22 cases with WBC increased (＞10.0×10~9/L), accounting for 22.92%. Classification mainly as neutrophils (＞70%) of 70 cases (72.92%), lymphocyte predominance (＞40%) O.In 327 Tuberculous meningitis patients, 301 existed CSF leukocyte counts increasing(92.04%), trace protein increased in 303 cases (93%), glucose decreasing in 205 cases (64.26%), lowering chloride were 267 cases (81.7%). In 96 cases of cryptococcal meningitis patients, cerebrospinal fluid leukocyte counts increased in 83 cases (86.47%), trace protein increased in 80 cases (83.33%), glucose decreased in 62 cases (64.58%), CSF chloride reduction in 59 cases (61.5%).In 327 Tuberculous meningitis patients, 178 patients had done a head CT examination, abnormality found in 118 cases (66.67%). A total of 111 cases done brain MRI, 98 patients revealed problem(88.28%). In 96 cases of cryptococcal meningitis patients, 40 cases had a brain CT examination, 24 patients had abnormal CT results (60%). 32 cases had brain MRI, 30 patients (93.75%) demonstrated problem.Pathogens test of 96 cases of cryptococcal meningitis, all found cryptococcus sp. by smear staining or culture. In 327 cases of tuberculous meningitis patients, 10 cases found Mycobacterium tuberculosis by smear antiacid staining or pathological examination, 9 cases found M. tuberculosis by quantitative PCR only involved in44 patients.In 327 Tubercular meningitis, none was cured, and marked improvement in 219 cases (66.97%), improvement in 47 cases (14.37%), failure in 24 cases (7.41%). 6 cases(1.83%) deaths, 30 cases(9.17%) withdrawn from our hospital. The total effectiveness rate was 81.65%. In 96 cases of patients with cryptococcal meningitis, 3 were cured and marked improvement in 47 cases, improvement in 6 cases, failure in 5 cases. There were 14 patients died, 24 cases withdrawn from our hospital. The total effectiveness rate was 58.33%.[Conclusion]1. Tuberculous meningitis and cryptococcal meningitis are mainly attack male persons, especially in young adults. The therapeutic results showed that tuberculous meningitis is more efficient than cryptococcal meningitis.2. More than two-thirds cryptococcal meningitis patients had underlying diseases, tuberculosis meningitis is associated with one-third of underlying diseases.3. Of tuberculous meningitis, fever is the most important symptom, and for cryptococcal meningitis, headache is an important symptom. 4. Leukocyte count in CSF is not high, but both showed the proportion of the neutral increased.5. The CSF pressure of cryptococcal meningitis increased higer than that of tuberculous meningitis. The trace protein of tuberculous meningitis was significantly higher than that in cryptococcal meningitis, chloride of tuberculous meningitis was lower than that in cryptococcal meningitis. The CSF glucose of cryptococcal meningitis is lowerer than that of tuberculous meningitis. The elevation of WBC in CSF had no differences between two kind meningitis.6. MRI is more effective for brain lesions finding than CT.7. we should follow-up chronic meningitis patients chronically.更多还原