综合性医院结核性脑腺炎患者的临床特点分析

发布时间：2018-01-10 07:35

本文关键词：综合性医院结核性脑腺炎患者的临床特点分析　出处：《第四军医大学》2016年硕士论文　论文类型：学位论文

【摘要】：结核性脑膜炎(Tuberculous meningitis,TBM)占肺外结核疾病的7-12%,50%以上的患者会致死或致残[1,2]。对TBM患者尽早进行抗结核治疗极为重要,当后期症状出现时再进行抗结核治疗将难以改善预后[3]。结核专科医院TBM病例多合并活动性肺结核,通常早期即进行抗结核治疗。但是综合性医院大多数TBM病例未发现中枢神经系统以外的结核病灶,同时由于TBM病原学检查阳性率低下且早期常表现为非特异性症状,因此容易漏诊并贻误早期治疗的时机。为避免漏诊TBM,Lancet评分系统被广泛应用于诊断未明确病原的脑膜炎患者。在使用Lancet评分系统时如何既避免延误诊断,又避免过度诊断,成为了临床医生面临的又一难题。此外,Lancet评分系统中各项标准和相对权重分配基于文献回顾和国际专家共识,其诊断效力尚待得到进一步评估。因此,有必要完整认识综合性医院TBM的临床特征,评估Lancet评分系统对综合性医院TBM的诊断效力。目的:使用回顾性研究的方法描述综合性医院TBM的临床特征,随后通过对比分析综合性医院TBM和其他常见感染性脑膜炎的临床特征,评估Lancet评分系统的诊断效力。方法:本研究主要分为两部分。首先通过回顾性研究方法,对20余家综合性医院TBM患者的人口学特征、临床表现、实验室检查和头颅影像学等资料进行描述分析。其次,对综合性医院收治的TBM和其余常见的感染性脑膜炎确诊病例进行对比分析,进而评估lancet评分系统的诊断效力。所有数据统计及分析采用流行病学软件openepi和统计学软件spss19.0。结果:1、综合性医院tbm确诊病例就诊时症状持续时间中位数及四分位数为12(7,26.5)天,85%以上未发现cns外结核病灶,绝大多数仅呈现非特异性症状,结核全身症状出现比率低于5%。头颅影像学检查67.4%的病例无特征性改变。按照lancet评分系统中脑脊液标准,20%-60%的确诊病例脑脊液检查表现不典型。2、综合性医院15-36岁tbm确诊患者对mtb的免疫应答较36岁以上患者强烈,且更有可能合并肺部结核病灶。因此对于15-36岁患者应该更加注重糖皮质激素辅助治疗和排查肺部结核病灶。36岁以上确诊患者脑梗死比率(30.7%)高于15-36岁患者脑梗死比率(12.6%)约2.5倍。因此对于36岁以上患者应考虑使用阿司匹林改善预后。3、综合性医院mrc2期tbm确诊患者就诊时症状持续时间中位数及四分位数为15(7,30)天,长于其余两期患者。mrc2期患者脑膜刺激征出现比率较低可能是造成延误诊断的原因。因此对于mrc2期的脑膜炎患者应提高重视防止延误诊断。4、综合性医院非确诊tbm病例就诊时症状持续时间中位数及四分位数为20(10,32.5)天,显著长于确诊tbm的12(7,26.5)天,且病情较确诊tbm轻。提示其病原学未确诊的可能原因是脑脊液结核菌载量较低,因此多次进行病原学检测并增加脑脊液送检量十分必要。5、lancet评分系统roc曲线下面积为0.76,诊断准确性中等。对于区分tbm和其他常见感染性脑膜炎,很可能的tbm标准特异度和敏感度分别为98.8%和14.3%,因此如患者被评估为很可能的tbm应即时开始抗结核治疗和糖皮质激素辅助治疗。可能的tbm标准特异度和敏感度分别为26.8%和94.0%,因此如患者被评估为可能的tbm应采用每一种临床可提供的微生物学诊断方法排除其余可能的诊断后再慎重的开始抗结核治疗。暂不考虑为tbm标准可能会漏诊6%的tbm患者,因此对于治疗效果不佳的脑膜炎患者应再次评估以避免漏诊。结论:综合性医院收治的确诊tbm患者大多数未发现中枢神经系统以外结核病灶,绝大多数仅呈现非特异性症状,一半以上的患者神经影像学及脑脊液细胞学检查不典型,因此容易漏诊和延误治疗。综合性医院36岁及以下TBM患者应更加注重糖皮质激素辅助治疗和排查肺部结核病灶,36岁以上患者应考虑使用阿司匹林防治脑梗死以改善预后。对于疑似TBM病例,如Lancet评分系统评估为很可能的TBM应即时开始抗结核治疗和糖皮质激素辅助治疗,如评估为可能的TBM应采用每一种临床可提供的微生物学诊断方法排除其余可能的诊断后再慎重的开始抗结核治疗,如评估为暂不考虑TBM也应定期再次评估以避免漏诊。
[Abstract]:Tuberculous meningitis (Tuberculous meningitis, TBM) for tuberculosis disease 7-12%, more than 50% of the patients with fatal or disabling [1,2]. of TBM patients as soon as possible to the anti tuberculosis treatment is very important, when the late symptoms of anti tuberculosis treatment to improve the prognosis of [3]. in tuberculosis hospital of TBM cases with active pulmonary tuberculosis usually, the early stage of anti tuberculosis treatment. But comprehensive hospital in most cases of TBM were found outside the central nervous system of tuberculosis, and because the etiology of TBM positive rate and low examination early Changbiaoxianwei nonspecific symptoms, and therefore easy to misdiagnosis and delaying early treatment time. In order to avoid misdiagnosis of TBM, Lancet score the system is widely used in the diagnosis of meningitis is not clear pathogens. How to avoid using the Lancet score system and to avoid excessive delay in diagnosis, clinical diagnosis, become Another problem faced by physicians. In addition, the standard Lancet score system and the relative weights of literature review and expert consensus based on international, the diagnosis efficiency remains to be further evaluated. Therefore, clinical characteristics necessary for a complete understanding of comprehensive hospital TBM, evaluation of Lancet scoring system in diagnosis of comprehensive hospital TBM objective effect. Methods: the clinical features were retrospectively studied to describe the General Hospital of TBM, followed by a comparative analysis of the clinical characteristics of hospital TBM and other common infectious meningitis, as assessed by the Lancet score system diagnosis effect. Methods: This study is mainly divided into two parts. First, through the method of retrospective study on demographic characteristics more than 20 of TBM patients in general hospital clinical manifestation, laboratory examination and brain imaging data were described and analyzed. Secondly, admitted to the general hospital and other TBM Comparative analysis of infectious meningitis cases common, and evaluate the diagnostic lancet scoring system. The validity of the statistics and analysis of all data by using epidemiological software openepi and statistical software spss19.0. results: 1, general hospital confirmed cases of TBM symptom duration four median and quartile 12 (7,26.5) days, more than 85% not found CNS tuberculosis, the majority showed only nonspecific symptoms, systemic symptoms of tuberculosis rate is lower than 5%. brain imaging examination of 67.4% cases of no characteristic change. According to the lancet score standard of cerebrospinal fluid system, cerebrospinal fluid examination confirmed cases of atypical.2 manifestations of 20%-60%, general hospital 15-36 years old TBM patients diagnosed by the immune response to MTB compared with the patients over the age of 36 strong, and are more likely to be complicated with pulmonary tuberculosis. So for the 15-36 year old patients should pay more attention to glucocorticoids The auxiliary treatment and investigation of pulmonary tuberculosis lesions in.36 years old patients diagnosed cerebral infarction rate (30.7%) higher than that of 15-36 years old patients with cerebral infarction (12.6%) ratio of about 2.5 times. So for patients over 36 years of age should consider the use of aspirin to improve the prognosis of.3, general hospital mrc2 TBM diagnosed in patients with symptoms of median duration and four quartile 15 (7,30) days, longer than the remaining two patients with stage.Mrc2 patients with meningeal irritation appears to lower the ratio may be the cause of delayed diagnosis. So for meningitis in patients with stage mrc2 should pay more attention to prevent delays in the diagnosis of.4, non TBM cases were treated in general hospital when the duration of symptoms four median and quartile 20 (10,32.5) days, significantly longer than the diagnosis of TBM (7,26.5) 12 days, and the illness is diagnosed TBM light. The etiology may prompt causes undiagnosed tuberculosis cerebrospinal fluid load is low, so repeatedly For pathogen detection and increase the amount necessary for cerebrospinal fluid.5, Lancet score system of area under the ROC curve was 0.76, the diagnostic accuracy of medium. To distinguish between TBM and other common infectious meningitis, it is likely that TBM standard sensitivity and specificity were 98.8% and 14.3% respectively, as patients being evaluated for possible TBM should be instant start anti tuberculosis treatment and glucocorticoid treatment. Possible TBM sensitivity and specificity were 26.8% and 94% respectively, as patients being evaluated for possible TBM should be excluded from the remaining possible diagnosis by a clinical diagnosis of each available microbiological method after anti tuberculosis treatment started cautiously temporarily. Consider the TBM standard would be missed 6% of TBM patients, so for re assessment to avoid missed diagnosis of meningitis patients should be poor treatment. Conclusion: admitted to general hospital diagnosed TBM patients Most were found outside the CNS tuberculosis, most patients showed only nonspecific symptoms, neuroimaging studies and more than half of the cerebrospinal fluid cytology is not typical, so easy to misdiagnosis and delayed treatment. General hospital under the age of 36 and TBM patients should pay more attention to the investigation and glucocorticoid in the treatment of pulmonary tuberculosis lesions, 36 older patients should consider the use of aspirin for prevention of cerebral infarction to improve the prognosis. For suspected TBM cases, such as the Lancet assessment system for possible TBM should immediately start anti tuberculosis treatment and glucocorticosteroid therapy, such as TBM should be evaluated for possible exclusion of other possible diagnoses by each clinical diagnosis provided by microbiological method after careful to anti tuberculosis treatment, such as the assessment will not consider the TBM should also regularly re evaluation in order to avoid misdiagnosis.

【学位授予单位】：第四军医大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R529.3

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