隐球菌性脑膜炎临床特征及1,3-β-D葡聚糖的诊断价值分析

发布时间：2018-06-17 00:45

本文选题：隐球菌性脑膜炎 + 诊断　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:1分析并总结隐球菌性脑膜炎患者的临床特征、脑脊液特点、治疗及转归,为早期诊断和有效治疗提供经验。2探讨隐球菌性脑膜炎患者脑脊液及血清中的1,3-β-D葡聚糖的诊断价值。方法:1回顾性分析2003年1月~2017年1月14年间就诊于河北医科大学第二医院的95例隐球菌性脑膜炎患者的病例资料,总结其临床特征、影像学、脑脊液检查、治疗及转归情况。2采用动态浊度法,检测隐球菌性脑膜炎患者脑脊液及血浆中1,3-β-D葡聚糖的含量。结果:95例患者中,平均年龄42.86±19.33岁,男患者与女患者比例为59:36,其中农民67人,约占总人数的70.53%。发病前健康者50例,基础疾病者45例,口服激素18例,免疫抑制剂6例。有鸽子及禽类接触者10例。75例(78.95%)为亚急性或慢性起病。临床主要表现为进行性的头痛、体温升高、恶心呕吐和脑膜刺激征。视力损害、听力损害以及外展神经受损最多见。88.04%隐脑患者颅内压增高(81/92),其中59例患者颅内压小于500mm H2O,大于500mm H2O者22例。80.28%隐脑患者脑脊液白细胞增高(57/71),中位数为50×106/L(0~828)。71.83%隐脑患者脑脊液葡萄糖降低(51/71),均值为1.87±1.28mmol/L(0.08~5.3)。90.14%隐脑患者脑脊液蛋白升高(64/71),中位数0.73g/L(0.06~4.83)。67.61%隐脑患者脑脊液氯化物降低(48/71),平均114.46±7.84mmol/L(97~134)。隐球菌性脑膜炎患者的脑脊液压力、白细胞计数、葡萄糖含量与病情严重程度有线性相关关系,脑脊液蛋白、氯化物含量与疾病严重程度无线性相关关系。本组95例患者中有55例(57.89%)脑脊液细胞学检查发现背景细胞异常。其中,呈淋巴细胞反应为主者21例,混杂细胞学反应者19例,嗜中性粒细胞反应为主者15例。发病小于10天的病例,细胞学多呈以嗜中性粒细胞反应为主或者为以嗜中性粒细胞为主的混杂细胞学反应为主(12/14),发病处于10~30天之间的病例多以混合细胞学反应为主(10/24),发病大于30天的病例多以淋巴细胞反应为主(10/17)。头颅影像学以脑膜强化、炎性病灶、脑积水最为常见。肺CT检查最为多见的异常表现为炎性改变。隐球菌性脑膜炎的误诊率较高,本组共34例(35.79%)隐脑患者确诊前被误诊为其他疾病,其中被误诊为结核性脑膜炎者16例,所占比例最大。首次腰穿脑脊液细胞学迈-格-姬(MGG)染色阳性率为75.79%,阿利新蓝染色阳性率为77.89%,联合两种染色2次以上阳性率为100%。本研究通过动态浊度法进行1,3-β-D葡聚糖检测,结果证实在隐球菌性脑膜炎患者的脑脊液中可以检测到1,3-β-D葡聚糖,27例隐脑患者17例(62.96%)阳性;在隐脑患者的血浆中同样也可以检测到1,3-β-D葡聚糖,11例隐球菌性脑膜炎患者仅1例(9.09%)阳性。阿利新蓝染色、迈-格-姬染色(MGG)及脑脊液1,3-β-D葡聚糖检测敏感性两两之间无差别,前三种方法与血浆1,3-β-D葡聚糖检测敏感性有差别。本组共82例隐脑患者接受抗真菌治疗,38例接受两性霉素B或脂质体联合氟康唑治疗,20例接受两性霉素B或脂质体联合伏立康唑治疗,15例接受氟康唑单药治疗,5例接受两性霉素B单药治疗,4例接受伏立康唑单药治疗。抗真菌方案治疗的总体有效率为71.95%,联合用药方案治疗的有效率为82.76%,单药治疗方案治疗的有效率为45.83%。采用外科手术进行脑脊液引流可有效缓解顽固性高颅压。结论:1隐球菌性脑膜炎多见于中年人,男性患者多于女性患者,农民最为常见,多呈亚急性或慢性起病。常以头痛、体温升高为首发症状,颅神经损害中以视神经、前庭蜗神经及展神经受损多见。2脑脊液压力、白细胞计数越高,葡萄糖含量越低,患者病情越严重。3隐脑患者脑脊液细胞学类型与发病时间有关。4本病误诊率高,确诊前被误诊为结核性脑膜炎者最多见。5在隐球菌性脑膜炎患者的脑脊液中可以检测到1,3-β-D葡聚糖,并可对临床诊断提供有效信息。6阿利新蓝染色、迈-格-姬染色(MGG)及脑脊液1,3-β-D葡聚糖检测敏感性高于血浆1,3-β-D葡聚糖检测敏感性。7联合抗真菌治疗效果优于单药治疗隐球菌性脑膜炎。
[Abstract]:Objective: 1 to analyze and summarize the clinical features, cerebrospinal fluid characteristics, treatment and prognosis of cryptococcal meningitis patients, and provide empirical.2 for early diagnosis and effective treatment to explore the diagnostic value of 1,3- beta -D glucan in cerebrospinal fluid and serum of cryptococcal meningitis patients. Method: 1 retrospective analysis in January 2003, ~2017 year, 14 years in the river. The data of 95 cases of cryptococcal meningitis in Second Hospital of North Medical University, the clinical features, imaging, cerebrospinal fluid examination, treatment and prognosis of.2 were measured by dynamic turbidimetric method, and the content of 1,3- beta -D glucan in cerebrospinal fluid and plasma of cryptococcal meningitis patients was detected. Results: the average age was 42.86 + 19.33 in 95 patients. The proportion of male and female patients was 59:36, of which 67 were farmers, 50 were healthy before the onset of 70.53%., 45 cases of basic diseases, 18 cases of oral hormones, 6 cases of immunosuppressive agents. 10 cases of dove and poultry exposed to.75 (78.95%) were subacute or chronic onset. Clinical manifestations were progressive headache, body temperature rise, nausea. Emesis and meningeal irritation. Visual impairment, hearing impairment, and abduction nerve damage were most seen in.88.04% patients with intracranial hypertension (81/92), of which intracranial pressure was less than 500mm H2O, and 22 cases of.80.28% Cryptomeria were higher than 500mm H2O, and the median was 50 x 106/L (0~828).71.83% Cryptomeria cerebrospinal fluid Glucose decreased (51/71), the mean value of the cerebrospinal fluid protein increase (64/71) in patients with 1.87 + 1.28mmol/L (0.08~5.3).90.14% cryptobrain, the decrease of chloride in cerebrospinal fluid (48/71) in the median 0.73g/L (0.06~4.83).67.61% saphenous brain (48/71), the average of 114.46 + 7.84mmol/L (97~134). The cerebrospinal pressure, leukocyte count, glucose content and the amount of glucose in the patients with cryptococcal meningitis There was a linear correlation between the severity of the disease, and there was no linear correlation between the cerebrospinal fluid protein and the content of chloride and the severity of the disease. 55 of the 95 patients in this group (57.89%) found abnormal background cells in the cerebrospinal fluid cytology. Among them, there were 21 cases of lymphocyte reaction, 19 cases of mixed cytology and neutrophils response to neutrophil. The 15 cases were less than 10 days. Most of the cases were mainly neutrophil reaction or the predominantly neutrophil mixed cytological reaction (12/14), and most cases with 10~30 days were mainly mixed cytological reaction (10/24), and most cases with hair disease more than 30 days were mainly lymphocyte reaction (10/17 The most common abnormal manifestation of CT examination was inflammatory change. The misdiagnosis rate of cryptococcal meningitis was higher. 34 cases (35.79%) of this group were misdiagnosed as other diseases before diagnosis, and 16 cases were misdiagnosed as tuberculous meningitis, the largest proportion accounted for the most. The positive rate of MGG staining in the cerebrospinal fluid cytology was 75.79%, the positive rate of alien blue staining was 77.89%, and the positive rate of the combined two kinds of staining was 100%., and the positive rate of the combined two kinds of staining was 100%.. The results showed that the 1,3- beta -D glucan could be detected in the cerebrospinal fluid of the patients with cryptococcal meningoencephalitis. The results showed that the 1,3- beta -D glucan could be detected in the cerebrospinal fluid of cryptococcal meningoencephalitis patients. 27 cases of cryptobrain patients (62.96%) were positive; 1,3- beta -D glucan was also detected in the plasma of the patients with cryptococcosis, and only 1 cases (9.09%) were positive in 11 cases of cryptococcal meningitis. There was no difference between the aligan blue staining, the MGG and 1,3- beta -D dextran sensitivity 22, the first three methods and the plasma 1,3- beta -D The sensitivity of dextran detection was different. 82 cases of saphenous brain patients received antifungal therapy, 38 received amphotericin B or liposome combined with fluconazole, 20 received amphotericin B or liposome combined with voriconazole, 15 received fluconazole single drug treatment, 5 received two amphotericin B single drug treatment, 4 cases received voriconazole monotherapy. Treatment. The total effective rate of antifungal therapy was 71.95%, the effective rate of combination regimen treatment was 82.76%, the effective rate of single drug treatment regimen was 45.83%. by surgical operation of cerebrospinal fluid drainage. Conclusion: 1 cryptococcal meningoencephalitis were found in middle-aged people more than those in women. Farmers are most common, mostly subacute or chronic onset. Often with headache, temperature rise as the first symptom, cranial nerve damage in the optic nerve, vestibule nerve and abducent nerve damage more.2 cerebrospinal fluid pressure, the higher the number of leukocyte count, the lower the glucose content, the patient's condition more serious.3 cryptobrain cerebrospinal fluid cytology type and onset time The misdiagnosis rate of.4 is high, and the patients who have been misdiagnosed as tuberculous meningitis before diagnosis are most likely to see.5 in the cerebrospinal fluid of patients with cryptococcal meningitis, 1,3- beta -D glucan can be detected, and the clinical diagnosis can provide effective information.6 alien blue staining. The sensitivity of MRI and MGG and 1,3- beta -D glucan in cerebrospinal fluid is higher than that of plasma 1,3 - beta -D dextran sensitivity.7 combined with antifungal therapy is superior to single drug therapy for cryptococcal meningitis.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R519.4

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