非艾滋病相关隐球菌脑膜炎的预后因素分析

Factors associated with mortality in cryptococcal meningitis

目的探讨影响非艾滋病（AIDS）相关隐球菌脑膜炎（隐脑）的预后因素。方法收集复旦大学附属华山医院感染科11年（1997至2007年）间收治的154例非AIDS相关隐脑病例，并随访1年，分析影响其病死率的危险因素。结果随访1年中，全因病死率为28．7％（41／143，11例失访），归因病死率为19．6％（28／143）。单因素分析结果显示，与全因病死率增加显著相关的因素包括年龄≥60岁、血液恶性肿瘤、实体恶性肿瘤、发病至确诊时间〉4个月、病程中出现意识障碍（昏迷、癫痫发作、脑疝），以及行脑脊液脑室外引流或分流术等。与全因病死率减少显著相关的因素包括初始治疗方案中含有两性霉素B者、初始治疗方案中含有氟胞嘧啶者，以及两性霉素B鞘内注射者。Cox多元回归分析结果显示，与全因病死独立相关的因素包括年龄≥60岁、发病至确诊时间〉4个月、昏迷、脑疝，以及初始治疗方案不含两性霉素B者；与归因病死独立相关的因素包括发病至确诊时间〉4个月、脑疝以及初始治疗方案不含两性霉素B者。结论非AIDS相关隐脑患者中年龄≥60岁、意识障碍、发病至确诊时间〉4个月者预后不佳，应用两性霉素B的初始治疗对预后改善起着关键性作用。

Objective To investigate factors associated with mortality in non-AIDS patients with cryptoeoccal meningitis. Methods We retrospectively reviewed 154 cases of non-HIV cryptococeal meningitis in a tertiary care hospital in China, from 1997 through 2007. Results The 1-year attributable mortality was 19. 6% （ 28/143 ） , and overall mortality was 28.7% （ 41/143 ） , Advanced age （ ≥ 60 years） , delay in diagnosis （ 〉4 months） , hematologic malignancy, solid malignancy, altered mental status （coma, seizure, herniation ） , and CSF drainage or shunting were factors associated with increased death; factors associated with increased survival were amphotericin B based initial therapy and flucytosine containing therapy. In multivariate analysis, age ≥60 years, the time from symptom onset to diagnosis 〉 4 months, coma, cerebral herniation, and non-amphotericin B based initial therapy were independently associated with increased overall mortality; factors independently associated with cause-specific mortality were time from symptom onset to diagnosis 〉 4 months, cerebral herniation and non-amphoterlcin B based initial therapy. Conclusion A variety of factors were associated with mortality in non-AIDS eryptocoecal meningitis. Amphotericin B based initial treatment was independently correlated to improved 1-year survival.