366例结核性脑膜炎临床分析

A retrospective study in 366 cases with tuberculous meningitis

目的探讨结核性脑膜炎(TBM)临床特点。方法回顾性分析1980—2008年经临床诊断住院TBM病人366例,采用SPSS 11.5统计学软件,对其病历资料进行分析。结果(1)近10年来TBM住院病例有增多趋势,主要是农民工TBM的增多占41.0%(87/212)。(2)脑脊液(CSF)培养结核菌321例,阳性28例;涂片60例,阳性4例。(3)颅脑MRI、CT检查异常最常见部位是基底节区70例(59.3%),合并脑积水76例(64.4%)。MRI影像异常发现率84.7%,主要表现为斑片、小结节、环状异常信号,T1W1呈等或低信号,T2W1、FLAIR呈高信号;CT影像异常发现率69.6%,主要表现为斑片、小灶状低密度影、脑室扩张、脑积液等。颅脑增强扫描渗出性病变呈环状强化是TBM的特征性表现。(4)TBM病死率14.2%,死亡原因:脑疝30例(57.7%)、感染性休克10例(19.2%)、全身衰竭3例(5.77%)、消化道出血3例(5.77%)。(5)≤14岁组126例中本地78例,卡介苗接种史12例,农民工子女48例,卡介苗接种史3例。结论提高CSF分枝杆菌的检出率对提高TBM诊断水平十分重要;MRI检查对TBM诊断有重要意义;对脑疝的抢救、有效抗感染、营养支持、防治消化道出血等是TBM治疗成败的关键;需重视卡介苗接种和接种质量。

Objective To investigate the clinical and epidemiological features in patients with tuberculous meningitis（TBM）,especially in migrant workers with TBM. Methods We analyzed retrospectively the clinical data from 366 cases of TBM hospitalized from 1980 to 2008 by SPSS 11.5 statistical software. Results （1）The group of migrant workers older than 14 years old with TBM accounted for 31.9% in the same age group of patients hospitalized druing the last 10 years.Most patients＇age ranged from 16 to 38 years old.The children of migrant workers with TBM accounted for 71.4% in the same age group of patients hospitalized druing the last 10 years.（2） Cerebrospinal fluid（CSF） culture for mycobacterium tuberculosis was performed in 321 cases with 28 positive.CSF smear was performed in 60 cases with 4 positive.The common lesion site was basal ganglia among 70 cases（59.3%） in MRI or CT of brain.76 cases（64.4%） were complicated with hydrocephalus.The finding rate of abnormal imaging in MRI was 84.7%,which were patching,small nodule,circled abnormal signal,equal or low signal in T1W1 and high signal in T2W1 and FLAIR.The finding rate of abnormal imaging in CT was 84.7%,which were patching,focal with low density,ventriculomegaly and hydrocephalus.Ring enhancement of exudative lesion was one of characteristics in MRI imaging.（3）Mortality in TBM was 14.2%.The causes of death were as follows： cerebral hernia in 30 cases（57.7%）,septic shock in 10 cases（19.2%）,systemic failure in 3 cases（5.77%） and gastrointestinal bleeding in 3 cases（5.77%）.（4） Of 126 cases younger than 14 years old,78 cases were from local and 12 cases were vaccinated by BCG（vaccinal scar in 3 cases）,and 48 cases were children of migrant workers and 3 cases were vaccinated by BCG（vaccinal scar in 1 cases）. Conclusions It is very important for diagnosis of TBM that the dectection rate of mycobaterium tuberculosis from CSF should be improved and other related detection methods are developed.MRI should be one of the routine tool to diagnose TBM.The measures for successful treatment of TBM are rescue of cerebral hernia,effective anti-infection treatment,nutrition support,preventiong of gastrointestinal bleeding.Putting important attention to BCG vaccination and its quality can prevent effectively TBM.Because the incidence of TBM is increasing among migrant workers and their children and it is difficult to treat TBM.The point of tuberuclosis control should be on this kind of disease.