新型隐球菌性脑膜炎相关免疫重建脑炎综合征的识别与治疗

Recognition and treatment of cryptococcal meningitis associated immune reconstruction inflammatory syndrome

目的探讨新型隐球菌性脑膜炎(CM)和CM相关免疫重建脑炎综合征(IRIS)的临床识别与治疗。方法回顾性调查100例CM患者,其中仅有26例(26%)符合新型隐球菌性脑膜IRIS(CM-IRIS)的诊断标准。对26例脑CM-IRIS病例进行分组比较,1组:未出现脑IRIS,未使用糖皮质激素;2组:出现脑IRIS,未使用糖皮质激素;3组:出现脑IRIS,使用糖皮质激素2 w。此外,将CM分为未使用糖皮质激素组及使用糖皮质激素组作比较,计算两组脑IRIS发生率。结果 2组较1组脑脊液压力明显升高,脑脊液蛋白、白细胞总数2组均较1组减低,而淋巴细胞比率明显升高,差异均有显著性意义P<0.05;使用糖皮质激素治疗后3组较2组脑脊液压力明显降低,差异有显著性意义P<0.05;未使用糖皮质激素组脑IRIS发生率高于使用糖皮质激素组P<0.05。结论 CM患者在经治疗后临床症状消失或好转,CSF指标改善,临床表现突然加重,CSF压力再次升高、CSF白细胞总数不增多、淋巴细胞比率升高,MRI影像出现多发性脑白质斑片状信号,可诊断脑CM-IRIS;糖皮质激素治疗后,脑CM-IRIS组临床表现、脑脊液压力和MRI影像可获得明显改善;有效抗真菌治疗6 w后,CM患者加用糖皮质激素可降低脑CM-IRIS的发生率。

Objective To probe into the identification and treatment of cryptococcal meningitis（ CM） and CM related immune reconstruction inflammatory syndrome（ CM-IRIS）. Methods We retrospectively analyzed 100 patients with CM,among them,Only 26（ 26%） developed cryptococcosis Meningitis associated immune reconstitution inflammatory syndrome（ CM-IRIS）,and they were divided into 3 groups： group1： patients didn＇t treated with glucocorticoid before CM-IRIS developed; group2： patients didn＇t treated with glucocorticoid during CM-IRIS developed; group3： patients treated with glucocorticoid for two weeks during CM-IRIS developed. In addition,we divided all patients with CM into 2 groups,one treated with glucocorticoid and the other not,then calculated the incidence of IRIS in eatch group. Results Group 2 presented a significantly higher CSF pressure,lower CSF protein and leucocyte count together with increased lymphocyte proportion by comparison to the other groups（ P〈0. 05）. Given the glucocorticoid,it was obvious that CSF pressure in group 3 was lower than that of group 2,and the incidence of IRIS was higher in CM patients using glucocorticoid,the difference was significant（ P〈0.05）. Conclusion Those CM patients,who had a great improvement in clinical symptoms and cerebrospinal fluid examination after treatment,showed a deterioration of clinical condition again with raised CSF pressure,unaltered total leucocyte count,increased lymphocyte proportion and patchy cerebral white matter lesions detected on MRI,then could be diagnosed as cerebral CM related immune reconstruction inflammatory syndrome（ CM-IRIS）. Significant improvements could be observed in clinical symptoms,CSF pressure and imaging findings in cerebral CM-IRIS group patients after glucocorticoid treatment. On the basis of 6-week effective antifungal therapy,glucocorticoid treatment might reduce the incidence rate of cerebral CM-IRIS.