隐球菌性脑膜炎26例临床分析

A clinical study of 26 cases of cryptococcal meningitis

目的 总结隐球菌性脑膜炎的资料 ,提高对隐球菌性脑膜炎的认识。方法 回顾性总结近 2 0年 (1981年 10月至 2 0 0 1年 9月 )隐球菌性脑膜炎的一般资料、诊断及治疗情况。结果 共 2 6例患者 ,其中男 12例 ,女 14例 ,年龄 5～ 6 2岁 ,平均 35 6岁 ,有基础疾病者 16例 ,其中系统性红斑狼疮 (SLE) 9例 ,人类免疫缺陷病毒感染或艾滋病 (HIV/AIDS) 4例 ,其他疾病 3例 ;有明确鸽子接触史者12例 ;误诊结核性脑膜炎者 5例 ,狼疮脑病者 6例 ;墨汁染色找到隐球菌者 2 3例 (2 3/ 2 6 ) ,乳胶凝集试验抗原阳性 2 0例 (2 0 / 2 0 )。颅内压明显增高 >30 0mmH2 O者 15例 ,脑室扩大行侧脑室引流者 9例 ;12例给予两性霉素B(AmpB) +5氟胞嘧啶 ,6例又同时加氟康唑治疗 ,5例AmpB +氟康唑 ,1例单纯应用AmpB治疗。AmpB最大用量 :AmpB 10 0 5g+脂质体两性霉素B 2 0g,平均用量 2 6g ;治愈 17例 ,好转4例 ,死亡或自动出院 5例。同时发现近 5年隐球菌性脑膜炎病例数明显增多。结论 近年来 ,隐球菌性脑膜炎发病率明显增高 ,可能和免疫抑制剂和糖皮质激素的应用及HIV/AIDS增多有关 ,减少病死率的关键在于提高早期诊断率 ,治疗仍首选AmpB加 5氟胞嘧啶 ,侧脑室引流可减少AmpB的用量 ,提高治愈率 ,缩短疗程。

Objective To study the diagnosis and therapy of cryptococcal meningitis Methods Retrospective review of the clinical features, treatment and outcome of 26 patients with cryptococcal meningitis from October 1981 to September 2001 at Peking Union Medical College Hospital Results The age of the patients ranged from 5 to 62 years (mean:35 6 years), 12 were male and 14 were female There were 16 patients with underlying diseases ,9 had systemic lupus erythematosus(SLE),4 had human immunodeficiency virus (HIV)infection and/or acquired immunodeficiency syndrome(AIDS) and 3 had other diseases 12 patients had contact with pigeons The nonspecific clinical and laboratory findings in these patients led to misdiagnosis: as lupus encephalopathy in 6 cases and tuberculous meningitis in 5 cases 23 of the 26 cases were positive of cryptococcus on cerebrospinal fluid (CSF) smear 13 cases were positive on CSF culture, but latex coagulate test performed in 20 cases were all positive,15 patients had high intracranial pressure(>300 mm H 2O),9 patients with dilated ventricle received brain ventricular draining Only 2 cases used fluconazole monotherapy One patient only used amphotericin B. The rest of the patients were given amphotericin B in combination with flucytosine(12 patients) or fluconazole(5 cases),or flucytosine combined with fluconazole(6 cases) The mean dose of amphotericin B was 2 6 g, the highest dose of amphotericin B and liposomal amphotericin B was 10 05 g and 20 g, respectively. The outcome of the 26 cases showed that 17 were cured,4 improved, 3 patients were died and 2 patients gave up any further treatment. From Oct 1981 to Sep 1996 we found only 9 cases, but in recent 5 years we found 17 cases Conclusions The incidence of cryptococcal meningitis was increasing in the recent 5 years The conditions associated with this disease include extensive broad spectrum antibiotics, immunosuppressive drugs or ligh dose corticosteriods and increasing cases of HIV/AIDS The early diagnosis and treatment of cryptococcal meningitis may reduce death rate We still recommended amphotericin B plus flucytosine as the standard therapy for cryptococcal meningitis Ventricular drainage and amphotericin B intraventricularly via an implanted tube into dilated ventricle could improve the clinical condition of serious cryptococcal meningitis and decrease the dosage of systemic use of amphotericin B, therefore, reduce the side effects of the drugs