艾滋病合并隐球菌性脑膜脑炎42例临床分析

Clinical analysis on 42 AIDS patients with cryptococcal meningitis

目的探讨AIDS合并新型隐球菌性脑膜脑炎患者的临床特征及转归。方法回顾性分析2011-2013年北京佑安医院住院的42例AIDS合并隐球菌性脑膜脑炎患者的临床表现、实验室检查、治疗转归及相关影响因素。结果头痛（39例，92．9％）及发热（24例，57．1％）是最常见的首发症状，颈项强直及意识障碍也较为常见（各18例，42．9％）。CD4＋T淋巴细胞计数中位数为18（4～419）个／mm3。脑脊液压力≥200mmH2O39例（92．9％）。脑脊液蛋白定量0．4（0．1-13．7）g／L，13例（31．0％）患者的脑脊液蛋白〉2g／L；糖为3．0（0．1—4．7）mmoL／L；氯化物为117．0（102．3～125．1）mmoL／L；细胞数为12（0—56）×10^6／L，单核细胞占68．7（0．0—100．0）％。总病死率为23．8％。颈项强直、意识障碍、病理征阳性、较低的基线CD4＋T淋巴细胞及尚未启动抗病毒治疗与较差的预后（死亡）显著相关（P〈0．01）。59．5％的患者应用两性霉素B及氟康唑联合抗真菌治疗，有效率为76．0％，与两性霉素B联合5-氟胞嘧啶的疗效相当（P〉0．05）。结论对疑似AIDS合并新型隐球菌性脑膜脑炎的病例应及时行脑脊液检测及病原学检查以明确诊断，降低隐球菌病病死率的关键是早期诊断和治疗。

Objective To investigate the clinical manifestation and prognosis of AIDS patients with cryptococcal meningitis. Methods The clinical data of 42 AIDS patients with cryptococcal infection from Beijing You＇ an Hospital during 2011-2013 were retrospectively analyzed,including clinical symptoms, signs, imaging, laboratory examination and prognosis and related factors. Results The common initial symptoms included headache （ 39 cases, 92.9%） and fever（24 cases, 57.1%）. There were 18 cases （42.9%） with stiff neck and conscious disturbance respectively. The count of CD4＋ T cells was 18 （4-419）cells/mm% There were 39 cases （92.9%） with cerebrospinal fluid （CSF） pressure≥200 mmH20. The level of CSF protein, glucose and chloride was 0.4 （0.1-13.7）g/L, 3.0 （0.1-4.7） mmoL/L and 117.0 （ 102.3-125.1） mmoL/L, respectively. The count of cells in CSF was 12（0-56）× 10^6/L, the percentage of monocytes was 68.7 （0.0-100.0）%. The overall mortality was 23.8%. Stiff neck and conscious disturbance, positive pathologic reflex, lower baseline CD4＋ T cell count and no antiviral therapy were associated with poor outcome（death）（P 〈 0.01 ）. Amphotericin B combined with flu- conazole were used in 59.5% patients, the effective rate was 76.0%, which was not inferior to amphotericin B plus 5-FC （Flucytosine）. Conclusion The CSF examination should be carried out as early as possible in suspected cases ,and timely initiate anti-cryptococcosis treatment may reduce the mortality rate.