27例隐球菌性脑膜炎患者的临床分析

Clinical analysis of 27 patients with cryptococcal meningitis

目的探讨隐球菌性脑膜炎的临床特征,以提高该病的诊治水平及预后。方法回顾性分析复旦大学附属华山医院收治的27例诊断为隐球菌性脑膜炎患者的临床资料。结果 88.89%(24例)隐球菌性脑膜炎患者以头痛为首发症状;脑脊液糖(1.81±0.69 mmol/L)降低尤为显著;若并发颅神经损害,多累及视神经和听神经;头颅CT或MR可见脑缺血病灶(37.04%)及软脑膜不同程度强化灶(59.26%);所有患者均有不同程度的颅内压增高,病原学脑脊液墨汁染色阳性患者22例(占81.48%),隐球菌培养阳性患者20例(占74.07%),荚膜多糖抗原检测(乳胶凝集试验)阳性占100%;两性霉素B(Amp B)联合5-氟胞嘧啶(5-FC)治愈好转率100%(17/17),Amp B+5-FC+氟康唑治疗的4例患者中好转3例。结论隐球菌性脑膜炎早期误诊率较高,脑脊液墨汁染色、隐球菌乳胶凝集试验及培养有助于确诊;两性霉素B联合5-氟胞嘧啶仍是目前经典的抗真菌治疗方案,两性霉素B与伊曲康唑联合治疗方案有待大样本的临床验证;早期控制真菌及颅高压是改善预后关键,必要时可尽早外科干预。

Objective To investigate the clinical features of cryptococcal meningitis（CM）, and to improve its diagnosis, treatment and prognosis. Methods The clinical data of 27 cases with CM in Huashan Hospital, Fudan University were analyzed, retrospectively and the treatment experience were summarized. Results There were 24 cases（88.89%） had headache as the first symptom of cryptococcal meningitis; CSF glucose（1.81 ± 0.69 mmol/L） reduced significantly; optic and auditory nerve damages common if accompanied with cranial nerve damage; cerebral ischemic（37.04%） and leptomeningeal strengthening（59.26%） could be seen in CT or MR; all patients had increased intracranial pressure for certain degrees, etiological test turned out that the positive rate of cerebrospinal fluid ink staining accounted for 81.48%（22 cases）, the rate of cryptococcal culture positive accounted for 74.07%（20 cases）, while capsular polysaccharide antigen detection（latex agglutination test） was 100% positive; 100%（17/17） patients were cured or better after receiving the combined treatment of amphotericin B（Amp B） and 5-fluorocytosine（5-FC）, 3 among 4 patients were cured or better after treatment of Amp B combined 5-FC and fluconazole. Conclusions Cryptococcal meningitis could prone to be misdiagnosed at early stage, cerebrospinal fluid ink stain, fungi culture and cryptococcal latex agglutination test are beneficial to the diagnosis. The combination of Amp B and 5-FC is still the classic anti-fungal treatment options, the efficacy of Amp B and itraconazole needs clinical trials for huge samples. Effective control of fungal and intracranial hypertension is crucial to improve the prognosis in early stage, surgical intervention can be involved as soon as possible if necessary.