原发性广泛耐药结核性脑膜炎一例报告并文献复习

Primary Extensively Drug-Resistant Tuberculosis Meningitis: One Case Report and Literature Review

目的探讨原发性广泛耐药结核性脑膜炎的临床表现、诊断方法及治疗方案,提高对原发性广泛耐药结核性脑膜炎的认识。方法对1例确诊原发性广泛耐药结核性脑膜炎患者的临床表现、影像学改变、实验室诊断及治疗结合相关文献进行回顾性分析。结果患者男性,24岁,因"头痛、呕吐5 d,加重伴精神异常10 h"收入院。既往无肺结核病史,胸部X线片未见异常,头颅CT检查提示轻度脑积水、环池轻度狭窄,疑脑膜炎。予异烟肼0.3 g静脉滴注(1次/d),口服异烟肼0.3 g(1次/d),利福平0.45 g(1次/d),吡嗪酰胺1.5 g(1次/d),乙胺丁醇0.75 g(1次/d)抗结核化疗,予地塞米松15 mg减轻结核中毒症状,但患者病情进展迅速,治疗无效死亡。3个月后脑脊液培养提示耐药结核分枝杆菌生长(对异烟肼、利福平、链霉素、环丙沙星、对氨基水杨酸、卡那霉素、丙硫异烟胺耐药),确诊为原发广泛耐药结核性脑膜炎。在万方数据库和Pub Med数据库上检索到广泛耐药结核性脑膜炎相关文献共4篇,共5例,其中2例初治,另外3例未提示为初治还是复治。结论初治原发耐药结核性脑膜炎临床上少见,病情重,进展快,病死率高。临床应加强警惕,尽早获得药敏结果,根据情况调整治疗方案,条件允许情况下应开展分子药敏试验。

Objective To investigate the clinical manifestations,diagnosis and treatment of extensively drug-resistant tuberculosis（ XDR-TB） meningitis. Methods One case of primary tuberculousis meningitis infected with multidrug-resistant mycobacteria was analyzed retrospectively. Relevant literatures were also reviewed by retrieving information through Wanfang Database and Pubmed using key words＂multiple drug resistant tuberculosis meningitis＂,＂MDR tuberculosis meningitis＂,＂multiple drug resistant TBM＂,＂mul-drug resistant tuberculous meningitis＂,＂extensively drug resistant tuberculosis meningitis ＂,＂XDR TBM＂,＂extensively drug resistant TBM＂both in Chinese and English. Results A 24-year-old male patient,complained of headache,vomiting for 5 days,aggravated with mental abnormalities for 10 hours,with no history of pulmonary tuberculosis,was hospitalized in the Affiliated Hospital of Zunyi Medical College. The chest plain film was normal. Craniocerebral CT scan showed mild-hydrocephalus and cisterna ambiens stenosis. The patient died after undergoing anti-TB treatments with isoniazid（ INH） 0. 3g iv qd,INH 0. 3g po qd,rifampicin（ RFP） 0. 45 g qd,pyrazinamide（ PZA） 1. 5g qd,ethambutol（ EMB） 0. 75 g qd,and dexamethasone（ DEX） 15 mg qd. He was diagnosed as XDR-TB meningitis（ as drug-resistant to isoniazid,rifampicin,streptomycin,ciprofloxacin,paminosalicylic acid,kanamycin,and protionamide）. Mycobacteria tuberculosis was isolated from his cerebrospinal fluid after 3 months. Five cases in 4 literatures were retrieved through Wanfang database and Pubmed among which 2 cases were initial treated,3 cases was unknown about initial treatment or re-treatment. Conclusions XDR-TB meningitis is rare in clinical practice with serious condition,rapid progress and high mortality rate. It is necessary to acquire drug susceptibility test results as soon as possible and adjust treatments according different conditions. A molecular drug susceptibility test may be helpful in the future.