结核性脑膜炎与其他脑膜炎的鉴别诊断

Differential diagnosis of tuberculous meningitis and other meningitis

目的了解结核性脑膜炎（结脑）的临床特征及其与病毒性脑膜炎（病脑）、隐球菌性脑膜炎（隐脑）和化脓性脑膜炎（化脑）鉴别诊断要点，提高治愈率。方法收集2013年1月至2015年12月间在浙江省人民医院住院的结脑患者45例，病脑患者20例、隐脑患者15例和化脑患者15例的临床资料，并比较其临床特征。结果结脑患者常合并肺结核或肺外结核疾病（29例，64．4％）；基础疾病以艾滋病、糖尿病和高血压多见；起病形式多样，但以亚急性和慢性起病为主（分别为26例，57．8％和11例，24.4％）；结脑早期临床表现主要以发热（45例，100％）、头痛（29例，64．4％）和恶心呕吐（27例，60．0％）为主，进而可出现颅神经和脑实质损害征象；脑脊液符合特征性的改变，并见腺苷脱氨酶含量升高达（6．67±5．32）U／L。影像学上表现以脑实质改变多见（16例，35．6％）。结论结脑的早期诊断需综合临床表现、脑脊液检查、影像学检查，其中脑脊液检查和及时的头颅CT或磁共振检查对诊断尤为重要。

Objective To understand the clinical characteristics of tuberculosis meningitis, and the differential diagnosis features with other types of meningitis such as viral meningitis, cryptoeoccal meningitis, purulent meningitis, so as to improve the recovery rate of this disease. Methods There were 45 patients with tuberculosis meningitis, 20 patients with viral meningitis, 15 patients with cryptococcal meningitis and 15 patients with purulent meningitis in Zhejiang Provincial Peoplels Hospital from January 2013 to December 2015 collected in the study. The clinical features of tuberculosis meningitis were compared with those of other three types of meningitis. Results Tuberculosis meningitis patients were commonly complicated with pulmonary tuberculosis and other tuberculosis （29 cases, 64.4%）; the main underlying diseases were AIDS, diabetes and hypertension; the onset of tuberculosis meningitis was diverse, but usually with sub-acute and chronic symptoms [26 cases （57.8%） and 11 cases （24.4%）]. The main early symptoms of tuberculosis meningitis were fever （45 cases, 100% ）, headache （29 cases, 64.4%）, nausea and vomiting （27 cases, 60.0%）, followed by the damage of central nerve system with the disease progress. The cerebrospinal fluid had characteristic changes with an increased adenosine deaminase （ADA） of （6.67±5.32） U/L. The cerebral parenchyma damage was the most common feature by neuroimaging （16 cases, 35.6% ）. Conclusions Early diagnosis of tuberculosis meningitis should be combined with clinical evaluation, cerebrospinal fluid laboratory test and graphic assessment, in which cerebrospinal fluid, head CT or MRI are of great value.