中枢神经系统真菌感染的临床诊治

Clinical diagnosis and treatment of intracranial fungal infection

目的 探讨中枢神经系统真菌感染的临床特点、诊断及手术治疗情况.方法 回顾性分析2011年2月至2016年10月首都医科大学附属北京地坛医院神经外科收治的40例中枢神经系统真菌感染患者的临床表现、影像学特征、手术方式及治疗效果.40例患者均予以抗真菌药物治疗,其中新型隐球菌感染致高颅压23例,降颅压治疗无效后予以分流术治疗;颅内占位病变17例,其中2例采用立体定向活检术,15例采用开颅病变切除术.结果 新型隐球菌感染致高颅压的23例患者中,21例为艾滋病患者,2例因合并其他疾病致免疫功能下降,实施分流术后高颅压症状消失18例,改善5例,未造成新型隐球菌感染扩散.随访6个月,19例无明显临床症状,3例原有症状明显改善,1例因肺部严重感染后死亡.颅内占位病变的17例患者中,16例为艾滋病患者,1例为开颅手术后真菌感染,其中行立体定向活检术确诊的2例患者予抗真菌治疗后症状明显改善;行开颅病变切除术后的15例患者症状改善良好,无神经功能缺失,仅1例因合并脑室内铜绿假单胞菌感染及脑积水后死亡.结论 中枢神经系统真菌感染多发生于免疫缺陷的患者,主要表现为脑积水或颅内占位性病变,可发生于颅底、脑实质及脑室系统,影像学无特异性.治疗采用分流术或病灶切除术,并结合抗真菌药物治疗.

Objective To investigate the clinical features,diagnosis and surgical treatment of fungal infection of the central nervous system.Methods In this retrospective study,clinical data including manifestations,imaging,surgical procedure and therapeutic effect of 40 patients who were consecutively diagnosed as intracranial fungal infection from February 2011 to October 2016 at Department of Neurosurgery,Beijing Ditan hospital,Capital Medical University were analyzed.All 40 patients were treated with antifungal treatment.Among them,there were 23 cases with high intracranial pressure caused by Cryptococcus neoformans infection,and shunt operation was performed after failure of lowering intracranial pressure by treatment.There were 17 cases with intracranial occupying lesions,2 of which underwent stereotactic biopsy and 15 underwent craniotomy.Results Among the 23 patients with high intracranial pressure caused by Cryptococcus neoformans,21 cases had AIDS （acquired immunodeficiency syndrome）and the other 2 had immunodeficiency due to other diseases.After operation,symptoms related to high intracranial pressure disappeared in 18 cases and were relieved in 5 without spreading of Cryptococcus neoformans infection.At the 6-month follow-up,the patients＇ original symptoms completely disappeared in 19 cases and were improved in 3.In addition,1 case died of severe pulmonary infection.Among the 17 cases with intracranial lesions,16 cases had AIDS and 1 case had secondary fungal infection post operation.Two of them underwent stereotactic biopsy and 15 reported good outcomes after craniotomy.None of them developed significant neurological deficits.One patient died from Pseudomonas aeruginosa infection combined with hydrocephalus.Conclusions Fungal infection of the central nervous system fungal mostly occurs in patients with immunodeficiency and is mainly characterized by hydrocephalus or intracranial space occupying lesion.The lesions could be located at the brain parenchyma,skull base and the ventricle system with no specific imaging manifestations.Treatment could be administered by shunting or excision operation and antifungal therapy.