脑脊液细胞学在结核性脑膜炎病程中的动态变化及其诊断价值分析

Dynamic changes of cerebrospinal fluid cytology in the course of tuberculous meningitis and its diagnostic value

目的探讨脑脊液细胞学在结核性脑膜炎(TBM)病程中的动态变化特点及其诊断价值。方法选择2008年1月至2016年12月本科收治的37例TBM患儿作为观察组,选择同期收治的40例非结核性脑膜炎(包括病毒性脑膜炎及化脓性脑膜炎)患儿作为对照组,均收集脑脊液标本,行常规、生化、脑脊液细胞学检查,并行结核杆菌抗原结核菌素(PPD)阳性细胞率(单核细胞)检测,总结脑脊液细胞学对TBM的诊断价值。结果 (1)观察组腰穿压力、白细胞数、淋巴细胞数、蛋白定量均高于对照组各亚组,其葡萄糖、氯化物水平低于对照组各亚组(P <0. 05);(2)观察组脑脊液细胞学检查以混合细胞反应为主,占83. 78%,其次为淋巴细胞反应,占10. 81%;病毒性脑膜炎以淋巴细胞反应为主,占82. 14%;化脓性脑膜炎以多形粒细胞反应为主,占75. 00%;(3)观察组PPD抗原阳性率为81. 08%,明显高于病毒性脑膜炎、化脓性脑膜炎患儿(P <0. 05);(4)以蛋白含量> 0. 45 g/L诊断结核性脑膜炎的准确率为89. 19%,其次以脑脊液细胞学混合细胞反应诊断结核性脑膜炎的准确率为83. 78%;(5)结核性脑膜炎病程≤2周患儿白细胞计数、单核细胞所占比例、嗜中性粒细胞所占比例最高,与病程3~4周、病程> 4周患儿比较差异有统计学意义(P <0. 05);病程3~4周TBM患儿上述细胞学指标均降低,淋巴细胞比例升高,病程> 4周患儿白细胞计数、单核细胞、淋巴细胞、嗜中性粒细胞均低于病程3~4周患儿(P <0. 05)。结论 TBM病程前2周白细胞数、单核细胞比例、嗜中性粒细胞比例较高,维持时间为2周;2周后除淋巴细胞外上述细胞水平降低、淋巴细胞比例继续升高;4周后逐渐下降;脑脊液细胞学混合型反应对TBM诊断准确率较高,与结核杆菌抗原PPD检查一致性高,可作为TBM早期诊断的选择。

Objective To investigate the dynamic changes of cerebrospinal fluid( CSF) cytology in the course of tuberculous meningitis( TBM) and its diagnostic value. Methods 37 children with TBM who were treated in the department during January 2008 to December 2016 were selected as the observation group. Another 40 children with non-TBM( including viral encephalitis and suppurative encephalitis) were selected as the control group at the same time. The CSF samples were collected for routine,biochemical and CSF cytological examinations. The detection of mycobacterium tuberculosis antigen pure protein derivative( PPD) positive cell rate( monocyte) was performed,and the value of CSF cytology in the diagnosis of TBM was summarized. Results (1) The lumbar puncture pressure,white blood cell count,lymphocyte count and protein quantification in the observation group were higher than those in subgroups of the control group,while the glucose and chloride levels were lower than those in the subgroups( P < 0. 05). (2) The cytological examination of CSF in the observation group mainly was mixed cell reaction,accounting for 83. 78%,followed by lymphocyte reaction( 10. 81%). Viral meningitis mainly manifested as lymphocyte reaction,accounting for 82. 14%,while suppurative meningitis mainly manifested as polymorphonuclear response,accounting for 75. 00%. (3) The positive rate of PPD antigen in the observation group was 81. 08%,which was significantly higher than that in children with viral meningitis,suppurative meningitis( P < 0. 05). (4)The accuracy rate of protein level > 0. 45 g/L in the diagnosis of TBM was 89. 19%,and the accuracy rate of CSF cytological mixed cell response was 83. 78%. (5) The white blood cell count,the proportion of monocytes and the proportion of neutrophils were the highest in children with tuberculous meningitis less than 2 weeks,compared with those in children with 3-4 weeks and > 4 weeks( P < 0. 05). The above-mentioned cytological indexes were decreased while the proportion of lymphocytes was increased in children with TBM whose course of disease was 3-4 weeks. The white cell count,proportions of monocytes,lymphocytes and proportion of neutrophils in children whose course of disease was longer than 4 weeks were lower than those in children whose course of disease was 3-4 weeks( P < 0. 05). Conclusions The white blood cell count,proportion of monocyte and proportion of neutrophils were relatively higher in the first 2 weeks of TBM,and maintained for 2 weeks. 2 weeks later,levels of above-mentioned cells decreased except for lymphocytes while the proportion of lymphocytes increased continuously and then decreased gradually 4 weeks later. The diagnostic accuracy rate of CSF cytological mixed reaction to TBM was relatively higher,and the consistency with tuberculosis antigen PPD examination was high,which could be used as a choice for early diagnosis of TBM.