34例人类免疫缺陷病毒感染合并神经梅毒患者的临床特征、诊断及治疗分析

Clinical Features,Diagnosis and Treatment of HIV Infection Patients Merged with Neurosyphilis

目的分析34例人类免疫缺陷病毒(HIV)感染合并神经梅毒(NS)患者的临床特征、诊断及治疗。方法选取2012-2018年在南京市第二医院感染科住院的HIV感染合并确诊及疑似NS患者34例,回顾性分析其一般资料(包括性别、年龄、感染途径、治疗史、HIV感染情况、症状),疾病分型及入院原因,血清学、脑脊液及影像学检查结果,治疗方法及预后。结果 (1)34例患者中男33例(占97.1%),女1例(占2.9%);平均年龄(39.4±11.6)岁;感染途径:同性冶游17例(占50.0%),异性冶游5例(占14.7%),同性冶游伴吸毒1例(占2.9%),其他11例(占32.4%);治疗史:驱梅治疗14例(占41.2%),高效抗逆转录病毒治疗(HAART)10例(占29.4%);HIV感染情况:CD4+细胞数目<350个/μl者23例(占67.6%),机会性感染12例(占35.3%);症状:有症状14例(占41.2%),无症状20例(占58.8%)。(2)14例有症状患者疾病分型:脑膜型8例(占23.5%),脑膜血管型2例(占5.9%),脑实质型4例(占11.8%);20例无症状患者入院原因:Ⅱ期梅毒4例(占11.8%),门诊苄星青霉素驱梅效果欠佳7例(占20.6%),初诊梅毒筛查NS 11例(占32.4%)。(3)血清学、脑脊液及影像学检查结果:血清快速血浆反应素环状卡片试验(RPR)滴度≥1:32者18例(占52.9%);34例患者脑脊液梅毒螺旋体明胶凝集试验(TPPA)均为阳性(占100.0%),脑脊液RPR阳性者13例(占38.2%),脑脊液白细胞计数升高者7例(占23.5%),脑脊液蛋白含量升高者19例(占55.9%);34例患者中行颅脑磁共振成像(MRI)检查者30例(占88.2%),颅脑CT检查者2例(占5.9%),其中颅脑MRI检查异常者13例(占43.3%)。(4)治疗方法:33例(占97.1%)患者采用水剂青霉素G联合苄星青霉素治疗,1例(占2.9%)患者因青霉素过敏而采用头孢曲松钠治疗。(5)预后:21例患者完成3个月~2年随访,其中17例(占81.0%)脑脊液RPR及TPPA转阴,9例(占42.9%)症状改善,1例(占4.8%)遗留神经系统损伤但血清学改善,2例(占9.5%)伴精神异常者症状有所改善。结论 HIV感染合并NS患者临床表现复杂,以无症状NS多见,需结合血清学、脑脊液及影像学检查进行综合判断,而NS的治疗仍首选青霉素。

Objective To analyze the clinical features,diagnosis and treatment of HIV infection patients merged with neurosyphilis(NS). Methods From 2012 to 2018,a total of 34 HIV infection patients merged with confirmed or suspected NS were selected in the Department of Infectious Diseases,the Second Hospital of Nanjing,the general information(including gender,age,route of infection,history of treatment,infection status of HIV and symptoms),disease classification and cause of hospitalization,examination results of serology,cerebrospinal fluid and imaging,therapeutic methods and prognosis were retrospectively analyzed. Results(1)Of the 34 patients,33 cases(accounting for 97.1%)were male and the other 1 case(accounting for 2.9%)was female;the average age was(39.4±11.6)years old;route of infection:17 cases(accounting for 50.0%)due to same-sex venereal exposure,5 cases(accounting for 14.7%)due to heterosexual venereal exposure,1 case(accounting for 2.9%)due to same-sex venereal exposure and drug abuse,11 cases(accounting for 32.4%)due to other causes;history of treatment:14 cases(accounting for 41.2%)received anti-syphilitic treatment,10 cases(accounting for 29.4%)received highly active antiretroviral therapy(HAART);infection status of HIV:23 cases(accounting for 67.6%)with CD4+ cells count <350/μl,12 cases(accounting for 35.3%)with opportunistic infections;symptoms:14 cases(accounting for 41.2%)with symptoms and 20 cases(accounting for 58.8%)without symptoms.(2)Disease classification of 14 cases with symptoms :8 cases(accounting for 23.5%)were classified as meningeal type,2 cases(accounting for 5.9%)as meningeal vascular type,4 cases(accounting for 11.8%)as parenchymal type;cause of hospitalization of 20 cases without symptoms:4 cases(accounting for 11.8%)due to Ⅱ-stage syphilis,7 cases(accounting for 20.6%)due to poor anti-syphilitic treatment effect of benzathine benzylpenicillin in Outpatient Service,11 cases(accounting for 32.4%)due to screening for NS because of newly diagnosed syphilis.(3)Serological examination results found that 18 cases(accounting for 52.9%) performed as serum titer ≥ 1:32;cerebrospinal fluid examination results found that all of the 34 patients(accounting for 100.0%) occur positive TPPA,13 cases(accounting for 38.2%) occur positive RPR,7 cases(accounting for 23.5%) occur elevation of WBC,19 cases(accounting for 55.9%) occur elevation of protein content;30 cases(accounting for 88.2%)underwent craniocerebral MRI examination and 2 cases(accounting for 5.9%) underwent craniocerebral CT examination,thereinto 13 cases(accounting for 43.3%) occurred abnormal craniocerebral MRI examination results.(4)Therapeutic methods:33 cases(accounting for 97.1%)received penicillin G(aqueous solution)combined with benzathine benzylpenicillin,the other 1 case received ceftriaxone sodium due to allergy to penicillins.(5)Prognosis:a total of 21 patients completed the 3-month to 2-year follow-up,thereinto 17 cases(accounting for 81.0%)turned to negative RPR and TPPA in cerebrospinal fluid,9 cases(accounting for 42.9%)got improvement of symptoms,1 case(accounting for 4.8%)occurred residual nerve system injury with serological improvement,2 cases(accounting for 9.5%)complicated with psychological problem got improvement of symptoms to some extent. Conclusion Clinical manifestations of HIV infection patients merged with NS are complex,which mainly performed as asymptomatic NS,thus it is necessary to combine the examination results of serology,cerebrospinal fluid and imaging to make a synthetic judgment,moreover penicillin is still the first choice in the treatment of NS.