妊娠期结核性脑膜炎成功救治一例并文献复习

A case of pregnancy complicated with tuberculous meningitis and literature review

目的探讨妊娠期结核性脑膜炎的临床特征、临床诊断、治疗方法及母婴预后。方法根据北京大学深圳医院收治的1例及国内外文献报道的34例妊娠期及产褥期颅内结核患者的临床资料,对妊娠相关颅内结核感染的诊断与治疗方法及母婴预后进行回顾性分析。结果本例患者29岁,因“停经25+2周,反复头痛伴发热20d,精神异常2d”于2009年12月7日收入北京大学深圳医院神经内科,入院后症状进一步加重,随后出现脑膜炎刺激征,结合影像学表现高度怀疑结核性脑膜炎,即启动抗结核治疗;患者脑脊液结核分枝杆菌培养阳性;治疗过程中因考虑到链霉素对胎儿的致畸作用,决定使用异烟肼、利福平、乙胺丁醇及吡嗪酰胺四联治疗,最终于孕32周行剖宫产分娩一活婴。产后随访母婴体健。检索1956年至2020年文献报道的34例妊娠期和产褥期颅内结核患者,其临床症状包括头痛28例(82.35%),发热23例(67.65%),呕吐16例(47.06%),颈项强直15例(44.12%),Kernig征阳性6例(17.65%),抽搐8例(23.53%),偏瘫8例(23.53%),嗜睡8例(23.53%),神志不清8例(23.53%),视神经损害7例(20.59%)。在33例(97.06%)有描述孕产妇结局的文献中,经治疗后治愈9例(27.27%),好转17例(51.52%),死亡4例(12.12%),遗留视力损害3例(9.09%),失去随访1例。有25例(73.53%)描述新生儿结局,其中17例(68%)健康,4例(16%)患先天性结核病,4例(16%)死亡。结论妊娠期和产褥期颅内结核的临床特征主要为发热、头痛、恶心呕吐、颈项强直、Kernig征阳性,部分病例可伴有抽搐、视神经损害,严重时可出现昏迷;治疗方案以抗结核治疗为主;母婴的预后往往与开始抗结核治疗的时机相关,抗结核治疗开始越早,母婴预后越好,反之则越差。

Objective To investigate the elinical features,clinical diagnosis,treatment methods and matemal-infant prognosis of tuberculous meningitis in pregnancey.Methods Basod on one case,who was adnmitted to Peking University Shenzhen Hospital,and 34 cases of intracranial tuberculosis were reported in the literature,we retrospectively reviewed the diagnosis,treatment and prognosis of pregnancy-related intracnnial tuberculosis.Results The 29-year-old patient was adnmitted to the Department of Neurology,Peking University Shemzhen Hospital on December 7,2009 due to“pregnancy 25+2 week with repeated headaches with fever for 20 days and mental disorders for 2 days”.After admission,her symptoms further worsened.She was highly suspected of tuberculosis meningitis by meningitis iritation and imaging findings.Anti-tuberculosis treatment was initiated.Cenebrospinal fluid of the patient was mycobacterium tuberculosis positive.During the treatment,considering the teratogenie efeets of streptonycin on the fetus,it was decided to use quaduple therapy including tetrabuterol and pyrazinamide,isoniazid,and rifampicin.Finally,the pregnant womant gave bith to a live baby by cesarean section at 32 weeks of gestation.Follow up the health of mother and baby after delivery.In the literatures from 1956 to 2020,34 cases of intracranial tuberculosis in pregnancy and puerperum were repoted.The clinical symptoms included 28 cases with headache(82.35%),23 cases with fever(67.65%),and 16 cases with vomiting(47.06%),15 cases with neck siffness(44.12%),6 cases with Kemig Yang sign(17.65%),8 cases with convulsions(23.53%),8 cases with hemiplegia(23.53%),8 cases with drowsiness(23.53%),8 cases with unconsciousness(23.53%),and 7 cases with optic nerve damage(20.59%).Among 33 cases with descriptions of matemal outcomes,9 cases(27.27%)were cured after treatment.17 cases(51.52%)were improved.4 cases(12.12%)were died.3 cases(9.09%)were left with visual impairment.The pregnant woman lost follow-up after treatment in the other case.There were 25 cases(73.53%)with described neonatal outcomes,of which 17 cases(68%)were healthy,4 cases(16%)had congenital tuberculosis,and 4 cases(16%)died.Conclusions The clinical characteristics of tuberculous meningitis during pregnancy and puerperium mainly included fever,headache,nausea,vomiting,neck stiffness,and positive Kemig sign.Some cases may be accompanied by convulsions,and optic nerve damage.Coma appeared in severe cases.Anti-tuberculosis treatment is the main treatment plan.The prognosis of mothers and babies was related to the timing of starting anti-tuberculosis treatment.It is especially important to start anti tuberculosis treatment as early as possible before the occumence of coma.