儿童结核性脑膜炎临床特点及预后的危险因素分析

Analysis of clinical characteristics and risk factors for prognosis in children with tuberculous meningitis

目的分析儿童初诊结核性脑膜炎(TBM)的临床特点及该疾病预后的影响因素。方法回顾性分析2011年6月~2019年6月四川大学华西第二医院初诊为“结核性脑膜炎(包括结核性脑膜脑炎)”住院患儿的临床资料。结果共纳入患儿94例,结核性脑膜炎80例(85.1%),结核性脑膜脑炎14例(14.9%)。其中确诊病例1例(1.1%),高度疑似病例76例(80.8%),疑似病例17例(18.1%)。TBM的第Ⅰ期、Ⅱ期、Ⅲ期的病例分别为28例(29.8%)、32例(34.0%)、34例(36.2%)。根据儿童脑功能分类量表(PCPC)进行评分后,预后良好(PCPC评分≤3分)的病例为59例(62.8%),预后不良(PCPC评分>3分)的病例为35例(37.2%),其中死亡病例为3例(3.2%),均来自于TBM的第Ⅲ期。单因素分析显示抽搐、意识改变、外周神经功能受损、脑膜刺激征阳性、Babinski征阳性、颅神经损害、脑脊液糖含量下降、脑积水、合并颅外结核、入院时GCS评分低、入院时TBM的分期晚与患儿预后不良相关(均P<0.05)。多因素分析发现TBM的第Ⅲ期为预后的危险因素。结论儿童TBM预后不良的比例较高,采用新型检验技术及对合并颅外结核患者积极进行脑脊液检查有助于早期诊断,对怀疑诊断为TBM且病情进展快的儿童积极进行经验性抗结核治疗有助于早期治疗。TBM的第Ⅲ期为预后的危险因素,早期诊断及治疗可改善疾病预后。

Objective It was aimed to analyze the clinical characteristics of the children with initially-diagnosed tuberculous meningitis(TBM)and their prognostic risk factors.Methods The clinical data of hospitalized children with initially-diagnosed tuberculous meningitis(including tuberculous meningoencephalitis)between June 2011 and June 2019 were retrospectively analyzed.Results A total of 94 children were included,including 80 cases of TBM(85.1%)and 14 cases of tuberculous meningoencephalitis(14.9%).Among the children,there were 1 confirmed case(1.1%),76 probable cases(80.8%),and 17 possible cases(18.1%).Regarding of TBM staging,there were 28(29.8%),32(34.0%)and 34(36.2%)cases at stage Ⅰ,Ⅱ and Ⅲ,respectively.According to Pediatric Cerebral Performance Category(PCPC),there were 59 cases(62.8%)with a favourable prognosis(PCPC score≤3)and 35 cases(37.2%)with a poor prognosis(PCPC score>3).In addition,6 out of 94 cases(6.4%)died finally and all of them were at stage Ⅲ of TBM.Univariate analysis showed that convulsions,altered consciousness,impaired peripheral nerve function,positive signs of meningial irritation,positive Babinski's sign,damaged cranial nerves,decreased glucose level in cerebrospinal fluid(CSF),hydrocephalus,extracranial tuberculosis,low GCS score and advanced stage of TBM at admission were all associated with the poor prognosis of the cases(P<0.05).Multivariate analysis showed that stageⅢof TBM(OR=22.948,95%CI 1.880~280.113)was an independent risk factor for prognosis of the cases.Conclusion A big proportion of TBM patients has presented with a poor prognosis.The use of new testing techniques and active cerebrospinal fluid examinations for patients with extracranial tuberculosis can help early diagnosis.Active empirical anti-tuberculosis treatment for children who were suspected of being diagnosed with TBM and whose disease was progressing quickly can help early treatment.StageⅢof TBM was a risk factor for prognosis of the cases.Early diagnosis and treatment would be beneficial for improving the prognosis of TBM.