神经损伤标志物在儿童结核性脑膜炎中的动态变化特征及意义

Dynamic changes and significance of biomarkers of cerebral injury in pediatric tuberculous meningitis

目的:分析神经元特异性烯醇化酶(neuron specific enolase,NSE)、S100B、胶质纤维酸性蛋白(glial fibrillary acidic protein,GFAP)在结核性脑膜炎(tuberculous meningitis,TBM)患儿血清及脑脊液中表达的动态变化特征及其对患儿预后预测价值。方法:采用前瞻性研究方法,连续纳入2018年1月1日至2021年12月31日于南华大学附属长沙中心医院儿童结核科收治的72例TBM患儿作为TBM组。搜集同期住院,诊断为肺结核同时排除TBM的患儿20例作为肺结核组。TBM组患儿治疗6个月后根据预后情况,分为完全康复组(47例)和预后不良组(25例)。采用酶联免疫吸附试验法测定TBM组入院48 h内及治疗后(1、2、3周)和肺结核组入院48 h内的血清和脑脊液NSE、S100B、GFAP水平,并进行比较。采用受试者工作特征(receiver operating characteristic,ROC)曲线及曲线下面积(area under the curve,AUC)分析TBM患儿入院时脑脊液NSE、S100B、GFAP水平,预测其不良预后的阈值、敏感度及特异度。结果:入院时血清及脑脊液NSE、S100B、GFAP水平[中位数(四分位数)],TBM组分别为15.12(3.22,26.90)μg/L、1.11(0.40,3.20)μg/L、15.34(3.44,45.82)μg/L和37.90(6.50,142.70)μg/L、2.31(1.02,10.20)μg/L、65.31(10.87,252.60)μg/L,均明显高于肺结核组[分别为7.03(2.48,13.23)μg/L、0.25(0.12,0.36)μg/L、10.38(2.41,19.00)μg/L和7.56(2.12,12.79)μg/L、0.35(0.05,0.51)μg/L、7.86(2.41,13.80)μg/L],差异均有统计学意义(血清水平:Z值分别为-5.064、-6.817、-2.693,P值分别为0.000、0.000、0.007;脑脊液水平:Z值分别为-6.465、-6.816、-6.778,P值均为0.000);预后不良组脑脊液NSE、S100B、GFAP水平分别为60.16(24.90,142.70)μg/L、2.59(1.32,10.20)μg/L、118.74(58.83,252.60)μg/L,明显高于完全康复组[分别为29.37(6.50,68.82)μg/L、1.97(1.02,6.10)μg/L、45.39(10.87,84.93)μg/L],差异均有统计学意义(Z值分别为-4.855、-3.212、-6.334,P值分别为0.000、0.001、0.000)。治疗后1、2、3周,预后不良组脑脊液NSE分别为49.58(15.38,87.56)μg/L、41.53(9.60,82.00)μg/L、25.97(5.56,58.49)μg/L,S100B分别为10.15(3.63,15.72)μg/L、1.60(0.41,3.28)μg/L、0.75(0.41,1.60)μg/L,GFAP分别为99.75(65.79,180.84)μg/L、63.94(13.65,120.59)μg/L、38.03(10.87,85.40)μg/L,均明显高于完全康复组[NSE分别为18.49(4.87,36.12)μg/L、14.51(4.87,35.70)μg/L、8.53(2.12,21.70)μg/L;S100B分别为5.34(2.19,10.08)μg/L、0.66(0.19,1.56)μg/L、0.40(0.11,0.74)μg/L;GFAP分别为45.39(10.87,84.93)μg/L、17.77(5.66,38.15)μg/L、12.82(5.04,26.90)μg/L,差异均有统计学意义(NSE:Z值分别为-2.496、-3.815、-4.041,P值分别为0.013、0.000、0.000;S100B:Z值分别为-3.331、-4.745、-1.207,P值分别为0.047、0.000、0.036;GFAP:Z值分别为-4.940、-2.337、-3.745,P值分别为0.000、0.016、0.012)。ROC曲线分析,获得最大约登指数下入院时TBM患儿脑脊液NSE、S100B、GFAP水平对预后不良的预测阈值分别为51.92μg/L、2.75μg/L、77.54μg/L。结论:TBM患儿血清及脑脊液NSE、S100B、GFAP水平明显增高,经治疗后血清NSE、S100B、GFAP水平快速降至正常,而脑脊液NSE、S100B、GFAP水平下降缓慢。TBM患儿入院时脑脊液NSE≥51.92μg/L、S100B≥2.75μg/L或GFAP≥77.54μg/L,且经治疗后脑脊液NSE、S100B、GFAP下降缓慢,提示预后不良的可能。

Objective:To analyze the dynamic changes of expression of neuron specific enolase(NSE),S100B protein and glial fibrillary acidic protein(GFAP)in serum and cerebrospinal fluid of children with tuberculous meningitis(TBM)and their prognostic value.Methods:A prospective study was conducted in 72 children with TBM admitted to the Department of Pediatric Tuberculosis,Changsha Central Hospital affiliated to South China University from January 1,2018 to December 31,2021(TBM group).And 20 hospitalized children diagnosed with pulmonary tuberculosis and excluded TBM in the corresponding period were collected as pulmonary tuberculosis group.Children in TBM group were divided into complete recovery group(n=47)and poor prognosis group(n=25)according to the prognosis after 6-month treatment.Enzyme-linked immunosorbent assay(ELISA)was used to determine the NSE,S100B and GFAP levels in serum and cerebrospinal fluid of TBM group within 48 h after admission and after treatment(1,2 and 3 weeks)and of pulmonary tuberculosis group within 48 h after admission,the results were compared.The receiver operating characteristic(ROC)curve and area under the curve(AUC)were used to analyze NSE,S100B and GFAP levels in cerebrospinal fluid of TBM children at admission to predict the threshold,sensitivity and specificity of the poor prognosis.Results:NSE,S100B and GFAP levels(median(quartile))in serum and cerebrospinal fluid at admission were 15.12(3.22,26.90)μg/L,1.11(0.40,3.20)μg/L,15.34(3.44,45.82)μg/L and 37.90(6.50,142.70)μg/L,2.31(1.02,10.20)μg/L,65.31(10.87,252.60)μg/L,respectively in TBM group,which were all significantly higher than those in pulmonary tuberculosis group(7.03(2.48,13.23)μg/L,0.25(0.12,0.36)μg/L,10.38(2.41,19.00)μg/L,7.56(2.12,12.79)μg/L,0.35(0.05,0.51)μg/L and 7.86(2.41,13.80)μg/L,respectively)(serum levels:Z values were-5.064,-6.817 and-2.693,respectively;P values were 0.000,0.000 and 0.007,respectively)(cerebrospinal fluid level:Z values were-6.465,-6.816 and-6.778,respectively,all P=0.000).The levels of NSE,S100B and GFAP in cerebrospinal fluid of patients in the poor prognosis group were significantly higher than those in the complete recovery group(60.16(24.90,142.70)μg/L vs.29.37(6.50,68.82)μg/L,Z=-4.855,P=0.000;2.59(1.32,10.20)μg/L vs.1.97(1.02,6.10)μg/L,Z=-3.212,P=0.001;118.74(58.83,252.60)μg/L vs.45.39(10.87,84.93)μg/L,Z=-6.334,P=0.000,respectively).In the poor prognosis group,at the 1st,2nd and 3rd week after treatment,NSE levels of cerebrospinal fluid were 49.58(15.38,87.56)μg/L,41.53(9.60,82.00)μg/L and 25.97(5.56,58.49)μg/L,respectively;S100B levels were 10.15(3.63,15.72)μg/L,1.60(0.41,3.28)μg/L and 0.75(0.41,1.60)μg/L,respectively;GFAP levels were 99.75(65.79,180.84)μg/L,63.94(13.65,120.59)μg/L and 38.03(10.87,85.40)μg/L,respectively;which were all significantly higher than those in the complete recovery group(NSE:18.49(4.87,36.12)μg/L,14.51(4.87,35.70)μg/L and 8.53(2.12,21.70)μg/L,Z=-2.496,-3.815,-4.041,P=0.015,0.000,0.000,respectively;S100B:5.34(2.19,10.08)μg/L,0.66(0.19,1.56)μg/L and 0.40(0.11,0.74)μg/L,Z=-3.331,-4.745,-1.207,P=0.047,0.000,0.036,respectively;GFAP:45.39(10.87,84.93)μg/L,17.77(5.66,38.15)μg/L and 12.82(5.04,26.90)μg/L,Z=-4.940,-2.337,-3.745,P=0.000,0.016 and 0.012,respectively).ROC curve analysis showed that the predictive thresholds of NSE,S100B and GFAP levels in cerebrospinal fluid for poor prognosis of TBM children at admission were 51.92μg/L,2.75μg/L,and 77.54μg/L,respectively under the maximum Youden index.Conclusion:The levels of NSE,S100B and GFAP in serum and cerebrospinal fluid of TBM children were significantly increased,and after treatment,the levels of NSE,S100B and GFAP in serum quickly decreased to normal,while those in cerebrospinal fluid decreased slowly.In cerebrospinal fluid of TBM children,NSE≥51.92μg/L,S100B≥2.75μg/L,or GFAP≥77.54μg/L at admission and the levels decreased slowly after treatment,indicating the possibility of poor prognosis.