亚洲奴卡菌致脑脓肿1例病例分析

Case analysis of brain abscesses caused by Nocardia asiatica:A case report

目的探讨亚洲奴卡菌(Nocardia asiatica)致脑脓肿临床特征及诊断要点,为奴卡菌(Nocardia)所致颅内感染的诊治提供临床依据。方法选取1例于海南医学院第二附属医院确诊的亚洲奴卡菌肺病伴脑脓肿病例,分析其临床表现、脑脊液特点、肺部及头颅影像学特征、治疗方案,总结诊疗经验。结果患者为中老年女性,有糖尿病基础疾病,咳嗽为首发症状,干咳为主,无发热、头痛,病程初期曾在当地医院诊断为肺部感染、肺结核,予一般抗感染及抗结核治疗。治疗效果差,病情仍有进展,出现肢体乏力,呈进行性加重,继而出现意识障碍、昏迷。脑脊液腺苷脱氨酶、乳酸脱氢酶未见异常,脑脊液压力、脑脊液蛋白、脑脊液白细胞升高,以多个核细胞升高为主,脑脊液糖、氯化物在病程初期未见明显异常,病程后期则明显下降。脑脊液宏基因组检测提示亚洲奴卡菌,特异序列数537。肺部CT提示右肺渗出、脓肿、空洞。头颅MRI平扫+增强提示双侧大脑半球散在多发脓肿,脓肿大小不一,呈环形强化,周围广泛水肿,脑室受压。应用美罗培南、利奈唑胺、复方磺胺甲恶唑片治疗后脑脊液恢复、肺部及颅内病变吸收好转。结论亚洲奴卡菌脑脓肿与结核性脑膜炎临床症状、脑脊液特点及头颅影像相似,对合并糖尿病的颅内感染应警惕奴卡菌可能,脑脊液宏基因组检测有助于明确诊断。奴卡菌脑脓肿致死率、致残率高,早诊断、早联合治疗可改善预后。

Objective To investigate the clinical characteristics and diagnosis key points of brain abscess caused by Nocardia asiatica,and provide a clinical basis for diagnosing and treating intracranial infection caused by Nocardia.Methods A case of pulmonary Nocardia asiatica complicated with brain abscess diagnosed at the Second Affiliated Hospital of Hainan Medical University was selected to analyze the clinical manifestations,cerebrospinal fluid characteristics,pulmonary and cranial imaging features,and treatment plan,and to summarize the diagnosis and treatment experience.Results The patient was an elderly woman with a history of diabetes,dry cough was the first symptom without fever or headache.At the beginning of the course,it was diagnosed as pulmonary infection and tuberculosis in the local hospital,and received conventional antimicrobial and anti-tuberculosis therapies,but showed no improvement.The patient developed progressive limb weakness,followed by consciousness disorders,and coma.Cerebrospinal fluid(CSF)adenosine deaminase and lactate dehydrogenase were not abnormal,CSF pressure,protein and white blood cells were high,mainly with multiple nuclear cells.CSF glucose and chloride were normal in the early stage of the disease,but decreased significantly in the later stage.Metagenomic analysis of cerebrospinal fluid indicated Nocardia asiatica with a specific sequence number of 537.Lung CT showed exudation,abscess,and cavity in the right lung.Skull MRI scan+enhancement suggested multiple scattered abscesses in both cerebral hemispheres.The abscesses were of different sizes and showed ring enhancement,with extensive surrounding edema,and ventricular compression.After treatment with meropenem,linezolid,and compound sulfamethoxazole tablets,the cerebrospinal fluid recovered,and the lesions in the lungs and intracranial structures improved.Conclusions Brain abscess caused by Nocardia asiatica is similar to the tuberculous brain in clinical symptoms,cerebrospinal fluid examination,craniocerebral imaging,so we should be alert to the possibility of Nocardia infection in patients with diabetes.At the same time,metagenomic testing of the cerebrospinal fluid can help confirm the diagnosis.The mortality and disability rates of brain abscess caused by Nocardia are high.Early diagnosis and treatment can improve the prognosis.