儿童结核性脑膜炎抗结核治疗后头颅MRI病灶进展的原因及处理

Causes and management of brain MRI lesion progression in children with tuberculous meningitis during anti-tuberculosis treatment

目的探讨儿童结核性脑膜炎(TBM)抗结核治疗期间头颅MRI病灶进展的原因及处理方法。方法回顾性分析2011年2月至2022年5月该院儿科诊治的17例TBM患儿病历资料,包括发生时间、持续时间、临床症状、脑脊液结果、影像学特点、原因、处理方案。结果17例TBM患儿抗结核治疗后头颅MRI病灶进展平均时间为(33.59±19.50)d;11例(64.71%)无临床症状。头颅MRI病灶进展时表现为脑膜原病灶较前增厚11例(64.71%),脑实质原病灶增大9例(52.94%),原病灶此消彼长6例(35.29%),出现新增病灶1例(5.88%)。鉴定原因为矛盾反应(PR)14例(82.35%),诊断耐药结核1例(5.88%),与异烟肼代谢类型为快乙酰化型有关的1例(5.88%),1例(5.88%)未规范抗结核治疗导致病灶增多。14例PR处理方案为在HRZE(H:异烟肼;R:利福平;E:乙胺丁醇;Z:吡嗪酰胺)或HRZ联用或未联用利奈唑胺抗结核药物基础上,延长或加用糖皮质激素9例,加用左氧氟沙星3例,未特殊处理5例;异烟肼代谢类型为快乙酰化型的患儿调整至15 mg/kg;耐药结核患儿更改为耐药方案;依存性差患儿未改变治疗方案。结论儿童TBM抗结核治疗后头颅MRI病灶进展的常见原因为PR,糖皮质激素治疗可促进病灶吸收。

Objective To investigate the causes and management of cranial magnetic resonance imaging(MRI)lesion progression during anti-tuberculosis treatment of tuberculous meningitis(TBM)in children.Methods The medical records of 17 children with TBM from February 2011 to May 2022 in this hospital were analyzed retrospectively,including the occurrence time,duration,clinical symptoms,cerebrospinal fluid results,imaging characteristics,causes and treatment schemes.Results The mean duration of cranial MRI lesion progression in 17 children with TBM after anti-tuberculosis treatment was(33.59±19.50)days;11 cases(64.71%)had no clinical symptoms.The progression of cranial MRI lesions was manifested as thickening of the original meningeal lesion compared with the previous one in 11 cases(64.71%),enlarging of the original lesion in the brain parenchyma in nine cases(52.94%),the original lesion disappeared in six cases(35.29%),and the appearance of a fresh lesion in one case(5.88%).The reasons identified were paradoxical response(PR)in 14 cases(82.35%),diagnosis of drug-resistant tuberculosis in one case(5.88%),association with isoniazid metabolism type of rapid acetylation in one case(5.88%),and increase in foci due to unregulated anti-tuberculosis treatment in one case(5.88%).The treatment regimens for the 14 cases of conflicting reactions were:HRZE(H:isoniazid;R:rifampicin;E:ethambutol;Z:pyrazinamide)or HRZ in combination with or without linezolid,extended or additional glucocorticoids in nine cases,addition of levofloxacin in three cases,no specific therapy in five cases;The metabolic type of fast acetylated isoniazid was adjusted to 15 mg/kg in children.The children with drug-resistant tuberculosis were changed to drug-resistant regimen;Children with poor dependence did not change the treatment plan.Conclusion PR is the common reason for the progress of brain MRI lesions after TBM anti-tuberculosis treatment in children,and glucocorticoid treatment can promote the lesion absorption.