结核性脑膜炎并发矛盾反应一例

A case of tuberculous meningitis complicated with paradoxical reaction

目的分析1例结核性脑膜炎并发矛盾反应患者的临床特征,以提升临床对结核性脑膜炎并发矛盾反应的关注度。方法回顾性分析中国医学科学院北京协和医院2020年9月8日收治的1例结核性脑膜炎并发矛盾反应患者的临床资料、诊疗经过和预后。结果该患者以发热、头痛起病,脑脊液检查提示颅压明显升高,白细胞总数、蛋白水平高,氯化物水平降低,脑脊液及外周血结核分枝杆菌感染T细胞检测阳性,头颅核磁共振提示多发异常信号,其余病原学检查均为阴性,考虑结核性脑膜炎可能性大,予诊断性抗结核治疗,临床症状和脑脊液指标一度好转,糖皮质激素减量后病情再度恶化,经系统检查除外其他感染后,考虑矛盾反应,糖皮质激素再次加量后好转。出院后1年复查头颅核磁共振未见明显异常。结论结核性脑膜炎并发矛盾反应的病例临床较少见,易漏诊、误诊而延误治疗。对抗结核治疗启动后反而出现病情加重者应警惕并发矛盾反应,治疗首选糖皮质激素。

Objective To analyze a case with tuberculous meningitis complicated with paradoxical reaction,and to raise the attention to tuberculous meningitis complicated with paradoxical reaction.Methods The clinical data,diagnosis and treatment process and prognosis of a patient with tuberculous meningitis complicated with paradoxical reaction admitted to Peking Union Medical College Hospital,Chinese Academy of Medical Sciences on September 8th 2020 were analyzed,retrospectively.Results The patient presented clinically with headache and fever,the cerebrospinal fluid examination showed that the intracranial pressure was significantly increased,the white blood cells and protein level were high,and the chlorine level was low.Mycobacterium tuberculosis infection of T cells spot test were positive both in peripheral blood and cerebrospinal fluid,brain Magnetic Resonance Imaging(MRI)showed multiple abnormal signals,while the rest of the etiological examination was negative.The patient was considered tuberculous meningitis and started diagnostic anti-tuberculosis treatment.The clinical symptoms and cerebrospinal fluid tests improved for a while,but the condition deteriorated again after the reduction of glucocorticoids.The patient was considered paradoxical reaction.After increased doses of glucocorticoid,the patient improved rapidly.MRI at 1 year was essentially unremarkable.Conclusions Tuberculous meningitis complicated with paradoxical reaction is rare,which is easy to be misdiagnosed and delayed to receive treatment.Therefore,clinicians are reminded to be alert to tuberculous meningitis complicated by paradoxical reaction for patient with aggravation of the disease after anti-tuberculosis treatment,high-dose glucocorticoids is the preferred treatment.