13例隐球菌脑膜炎患者临床特点分析

The clinical characteristics of 13 cases of patients with cryptococcus meningitis

目的分析隐球菌性脑膜炎(cryptococcal meningitis,CM)患者临床特征,联合抗真菌治疗的方案选择及预后转归,提高对该病的认识和临床诊疗水平。方法回顾性分析2013年1月至2023年8月在南充市中心医院住院确诊为CM患者临床资料,分析其临床疗效、药物不良反应及转归。结果13例CM患者的年龄为38~81岁,1例有明确的鸟类接触史。8例有合并症,其中艾滋病5例,肾脏疾病2例,慢性阻塞性肺疾病合并帕金森病1例。临床表现以头痛与发热为主。影像学检查显示6例颅内异常。12例脑脊液隐球菌镜检阳性,10例真菌培养阳性。11例外周血CD4+T细胞水平明显降低。治疗方面,10例患者使用两性霉素B(amphotericin B,AmB)联合5-氟胞嘧啶(5-flucytosine,5-FC)初始治疗,其中2例感染难以控制,1例因家庭原因,予以终止治疗。7例患者中位诱导疗程为7周(4~8周)。最突出的不良反应为低钾血症,发生率可达57.1%(4/7);其次,为肝肾功能指标异常,但多数轻微。2例肾病患者采用不同联合治疗方案(高剂量氟康唑和AmB三联疗法)。2例患者因不良反应更改诱导方案。手术引流者2例(1例侧脑室-腹腔分流术,1例脑室外引流术)。抗真菌治疗结束时,完全缓解10例,失败1例,死亡2例。结论免疫功能低下可能为隐球菌感染的易患因素。治疗方案主要以AmB联合5-FC为主的个体化抗真菌治疗。积极控制颅内压是降低病死率、改善预后的关键。

Objective To improve the level of the clinical diagnosis and treatment by analyzing the clinical features and combined antifungal therapy in patients with cryptococcal meningitis(CM).Methods Thirteen patients with cryptococcosis neoformans infection in Nanchong City Central Hospital from January 2013 to August 2023 were retrospectively enrolled.Clinical features including clinical characteristics,clinical responses,drugrelated adverse events,and prognosis were evaluated.Results The age of the 13 patients with CM ranged from 38 to 81 years old.One patient had a history of bird exposure.Of the 13 patients,8 patients suffered had comorbidities,including 5 cases of AIDS(HIV infection),2 cases of kidney disease,and 1 case of COPD with Parkinson’s disease.The most common symptoms of CM were headache and fever.Abnormalities of imaging examination were found in 6 cases.Twelve cases had positive microscopic examination of cryptococcus in cerebrospinal fluid,and 10 cases had positive fungal culture.Eleven cases had significantly decreased levels of CD4+T cells.Ten patients were treated with amphotericin B(AmB)in combination with 5-flucytosine(5-FC).Two patients experienced infections that were difficult to control,and 1 patient discontinued treatment due to family reasons.The median course for the 7 patients was 7 weeks(4-8 weeks).Hypokalemia was the most prominent adverse effect with an incidence of 57.1%(4/7).Mild abnormal liver and kidney function tests were found.Two patients with nephropathy in this study were treated with different combination regimens(high-dose fluconazole and voriconazole,AmB combined with 5-FC).Two patient required to change regimen due to adverse effects.Two patients had surgical drainage(1 case of lateral ventricle-peritoneal shunt,1 case of extraventricular drainage).At the end of antifungal treatment,10 cases were in complete remission,1 case failed,and 2 cases died due to cryptococcal meningitis.Conclusion Low immune function may be a susceptible factor for cryptococcal infection.The main antifungal treatment was AmB combined with 5-FC.Active control of intracranial pressure is the key to reduce the case-fatality rate and improve the prognosis.