隐球菌脑膜炎15例临床诊治分析

Clinical features and management of cryptococcal meningitis: A series of 15 cases

目的通过分析隐球菌脑膜炎(cryptococcal meningitis,CM)的临床特点,进一步提高CM的临床诊疗水平。方法回顾性分析2016年1月-2017年12月解放军总医院第四医学中心隐球菌性脑膜炎住院患者的临床资料、临床表现、实验室检查、头颅影像学检查、治疗方案及预后。结果共纳入15例患者,其中10例男性,5例女性,年龄26～87(54.53±15.92)岁,8例合并基础疾病,仅1例有明确鸽子接触史。12例以"发热、头痛"为首发症状,12例出现高颅压,8例脑脊液压力>300 mmH_2O(1 mmH_2O=0.009 8kPa),其中4例实施了Ommaya囊置入术。首次就诊时误诊10例。患者出现不适至明确诊断时间为15 d～3个月。15例荚膜抗原检测阳性,其中7例患者首次墨汁染色阴性。伏立康唑单药治疗8例,两性霉素B脂质体+氟胞嘧啶联合治疗2例,伏立康唑+两性霉素B脂质体+氟胞嘧啶联合治疗5例。1例死亡,14例治愈。结论 CM易误诊为结核或病毒感染,荚膜抗原检测敏感性高。CM患者多出现高颅压,Ommaya囊置入治疗可减轻患者高颅压症状。伏立康唑对隐球菌脑膜炎效果较肯定,尤其对老年多脏器功能障碍及肾移植术后患者。

Objective To study the clinical characteristics of cryptococcal meningitis(CM), and provide further evidence for its clinical diagnosis and therapy. Methods Clinical data about inpatients with CM admitted to the department of neurology, the Fourth Medical Center of Chinese PLA General Hospital from January 2016 to December 2017 were collected, and their clinical manifestations, laboratory test results, cranial imaging examination, treatment and prognosis were analyzed retrospectively.Results There were 10 males and 5 females with age ranging from 26 to 87 years(average age of 54.53±15.92 years). Of the 15 cases, 8 patients had underlying diseases and 1 patient had contact history with pigeon, 12 patients had 'fever, headache' as the first symptom. Intracranial hypertension occurred in 12 patients, and the intracranial pressure in 8 patients was higher than 300 mmH2 O.Four patients underwent Ommaya cyst implantation. The misdiagnosis at the first visit occurred in 10 cases. The time to diagnosis ranged from 15 days to 3 months. All patients had positive results to incapsular antigen detection, while 7 cases had negative results to the first India ink stain. Voriconazole monotherapy was performed in 8 cases, Amphotericin B liposome + flucytosine combination therapy in 2 cases, voriconazole + amphotericin B liposome + flucytosine in 5 cases. One patient died and 14 patients were cured.Conclusion CM is easy to be misdiagnosed as tuberculosis or virus infection. The sensitivity of capsular antigen detection is high. Intracranial hypertension often occurs in patients with CM, while Ommaya capsule implantation treatment can alleviate the symptoms. Voriconazole is effective on CM, especially for elderly patients with multiple organ dysfunction and renal transplantation.