本文選題：隱球菌性腦膜炎 + 診斷��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:1分析并總結(jié)隱球菌性腦膜炎患者的臨床特征、腦脊液特點(diǎn)、治療及轉(zhuǎn)歸,為早期診斷和有效治療提供經(jīng)驗(yàn)。2探討隱球菌性腦膜炎患者腦脊液及血清中的1,3-β-D葡聚糖的診斷價(jià)值。方法:1回顧性分析2003年1月~2017年1月14年間就診于河北醫(yī)科大學(xué)第二醫(yī)院的95例隱球菌性腦膜炎患者的病例資料,總結(jié)其臨床特征、影像學(xué)、腦脊液檢查、治療及轉(zhuǎn)歸情況。2采用動(dòng)態(tài)濁度法,檢測(cè)隱球菌性腦膜炎患者腦脊液及血漿中1,3-β-D葡聚糖的含量。結(jié)果:95例患者中,平均年齡42.86±19.33歲,男患者與女患者比例為59:36,其中農(nóng)民67人,約占總?cè)藬?shù)的70.53%。發(fā)病前健康者50例,基礎(chǔ)疾病者45例,口服激素18例,免疫抑制劑6例。有鴿子及禽類接觸者10例。75例(78.95%)為亞急性或慢性起病。臨床主要表現(xiàn)為進(jìn)行性的頭痛、體溫升高、惡心嘔吐和腦膜刺激征。視力損害、聽(tīng)力損害以及外展神經(jīng)受損最多見(jiàn)。88.04%隱腦患者顱內(nèi)壓增高(81/92),其中59例患者顱內(nèi)壓小于500mm H2O,大于500mm H2O者22例。80.28%隱腦患者腦脊液白細(xì)胞增高(57/71),中位數(shù)為50×106/L(0~828)。71.83%隱腦患者腦脊液葡萄糖降低(51/71),均值為1.87±1.28mmol/L(0.08~5.3)。90.14%隱腦患者腦脊液蛋白升高(64/71),中位數(shù)0.73g/L(0.06~4.83)。67.61%隱腦患者腦脊液氯化物降低(48/71),平均114.46±7.84mmol/L(97~134)。隱球菌性腦膜炎患者的腦脊液壓力、白細(xì)胞計(jì)數(shù)、葡萄糖含量與病情嚴(yán)重程度有線性相關(guān)關(guān)系,腦脊液蛋白、氯化物含量與疾病嚴(yán)重程度無(wú)線性相關(guān)關(guān)系。本組95例患者中有55例(57.89%)腦脊液細(xì)胞學(xué)檢查發(fā)現(xiàn)背景細(xì)胞異常。其中,呈淋巴細(xì)胞反應(yīng)為主者21例,混雜細(xì)胞學(xué)反應(yīng)者19例,嗜中性粒細(xì)胞反應(yīng)為主者15例。發(fā)病小于10天的病例,細(xì)胞學(xué)多呈以嗜中性粒細(xì)胞反應(yīng)為主或者為以嗜中性粒細(xì)胞為主的混雜細(xì)胞學(xué)反應(yīng)為主(12/14),發(fā)病處于10~30天之間的病例多以混合細(xì)胞學(xué)反應(yīng)為主(10/24),發(fā)病大于30天的病例多以淋巴細(xì)胞反應(yīng)為主(10/17)。頭顱影像學(xué)以腦膜強(qiáng)化、炎性病灶、腦積水最為常見(jiàn)。肺CT檢查最為多見(jiàn)的異常表現(xiàn)為炎性改變。隱球菌性腦膜炎的誤診率較高,本組共34例(35.79%)隱腦患者確診前被誤診為其他疾病,其中被誤診為結(jié)核性腦膜炎者16例,所占比例最大。首次腰穿腦脊液細(xì)胞學(xué)邁-格-姬(MGG)染色陽(yáng)性率為75.79%,阿利新藍(lán)染色陽(yáng)性率為77.89%,聯(lián)合兩種染色2次以上陽(yáng)性率為100%。本研究通過(guò)動(dòng)態(tài)濁度法進(jìn)行1,3-β-D葡聚糖檢測(cè),結(jié)果證實(shí)在隱球菌性腦膜炎患者的腦脊液中可以檢測(cè)到1,3-β-D葡聚糖,27例隱腦患者17例(62.96%)陽(yáng)性;在隱腦患者的血漿中同樣也可以檢測(cè)到1,3-β-D葡聚糖,11例隱球菌性腦膜炎患者僅1例(9.09%)陽(yáng)性。阿利新藍(lán)染色、邁-格-姬染色(MGG)及腦脊液1,3-β-D葡聚糖檢測(cè)敏感性兩兩之間無(wú)差別,前三種方法與血漿1,3-β-D葡聚糖檢測(cè)敏感性有差別。本組共82例隱腦患者接受抗真菌治療,38例接受兩性霉素B或脂質(zhì)體聯(lián)合氟康唑治療,20例接受兩性霉素B或脂質(zhì)體聯(lián)合伏立康唑治療,15例接受氟康唑單藥治療,5例接受兩性霉素B單藥治療,4例接受伏立康唑單藥治療�？拐婢桨钢委煹目傮w有效率為71.95%,聯(lián)合用藥方案治療的有效率為82.76%,單藥治療方案治療的有效率為45.83%。采用外科手術(shù)進(jìn)行腦脊液引流可有效緩解頑固性高顱壓。結(jié)論:1隱球菌性腦膜炎多見(jiàn)于中年人,男性患者多于女性患者,農(nóng)民最為常見(jiàn),多呈亞急性或慢性起病。常以頭痛、體溫升高為首發(fā)癥狀,顱神經(jīng)損害中以視神經(jīng)、前庭蝸神經(jīng)及展神經(jīng)受損多見(jiàn)。2腦脊液壓力、白細(xì)胞計(jì)數(shù)越高,葡萄糖含量越低,患者病情越嚴(yán)重。3隱腦患者腦脊液細(xì)胞學(xué)類型與發(fā)病時(shí)間有關(guān)。4本病誤診率高,確診前被誤診為結(jié)核性腦膜炎者最多見(jiàn)。5在隱球菌性腦膜炎患者的腦脊液中可以檢測(cè)到1,3-β-D葡聚糖,并可對(duì)臨床診斷提供有效信息。6阿利新藍(lán)染色、邁-格-姬染色(MGG)及腦脊液1,3-β-D葡聚糖檢測(cè)敏感性高于血漿1,3-β-D葡聚糖檢測(cè)敏感性。7聯(lián)合抗真菌治療效果優(yōu)于單藥治療隱球菌性腦膜炎。
[Abstract]:Objective: 1 to analyze and summarize the clinical features, cerebrospinal fluid characteristics, treatment and prognosis of cryptococcal meningitis patients, and provide empirical.2 for early diagnosis and effective treatment to explore the diagnostic value of 1,3- beta -D glucan in cerebrospinal fluid and serum of cryptococcal meningitis patients. Method: 1 retrospective analysis in January 2003, ~2017 year, 14 years in the river. The data of 95 cases of cryptococcal meningitis in Second Hospital of North Medical University, the clinical features, imaging, cerebrospinal fluid examination, treatment and prognosis of.2 were measured by dynamic turbidimetric method, and the content of 1,3- beta -D glucan in cerebrospinal fluid and plasma of cryptococcal meningitis patients was detected. Results: the average age was 42.86 + 19.33 in 95 patients. The proportion of male and female patients was 59:36, of which 67 were farmers, 50 were healthy before the onset of 70.53%., 45 cases of basic diseases, 18 cases of oral hormones, 6 cases of immunosuppressive agents. 10 cases of dove and poultry exposed to.75 (78.95%) were subacute or chronic onset. Clinical manifestations were progressive headache, body temperature rise, nausea. Emesis and meningeal irritation. Visual impairment, hearing impairment, and abduction nerve damage were most seen in.88.04% patients with intracranial hypertension (81/92), of which intracranial pressure was less than 500mm H2O, and 22 cases of.80.28% Cryptomeria were higher than 500mm H2O, and the median was 50 x 106/L (0~828).71.83% Cryptomeria cerebrospinal fluid Glucose decreased (51/71), the mean value of the cerebrospinal fluid protein increase (64/71) in patients with 1.87 + 1.28mmol/L (0.08~5.3).90.14% cryptobrain, the decrease of chloride in cerebrospinal fluid (48/71) in the median 0.73g/L (0.06~4.83).67.61% saphenous brain (48/71), the average of 114.46 + 7.84mmol/L (97~134). The cerebrospinal pressure, leukocyte count, glucose content and the amount of glucose in the patients with cryptococcal meningitis There was a linear correlation between the severity of the disease, and there was no linear correlation between the cerebrospinal fluid protein and the content of chloride and the severity of the disease. 55 of the 95 patients in this group (57.89%) found abnormal background cells in the cerebrospinal fluid cytology. Among them, there were 21 cases of lymphocyte reaction, 19 cases of mixed cytology and neutrophils response to neutrophil. The 15 cases were less than 10 days. Most of the cases were mainly neutrophil reaction or the predominantly neutrophil mixed cytological reaction (12/14), and most cases with 10~30 days were mainly mixed cytological reaction (10/24), and most cases with hair disease more than 30 days were mainly lymphocyte reaction (10/17 The most common abnormal manifestation of CT examination was inflammatory change. The misdiagnosis rate of cryptococcal meningitis was higher. 34 cases (35.79%) of this group were misdiagnosed as other diseases before diagnosis, and 16 cases were misdiagnosed as tuberculous meningitis, the largest proportion accounted for the most. The positive rate of MGG staining in the cerebrospinal fluid cytology was 75.79%, the positive rate of alien blue staining was 77.89%, and the positive rate of the combined two kinds of staining was 100%., and the positive rate of the combined two kinds of staining was 100%.. The results showed that the 1,3- beta -D glucan could be detected in the cerebrospinal fluid of the patients with cryptococcal meningoencephalitis. The results showed that the 1,3- beta -D glucan could be detected in the cerebrospinal fluid of cryptococcal meningoencephalitis patients. 27 cases of cryptobrain patients (62.96%) were positive; 1,3- beta -D glucan was also detected in the plasma of the patients with cryptococcosis, and only 1 cases (9.09%) were positive in 11 cases of cryptococcal meningitis. There was no difference between the aligan blue staining, the MGG and 1,3- beta -D dextran sensitivity 22, the first three methods and the plasma 1,3- beta -D The sensitivity of dextran detection was different. 82 cases of saphenous brain patients received antifungal therapy, 38 received amphotericin B or liposome combined with fluconazole, 20 received amphotericin B or liposome combined with voriconazole, 15 received fluconazole single drug treatment, 5 received two amphotericin B single drug treatment, 4 cases received voriconazole monotherapy. Treatment. The total effective rate of antifungal therapy was 71.95%, the effective rate of combination regimen treatment was 82.76%, the effective rate of single drug treatment regimen was 45.83%. by surgical operation of cerebrospinal fluid drainage. Conclusion: 1 cryptococcal meningoencephalitis were found in middle-aged people more than those in women. Farmers are most common, mostly subacute or chronic onset. Often with headache, temperature rise as the first symptom, cranial nerve damage in the optic nerve, vestibule nerve and abducent nerve damage more.2 cerebrospinal fluid pressure, the higher the number of leukocyte count, the lower the glucose content, the patient's condition more serious.3 cryptobrain cerebrospinal fluid cytology type and onset time The misdiagnosis rate of.4 is high, and the patients who have been misdiagnosed as tuberculous meningitis before diagnosis are most likely to see.5 in the cerebrospinal fluid of patients with cryptococcal meningitis, 1,3- beta -D glucan can be detected, and the clinical diagnosis can provide effective information.6 alien blue staining. The sensitivity of MRI and MGG and 1,3- beta -D glucan in cerebrospinal fluid is higher than that of plasma 1,3 - beta -D dextran sensitivity.7 combined with antifungal therapy is superior to single drug therapy for cryptococcal meningitis.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R519.4

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 魏義勝;楊躍杰;姚雪華;張文忠;;腰大池持續(xù)引流治療隱球菌腦膜炎的臨床體會(huì)[J];中國(guó)實(shí)用神經(jīng)疾病雜志;2014年18期

2 廖柏明;羅光漢;袁海寧;黃利;鄧一鳴;韋穎華;;非艾滋病人群隱球菌性腦膜炎治療進(jìn)展[J];蛇志;2012年02期

3 吳偉本;俞同福;徐海;宗敏;;肺隱球菌病的CT表現(xiàn)[J];中國(guó)真菌學(xué)雜志;2010年04期

4 溫海;;隱球菌感染診治專家共識(shí)[J];中國(guó)真菌學(xué)雜志;2010年02期

5 徐朝陽(yáng);林維斌;陳峻嚴(yán);胡偉鵬;戴偉川;;V-P分流治療伴惡性顱高壓新型隱球菌性腦膜炎臨床分析[J];中國(guó)實(shí)用神經(jīng)疾病雜志;2010年05期

6 王露霞;石凌波;陳萬(wàn)山;肖增璜;成德;;乳膠凝集法檢測(cè)隱球菌莢膜多糖抗原在隱球菌性腦膜炎和隱球菌肺炎中的早期診斷價(jià)值[J];檢驗(yàn)醫(yī)學(xué);2008年01期

7 邵律成;盛春泉;張萬(wàn)年;;新結(jié)構(gòu)類型抗真菌先導(dǎo)化合物的研究進(jìn)展[J];藥學(xué)學(xué)報(bào);2007年11期

8 何俊瑛;何紅彥;孟兆華;金便芬;;隱球菌性腦膜炎早期診斷及療效探討(附30例報(bào)道)[J];中國(guó)神經(jīng)精神疾病雜志;2007年07期

9 呂沛華;趙蓓蕾;施毅;文昱婷;;1,3-β-D葡聚糖檢測(cè)診斷侵襲性真菌感染的臨床價(jià)值[J];中華結(jié)核和呼吸雜志;2007年01期

10 徐楠;溫海;陳江漢;;隱球菌性腦膜炎的藥物治療近況及進(jìn)展[J];中國(guó)真菌學(xué)雜志;2006年04期

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