摘要
目的总结中枢神经系统(CNS)曲霉菌病的临床特点和治疗效果。方法回顾性分析解放军总医院第一医学中心2000年1月至2021年1月诊治的37例CNS曲霉菌病患者的临床表现、实验室检查、影像学特征、治疗及预后, 并根据颅内病灶与鼻窦病灶的相关性分为鼻-脑曲霉菌病(RA, 21例)和脑曲霉菌病(CA, 16例)2组进行亚组分析。结果仅16.2%(6/37)的CNS曲霉菌病患者存在明确免疫抑制背景, 但35.1%(13/37)的患者合并糖尿病。CNS曲霉菌病最常见的临床表现依次为头痛(73.0%, 27/37)、脑神经受累(59.5%, 22/37)、发热(37.8%, 14/37)等。脑脊液特点为:压力升高(53.8%, 14/26)、白细胞计数增加(46.7%, 14/30)、葡萄糖水平降低(30.0%, 9/30)、蛋白水平升高(70.0%, 21/30), 病原学宏基因组二代测序有7/10的患者结果为阳性。头颅磁共振成像显示常见受累部位为鼻窦-眶尖-眶后-海绵窦(43.2%, 16/37)及脑叶(27.0%, 10/37)。治疗方案包括单纯抗真菌药物治疗(64.9%, 24/37)、药物+手术联合治疗(27.0%, 10/37)及单纯手术治疗(8.1%, 3/37)。与CA组相比, RA组男性比例较少[47.6%(10/21)比14/16, χ^(2)=6.34, P=0.012]、年龄较大[(54.2±19.4)岁比(38.4±18.4)岁, t=2.50, P=0.017], 易出现头痛[85.7%(18/21)比9/16, χ^(2)=4.00, P=0.046]和脑神经受累症状[81.0%(17/21)比5/16, χ^(2)=9.31, P=0.006]。本组中患者早期误诊率为73.0%(27/37)。共29例患者先后接受伏立康唑药物治疗(85.3%, 29/34), 治疗疗程为3.0(0.5, 10.4)个月;与补救治疗相比, 初始治疗病死率较低(4/17比9/12, χ^(2)=7.54, P=0.006)。随访至2021年12月, 共17例患者死亡, 病死率为45.9%(17/37)。结论 CNS曲霉菌病可无明确免疫抑制背景, 部分患者合并糖尿病, 临床表现缺乏特异性, 早期误诊率高, 脑脊液可无炎性改变, 病原学二代测序阳性率较高, 尽早、长程应用伏立康唑治疗可明显降低病死率。
Objective To summarize the clinical characteristics and therapeutic efficacy of central nervous system(CNS)aspergillosis.Methods The clinical manifestations,laboratory examination,neuroimaging features,treatment and prognosis of 37 cases of CNS aspergillosis diagnosed and treated in the First Medical Center of People′s Liberation Army General Hospital from January 2000 to January 2021 were retrospectively analyzed.According to the correlation between intracranial lesions and paranasal sinus lesions,they were divided into two groups:rhino-cerebral aspergillosis(RA,n=21)group and cerebral aspergillosis(CA,n=16)group.Results Only 16.2%(6/37)of CNS aspergillosis patients had a clear background of immunosuppression,but 35.1%(13/37)were complicated with diabetes.The most common clinical manifestations were headache(73.0%,27/37),cranial nerve involvement(59.5%,22/37)and fever(37.8%,14/37).Cerebrospinal fluid characteristics included increased pressure(53.8%,14/26),increased white blood cell count(46.7%,14/30),decreased glucose(30.0%,9/30),increased protein(70.0%,21/30),and high positive results of the metagenomic next-generation sequencing(mNGS)of pathogenic microorganism(7/10).Cranial magnetic resonance imaging showed that commonly involved sites were sinus,orbital apex,posterior orbit,cavernous sinus(43.2%,16/37)and cerebral lobes(27.0%,10/37).Treatment options included antifungal drugs alone(64.9%,24/37),combination of drugs and surgery(27.0%,10/37)and surgery alone(8.1%,3/37).Compared with the CA group,RA group had fewer males[47.6%(10/21)vs 14/16,X^(2)=6.34,P=0.012]and older age[(54.2±19.4)years vs(38.4±18.4)years,t=2.50,P=0.017],and was more prone to headache[85.7%(18/21)vs 9/16,X^(2)=4.00,P=0.046]and cranial nerve involvement[81.0%(17/21)vs 5/16,χ^(2)=9.31,P=0.006].The misdiagnosis rate of these patients in the early stage was 73.0%(27/37).A total of 29 patients(85.3%,29/34)were treated with voriconazole successively,and the course of treatment was 3.0(0.5,10.4)months.Compared with salvage therapy,the mortal
作者
谭锐书
张家堂
单煜恒
马玉宝
武雷
袁虎
陈雷
周涛
邹丽萍
朱剑
徐全刚
于生元
Tan Ruishu;Zhang Jiatang;Shan Yuheng;Ma Yubao;Wu Lei;Yuan Hu;Chen Lei;Zhou Tao;Zou Liping;Zhu Jian;Xu Quangang;Yu Shengyuan(Medical Department of Neurology,People′s Liberation Army General Hospital,Beijing 100853,China;Medical Department of Otorhinolaryngology Head and Neck Surgery,People′s Liberation Army General Hospital,Beijing 100853,China;Medical Department of Neurosurgery,People′s Liberation Army General Hospital,Beijing 100853,China;Medical Department of Pediatrics,People′s Liberation Army General Hospital,Beijing 100853,China;Department of Rheumatology and Immunology,the First Medical Center,People′s Liberation Army General Hospital,Beijing 100853,China;Medical Department of Ophthalmology,People′s Liberation Army General Hospital,Beijing 100853,China)
出处
《中华神经科杂志》
CAS
CSCD
北大核心
2023年第1期55-65,共11页
Chinese Journal of Neurology
关键词
中枢神经系统
真菌感染
曲霉菌
治疗
伏立康唑
Central nervous system
Fungal infection
Aspergillus
Treatment
Voriconazole
