艾滋病合并新型隐球菌脑膜炎文献回顾

获得性免疫缺陷综合征&新型隐球菌脑膜脑炎主诉：头痛8天，复视4天，发热意识欠清1天进行性加重头痛•颅高压症状视物成双、听力下降•颅神经受累症状发热•感染症状外院腰穿（2016.4.27）4.27潘式实验（-）脑脊液细胞总数1440*106/L脑脊液白细胞计数20*106/L墨汁染色蛋白0.184g/L葡萄糖2.6mmol/L氯化物113.0mmol/L压力头颅MRI：左侧半卵圆中心点状异常信号，T2Flair序列双顶叶皮层下点状略高信号（2016.4.27）入院后腰穿--略浑浊脑脊液入院后腰穿5.15.4潘式实验（1+）（1+）脑脊液RBC210*106/L420*106/L脑脊液WBC6*106/L2*106/L墨汁染色阳性阳性蛋白0.4g/L0.55g/L葡萄糖1.4mmol/L4.7mmol/L氯化物115mmol/L123mmol/L压力778mmH2O347mmH2O脑脊液细胞学—成团及散在带荚膜蓝染颗粒Wright-Giemsa染色放大倍数1：400脑脊液培养•新生隐球菌•报阳时间：48小时化验—白细胞计数及淋巴细胞计数14.5718.8816.3310.591.090.50.690.77024681012141618205/25/35/45/5109/L白细胞计数淋巴细胞计数化验—T细胞亚群分类百分比(%)参考范围总T淋巴细胞（CD3+）24.561.0~85.0T辅助/诱导细胞（Th,CD3+CD4+CD8-）1.834.0~70.0T抑制/细胞毒细胞（Ts,CD3+CD4-CD8+）93.325.0~54.0辅助/抑制T淋巴细胞比值0.020.68~2.47AIDS确诊实验诊断•新型隐球菌脑膜脑炎•获得性免疫缺陷综合征ClinicalInfectiousDiseases2010;50:291–322ChinJMycol,April2010,Vol5,No2Cryptococcus/隐球菌Cryptococcusneoformans/新型隐球菌Cryptococcusgattii/格特隐球菌Incidence•在免疫抑制患者中，隐球菌感染的发病率约为5%~10%，在AIDS患者中，隐球菌的感染率可以高达30%，而在免疫功能正常的人群中，隐球菌的感染率约为十万分之一左右•ItisestimatedthattheglobalburdenofHIV-associatedcryptococcosisapproximates1millioncasesannuallyworldwideClinicalInfectiousDiseases2010;50:291–322ChinJMycol,April2010,Vol5,No2Mortality•DespiteaccesstoadvancedmedicalcareandtheavailabilityofHAART,the3-monthmortalityrateduringmanagementofacutecryptococcalmeningoencephalitisapproximates20%•Furthermore,withoutspecificantifungaltreatmentforcryptococcalmeningoencephalitisincertainHIV-infectedpopulations,mortalityratesof100%havebeenreportedwithin2weeksafterclinicalpresentationtohealthcarefacilitiesClinicalInfectiousDiseases2010;50:291–322临床表现ChinJMycol,April2010,Vol5,No2CSFinterpretationforthemanagementofpatientswithsuspectedencephalitisJournalofInfection(2012)64,347e373艾滋病合并新型隐球菌脑膜脑炎的影像学表现血管周围间隙扩大胶状假囊（治疗3个月后）RadiolPractice，sep2009，Vol24，N0.9V-R间隙（血管周围间隙）扩大•血管周围间隙是与软脑膜下隙接续的,是软脑膜随着穿通动脉和流出静脉进出脑实质的延续而成•扩大的V-R间隙意味着大量的隐球菌酵母细胞聚集于血管周围间隙或者部分阻滞了脑脊液的流出ThreeriskgroupsofcryptococcalmeningoencephalitisHumanimmunodeficiencyvirus(HIV)–infectedindividualsOrgantransplantrecipientsNon–HIVinfectedandnontransplanthostsClinicalInfectiousDiseases2010;50:291–322ChinJMycol,April2010,Vol5,No2Cryptococcosisinaresource-limitedhealthcareenvironment•WithCNSand/ordisseminateddiseasewherepolyeneisnotavailable,inductiontherapyisfluconazole(800mgperdayorally;1200mgperdayisfavored)foratleast10weeksoruntilCSFcultureresultsarenegative,followedbymaintenancetherapywithfluconazole(200–400mgperdayorally)•WhereAmBdisnotavailableoraffordable,wherefacilitiesforadmissionandIVtherapydonotexist,orwhererenalandpotassiummonitoringarenotsufficientlyrapidorreliabletoallowsafeuseofAmBd,fluconazoleisoftentheonlytreatmentoption.ElevatedCSFPressure•IftheCSFpressureis25cmofCSFandtherearesymptomsofincreasedintracranialpressureduringinductiontherapy,relievebyCSFdrainage(bylumbarpuncture,reducetheopeningpressureby50%ifitisextremelyhighortoanormalpressureof20cmofCSF•Ifthereispersistentpressureelevation25cmofCSFandsymptoms,repeatlumbarpuncturedailyuntiltheCSFpressureandsymptomshavebeenstabilizedfor12daysandconsidertemporarypercutaneouslumbardrainsorventriculostomyforpersonswhorequirerepeateddailylumbarpunctures•PermanentVPshuntsshouldbeplacedonlyifthepatientisreceivingorhasreceivedappropriateantifungaltherapyandifmoreconservativemeasurestocontrolincreasedintracranialpressurehavefailed.Ifthepatientisreceivinganappropriateantifungalregimen,VPshuntscanbeplacedduringactiveinfectionandwithoutcompletesterilizationofCNS,ifclinicallynecessaryClinicalInfectiousDiseases2010;50:291–322颅高压处理ChinJMycol,April2010,Vol5,No2