結核性腦膜炎的診斷與治療進展

趙娟娟

【摘要】 結核性腦膜炎（TBM）是一種由結核分枝桿菌引起的腦膜非化膿性炎癥，可繼發于血行播散型肺結核及其他器官的結核。TBM在結核分枝桿菌感染性疾病中表現形式最為多樣，具有較高的死亡率、致殘率，TBM患者預后與診斷是否及時及治療措施是否有效有著極為密切的聯系。但由于TBM患者早期臨床癥狀缺乏特異性，極易被患者忽視，誤診率和漏診率較高，大部分患者在病情確診時，基本錯過了最佳治療時間。因此及早尋求一種特異性高、敏感度高的實驗室診斷方法，并實施有效的治療，是改善TBM患者預后的關鍵。本文從TBM診斷展開綜述，前者主要包括臨床表現、腦脊液檢查、微生物學診斷、分子檢測診斷、免疫學診斷、影像學檢查、腦脊液宏基因組測序技術，后者包括常用藥物、抗結核化療、CSF置換、小兒TBM治療、手術治療等多。

【關鍵詞】 結核性腦膜炎 免疫學檢查 生化檢查 抗結核治療 CSF置換

doi：10.14033/j.cnki.cfmr.2020.16.073 文獻標識碼 A 文章編號 1674-6805（2020）16-0-04

Progress in Diagnosis and Treatment of Tuberculous Meningitis/ZHAO Juanjuan. //Chinese and Foreign Medical Research， 2020， 18（16）： -183

[Abstract] Tuberculous meningitis （TBM） is a kind of non suppurative inflammation of meninges caused by Mycobacterium tuberculosis， which can be secondary to hematogenous pulmonary tuberculosis and tuberculosis of other organs. TBM has the most diverse forms in the infectious diseases of Mycobacterium tuberculosis， with high mortality and disability rate. The prognosis of patients with TBM is closely related to whether the diagnosis is timely and whether the treatment measures are effective. However， due to the lack of specificity in the early clinical symptoms of TBM patients， it is easy to be ignored by patients， and the misdiagnosis rate and missed diagnosis rate are high. Most patients basically miss the best treatment time when they are diagnosed. Therefore， the key to improve the prognosis of TBM patients is to find a specific and sensitive laboratory diagnosis method as early as possible and to implement effective treatment. This article reviews the diagnosis and treatment of TBM. The former includes clinical manifestations， CSF examination， microbiological diagnosis， molecular detection diagnosis， immunological diagnosis， imaging examination， CSF macrogenomic sequencing technology， and the latter includes commonly used drugs， antituberculous chemotherapy， CSF replacement， TBM treatment for children， surgical treatment and so on.

[Key words] Tuberculous meningitis Immunological examination Biochemical examination Antituberculous treatment CSF replacement

First-authors address： Nanning Fourth Peoples Hospital， Nanning 530023， China

結核分枝桿菌可通過血行或直接侵入患者脊髓、腦血管、腦神經、腦實質、蛛網膜、軟腦膜等部位，引發非化膿性炎癥[1-2]。結核性腦膜炎是較為嚴重的肺外結核病，如果診斷、治療不及時，極易引發嚴重不良后果[3]。既往有研究表明：獲得性免疫缺陷綜合征（AIDS）、惡性腫瘤、長期激素治療、糖尿病、嗜酒、營養不良等均為結核性腦膜炎（TBM）的易感因素[4]。TBM患者早期臨床癥狀不典型，隨著病情的發生、發展，患者會出現腦膜刺激征及中樞神經系統癥狀，病情嚴重的患者會出現肢體截癱、視力障礙、眼外肌麻痹、呼吸衰竭等，對其生命安全構成嚴重威脅[5]。……