艾滋病合并新型隱球菌腦膜炎文獻回顧課件

1、獲得性免疫缺陷綜合征&新型隱球菌腦膜腦炎主訴：頭痛8天，復視4天，發(fā)熱意識欠清1天外院腰穿（ 2016.4.27 ）4.27潘式實驗（-）腦脊液細胞總數(shù)1440*106/L 腦脊液白細胞計數(shù)20*106/L 墨汁染色蛋白0.184 g/L葡萄糖2.6 mmol/L氯化物113.0 mmol/L壓力頭顱MRI：左側(cè)半卵圓中心點狀異常信號，T2Flair序列雙頂葉皮層下點狀略高信號（2016.4.27）入院后腰穿-略渾濁腦脊液入院后腰穿5.15.4潘式實驗（1+）（1+）腦脊液RBC210*106/L 420*106/L 腦脊液WBC6*106/L 2*106/L 墨汁染色陽性陽性蛋白0.4 g/

2、L0.55 g/L葡萄糖1.4 mmol/L4.7 mmol/L氯化物115 mmol/L123 mmol/L壓力778 mmH2O347mmH2O腦脊液細胞學成團及散在帶莢膜藍染顆粒Wright-Giemsa染色 放大倍數(shù)1：400化驗T細胞亞群分類百分比(%)參考范圍總T淋巴細胞（CD3+）24.561.085.0T輔助/誘導細胞（Th,CD3+CD4+CD8-）1.834.070.0T抑制/細胞毒細胞（Ts,CD3+CD4-CD8+）93.325.054.0輔助/抑制T淋巴細胞比值0.020.682.47AIDS確診實驗診斷新型隱球菌腦膜腦炎獲得性免疫缺陷綜合征Incidence 在免疫

3、抑制患者中，隱球菌感染的發(fā)病率約為5%10%，在AIDS患者中，隱球菌的感染率可以高達 30%，而在免疫功能正常的人群中，隱球菌的感染率約為十萬分之一左右It is estimated that the global burden of HIV-associated cryptococcosis approximates 1 million cases annually worldwideClinical Infectious Diseases 2010; 50:291322Chin J Mycol ,April 2010,Vol 5,No 2MortalityDespite access t

4、o advanced medical care and the availability of HAART, the 3-month mortality rate during management of acute cryptococcal meningoencephalitis approximates 20%Furthermore, without specific antifungal treatment for cryptococcal meningoencephalitis in certain HIV-infected populations,mortality rates of

5、 100% have been reported within 2 weeks after clinical presentation to health care facilitiesClinical Infectious Diseases 2010; 50:291322臨床表現(xiàn)Chin J Mycol ,April 2010,Vol 5,No 2Three risk groups of cryptococcal meningoencephalitis Clinical Infectious Diseases 2010; 50:291322Chin J Mycol ,April 2010,V

6、ol 5,No 2Cryptococcosis in a resource-limited health care environmentWith CNS and/or disseminated disease where polyene is not available, induction therapy is fluconazole (800 mg per day orally; 1200 mg per day is favored) for at least 10 weeks or until CSF culture results are negative, followed by

7、maintenance therapy with fluconazole (200400 mg per day orally)Where AmBd is not available or affordable, where facilities for admission and IV therapy do not exist, or where renal and potassium monitoring are not sufficiently rapid or reliable to allow safe use of AmBd, fluconazole is often the onl

8、y treatment option. Elevated CSF PressureIf the CSF pressure is 25 cm of CSF and there are symptoms of increased intracranial pressure during induction therapy, relieve by CSF drainage (by lumbar puncture, reduce the opening pressure by 50% if it is extremely high or to a normal pressure of 25 cm of

9、 CSF and symptoms, repeat lumbar puncture daily until the CSF pressure and symptoms have been stabilized for 12 days and consider temporary percutaneous lumbar drains or ventriculostomy for persons who require repeated daily lumbar punctures Permanent VP shunts should be placed only if the patient is receiving or has received appropriate antifungal therapy and if more conservative measures to control increased intracranial pressure have failed. If the patient is receiving an appropriate antifungal regimen, VP shunts can be placed during active infection and