艾滋病合并新型隱球菌腦膜炎文獻(xiàn)回顧課件

1、獲得性免疫缺陷綜合征&新型隱球菌腦膜腦炎1獲得性免疫缺陷綜合征&新型隱球菌腦膜腦炎1主訴：頭痛8天，復(fù)視4天，發(fā)熱意識(shí)欠清1天進(jìn)行性加重頭痛顱高壓癥狀視物成雙、聽力下降顱神經(jīng)受累癥狀發(fā)熱感染癥狀2主訴：頭痛8天，復(fù)視4天，發(fā)熱意識(shí)欠清1天進(jìn)行性加重頭痛顱高外院腰穿（ 2016.4.27 ）4.27潘式實(shí)驗(yàn)（-）腦脊液細(xì)胞總數(shù)1440*106/L 腦脊液白細(xì)胞計(jì)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3外院腰穿（ 2016.4.27 ）4.27潘式實(shí)驗(yàn)（-）腦脊頭顱MRI：左側(cè)半卵圓中心點(diǎn)狀異常信號(hào)，T2Flair序列雙頂葉皮

2、層下點(diǎn)狀略高信號(hào)（2016.4.27）4頭顱MRI：左側(cè)半卵圓中心點(diǎn)狀異常信號(hào)，T2Flair序列雙入院后腰穿-略渾濁腦脊液5入院后腰穿-略渾濁腦脊液5入院后腰穿5.15.4潘式實(shí)驗(yàn)（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/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 mmH2O347mmH2O6入院后腰穿5.15.4潘式實(shí)驗(yàn)（1+）（1+）腦脊液RBC2腦脊液細(xì)胞學(xué)成團(tuán)及散在帶莢膜藍(lán)染顆粒Wright-Giemsa染

3、色 放大倍數(shù)1：4007腦脊液細(xì)胞學(xué)成團(tuán)及散在帶莢膜藍(lán)染顆粒Wright-Giem腦脊液培養(yǎng)新生隱球菌報(bào)陽時(shí)間：48小時(shí)8腦脊液培養(yǎng)新生隱球菌8化驗(yàn)白細(xì)胞計(jì)數(shù)及淋巴細(xì)胞計(jì)數(shù)9化驗(yàn)白細(xì)胞計(jì)數(shù)及淋巴細(xì)胞計(jì)數(shù)9化驗(yàn)T細(xì)胞亞群分類百分比(%)參考范圍總T淋巴細(xì)胞（CD3+）24.561.085.0T輔助/誘導(dǎo)細(xì)胞（Th,CD3+CD4+CD8-）1.834.070.0T抑制/細(xì)胞毒細(xì)胞（Ts,CD3+CD4-CD8+）93.325.054.0輔助/抑制T淋巴細(xì)胞比值0.020.682.4710化驗(yàn)T細(xì)胞亞群分類百分比(%)參考范圍總T淋巴細(xì)胞（CD3AIDS確診實(shí)驗(yàn)11AIDS確診實(shí)驗(yàn)11診斷新型隱球

4、菌腦膜腦炎獲得性免疫缺陷綜合征12診斷新型隱球菌腦膜腦炎12Clinical Infectious Diseases 2010; 50:29132213Clinical Infectious Diseases 2Chin J Mycol ,April 2010,Vol 5,No 214Chin J Mycol ,April 2010,Vol 5Cryptococcus /隱球菌 Cryptococcus neoformans/新型隱球菌Cryptococcus gattii/格特隱球菌 15Cryptococcus /隱球菌 Cryptococcus1616Incidence 在免疫抑制患者中

5、，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(dá) 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 217Incidence 在免疫抑制患者中，隱球菌感染的發(fā)病率

6、約為MortalityDespite access to 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 pop

7、ulations,mortality rates of 100% have been reported within 2 weeks after clinical presentation to health care facilitiesClinical Infectious Diseases 2010; 50:29132218MortalityDespite access to adv臨床表現(xiàn)Chin J Mycol ,April 2010,Vol 5,No 219臨床表現(xiàn)Chin J Mycol ,April 2010,VCSF interpretation for the manage

8、ment of patients with suspected encephalitisJournal of Infection (2012) 64, 347e37320CSF interpretation for the man艾滋病合并新型隱球菌腦膜腦炎的影像學(xué)表現(xiàn)血管周圍間隙擴(kuò)大膠狀假囊（治療3個(gè)月后）Radiol Practice，sep 2009 ，Vol 24，N 0 .921艾滋病合并新型隱球菌腦膜腦炎的影像學(xué)表現(xiàn)血管周圍間隙擴(kuò)大膠狀V-R 間隙（血管周圍間隙）擴(kuò)大血管周圍間隙是與軟腦膜下隙接續(xù)的,是軟腦膜隨著穿通動(dòng)脈和流出靜脈進(jìn)出腦實(shí)質(zhì)的延續(xù)而成擴(kuò)大的V-R 間隙意味著大量的隱

9、球菌酵母細(xì)胞聚集于血管周圍間隙或者部分阻滯了腦脊液的流出22V-R 間隙（血管周圍間隙）擴(kuò)大血管周圍間隙是與軟腦膜下隙接Three risk groups of cryptococcal meningoencephalitis Human immunodeficiency virus (HIV)infected individualsOrgan transplant recipientsNonHIV infected and nontransplant hosts23Three risk groups of cryptococClinical Infectious Diseases 2010;

10、 50:29132224Clinical Infectious Diseases 2Chin J Mycol ,April 2010,Vol 5,No 225Chin J Mycol ,April 2010,Vol 5Cryptococcosis 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

11、mg per day is favored) for at least 10 weeks or until CSF culture results are negative, followed by 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 monit

12、oring are not sufficiently rapid or reliable to allow safe use of AmBd, fluconazole is often the only treatment option. 26Cryptococcosis in a resource-lElevated CSF PressureIf the CSF pressure is 25 cm of CSF and there are symptoms of increased intracranial pressure during induction therapy, relieve

13、 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 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 o

14、r 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 without co