中枢神经系统感染.ppt

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1、中枢神经系统感染华山医院感染科陈澍中枢神经系统感染分类n n脑膜炎和脑实质感染：相互影响，可以转换n n脑膜炎可分为化脓性及非化脓性二大类n n化脓性：起病急，由各种化脓性细菌引起；化脓性：起病急，由各种化脓性细菌引起；n n非化脓性：由病毒及阿米巴原虫引起者起病多急，而非化脓性：由病毒及阿米巴原虫引起者起病多急，而由结核杆菌、新型隐球菌、及其它真菌所致者多呈亚由结核杆菌、新型隐球菌、及其它真菌所致者多呈亚急性或慢性过程。急性或慢性过程。脑膜炎分类n nInfectiousInfectious BacterialBacterial ViralViral FungalFungaln nNon-i

2、nfectiousNon-infectious Drug-InducedDrug-Induced NeoplasticNeoplastic AutoimmuneAutoimmune流行病学资料 n n年龄年龄年龄年龄 婴儿患者（婴儿患者（婴儿患者（婴儿患者（2M2M2M1(100)00)升高升高升高升高(60)(60)减少减少减少减少升高升高升高升高减少减少减少减少(80%(80%)(90(90%)%)化化化化脓脓脓脓性性性性脑脑脑脑膜膜膜膜 炎炎炎炎(部部部部分治疗分治疗分治疗分治疗)升高升高升高升高混浊混浊混浊混浊升高升高升高升高(1(1000000)升高升高升高升高（6060）减少不定减

3、少不定减少不定减少不定升高不升高不升高不升高不定定定定减少减少减少减少(60%(60%)(65%(65%)病病病病毒毒毒毒性性性性脑脑脑脑膜炎膜炎膜炎膜炎正常正常正常正常/升高升高升高升高清亮清亮清亮清亮升高升高升高升高(1(1000000)升高升高升高升高(10%(10%病例病例病例病例)升升升升高高高高正常正常正常正常正常正常正常正常轻度升轻度升轻度升轻度升高高高高正常正常正常正常真真真真菌菌菌菌性性性性脑脑脑脑膜炎膜炎膜炎膜炎升高升高升高升高常清常清常清常清亮或亮或亮或亮或混浊混浊混浊混浊升高升高升高升高(5(500)00)升高升高升高升高(13%(13%病例病例病例病例)升升升升高高高

4、高正常或正常或正常或正常或轻度减少轻度减少轻度减少轻度减少升高升高升高升高减少减少减少减少结结结结核核核核性性性性脑脑脑脑膜炎膜炎膜炎膜炎升高升高升高升高毛玻毛玻毛玻毛玻璃状璃状璃状璃状升高升高升高升高(1(1000000)升升升升高高高高减少减少减少减少明明明明显显显显升升升升高高高高明显明显明显明显减少减少减少减少抗酸杆抗酸杆抗酸杆抗酸杆菌菌菌菌结核杆结核杆结核杆结核杆菌（菌（菌（菌（8585）脑脑脑脑 肿肿肿肿 瘤瘤瘤瘤、脑脓肿脑脓肿脑脓肿脑脓肿常升常升常升常升高高高高清或清或清或清或不太不太不太不太清清清清升高升高升高升高(0(0500500)升高升高升高升高(095(095)不不不不

5、定定定定减减减减少少少少或或或或正正正正常常常常(占占占占25%)25%)通通通通常常常常升升升升高高高高(占占占占 7575)正常正常正常正常/减少减少减少减少/+/+/+/+化脓性脑膜炎BACTERIALMENINGITISWhat is it?n nBacterialmeningitisisaseriousinfectionofthespinalcordandthefluidthatsurroundsthebrain.What causes it?n nThereare3mainThereare3mainbacterialspeciesthatbacterialspeciesthatco

6、ntributetothiscontributetothisdisease:disease:HaemophilusHaemophilusinfluenzaetypebinfluenzaetypeb NeisseriameningitidisNeisseriameningitidis(Meningococcal)(Meningococcal)StreptococcusStreptococcuspneumoniaepneumoniae(Pneumococcal)(Pneumococcal)n n病原学肺炎链球菌肺炎链球菌2yrs/2yrs/老人老人肺炎肺炎/中耳炎中耳炎葡萄球菌葡萄球菌皮肤感染皮肤

7、感染/败血症败血症/腰穿腰穿/手术手术流感杆菌流感杆菌婴幼儿婴幼儿大肠杆菌大肠杆菌新生儿新生儿绿脓杆菌绿脓杆菌腰穿腰穿/麻醉麻醉/手术手术How is it diagnosed?n nWhenpatientWhenpatientpresentssymptomspresentssymptomsofMeningitis,aofMeningitis,asampleofCSFissampleofCSFisacquiredfromaacquiredfromaspinaltap,whichisspinaltap,whichisthenanalyzedforthenanalyzedforbacterialp

8、resence.bacterialpresence.Bacterial Meningitis Factsn nThereare1.2millioncasesannuallyThereare1.2millioncasesannuallyworldwide,approximately135,000deaths.worldwide,approximately135,000deaths.n nBacterialmeningitisis1ofthetop10Bacterialmeningitisis1ofthetop10infectiouscausesofdeathworldwide,infectiou

9、scausesofdeathworldwide,accordingtotheCDC.accordingtotheCDC.n nHalfofsurvivorssufferneurologicalHalfofsurvivorssufferneurologicaldamage,and/orotherpermanentsidedamage,and/orotherpermanentsideeffects.effects.Haemophilus influenzae type bn nAffectsabout13/1,000,000children(2005),3-4%arefatal.n nInfect

10、ionhasdecreaseddrastically:From4-10/10,000;sinceroutineuseofFrom4-10/10,000;sinceroutineuseoftheHibvaccine(since1990)theHibvaccine(since1990)n nAmajorcauseoflowerrespiratorytractinfectionsindevelopingcountriesNeisseria meningitidisn n5-50/1,000,000peopleareinfectedworldwide5-50/1,000,000peopleareinf

11、ectedworldwideeveryyear.everyyear.n nMostDeadlyformofBacterialMeningitisMostDeadlyformofBacterialMeningitisn nHumansareonlyhostofbacteria,itispresentinHumansareonlyhostofbacteria,itispresentinthenasopharynxthenasopharynxn n11-19%ofpeoplewhohaverecoveredsuffer11-19%ofpeoplewhohaverecoveredsufferfromp

12、ermanenthearingloss,mentalretardation,frompermanenthearingloss,mentalretardation,orotherserioushealthproblems.orotherserioushealthproblems.n n10-14%ofcasesarefatal10-14%ofcasesarefatalStreptococcus pneumoniaen nInfectionrateintheU.S.hasnowInfectionrateintheU.S.hasnowdecreasedto13/100,000,duetodecrea

13、sedto13/100,000,duetovaccination.(2002)vaccination.(2002)n nKills14%ofhospitalizedadultswithKills14%ofhospitalizedadultswithinvasivedisease.Insomerecoverycases,invasivedisease.Insomerecoverycases,thepatientssustainlearningdisabilities,thepatientssustainlearningdisabilities,and/orotherimpairmentstypi

14、calofand/orotherimpairmentstypicalofmeningitis,butlesssothanwithothermeningitis,butlesssothanwithotherformsofmeningitis.formsofmeningitis.n nOveruseofantibioticscontributestoOveruseofantibioticscontributestoemergingdrugresistanceinthisstrain.emergingdrugresistanceinthisstrain.Symptomsn nMostCommonMo

15、stCommon FeverFever HeadacheHeadache StiffNeckStiffNeck Nausea&vomitingNausea&vomiting SensitivitytolightSensitivitytolight ConfusionConfusion SleepinessSleepinessn nInInfantsInInfants InactivityInactivity IrritabilityIrritability VomitingVomiting PoorfeedingPoorfeedingn nAdvancedDiseaseAdvancedDise

16、ase BruisesdevelopunderBruisesdevelopunderskin&spreadrapidlyskin&spreadrapidlyn nAdvancedDiseasecanAdvancedDiseasecanleadto:leadto:BrainDamageBrainDamage ComaComa DeathDeathSymptomsRisk Factorsn nInfantsandyoungchildrenInfantsandyoungchildrenn nElderlyElderlyn nCollegefreshmenwholiveindormsCollegefr

17、eshmenwholiveindorms n nPatientswithoutspleensPatientswithoutspleensn nPeopleexposedtoactiveorpassivePeopleexposedtoactiveorpassivetobaccosmoke.tobaccosmoke.n nAfricanAmericans,AmericanIndians,AfricanAmericans,AmericanIndians,AlaskanNatives.AlaskanNatives.n nPeoplewithunderlyingmedicalconditionsPeop

18、lewithunderlyingmedicalconditions(Ex.HIV&Sickle-celldisease)(Ex.HIV&Sickle-celldisease)Treatment&Medicationn nAntibiotics:Broad-SpectrumcephalosporinBroad-SpectrumcephalosporinAmpicillin&Broad-SpectrumAmpicillin&Broad-SpectrumcephalosporincephalosporinVancomycinplusceftazidimeVancomycinplusceftazidi

19、men nAllantibioticsadministeredintravenouslyH.Influenzae&N.meningitidis-7daysH.Influenzae&N.meningitidis-7daysS.pneumoniae-10-14daysS.pneumoniae-10-14daysMedications Continuedn nN.meningitidisChloramphenicolresistanceChloramphenicolresistancen nUsedinUsedinresource-limitedsettingsresource-limitedset

20、tings(Sub-(Sub-SaharanAfrica).StoppedusinginWestSaharanAfrica).StoppedusinginWestbecauseofveryrare,yetserioussideeffect:becauseofveryrare,yetserioussideeffect:AplasticanemiaAplasticanemia.n nVerycheapsynthesisVerycheapsynthesisn nDerivedfrombacteria-disruptstranslationDerivedfrombacteria-disruptstra

21、nslationprocessbypreventingpeptidebondprocessbypreventingpeptidebondformationformationn nTherearenonon-pharmaceuticaltreatmentsforbacterialmeningitis.Vaccines:H.influenzae type bn nBacteriacontainspolysaccharidecapsulen nQuestionshavearisenonthelengthoftimethevaccineiseffective.n nCostofvaccine:$7.0

22、0(typicalvaccinesare$1.00)n nThecostofthisvaccinehaslimitedtheiruseindevelopingcountries,eventhoughthisbacteriaisamajorcauseofdeath.Vaccine:N.Meningitidisn nMeningococcalconjugatevaccine(MCV4)Meningococcalconjugatevaccine(MCV4)Price:$82;intramuscularlyassingledose.Price:$82;intramuscularlyassingledo

23、se.EffectiveinEffectiveinallallagegroupsagegroups PreferredoverMPSV4PreferredoverMPSV4n nMeningococcalPolysaccharideVaccineMeningococcalPolysaccharideVaccine(MPSV4)(MPSV4)Price:$86.10;subcutaneouslyassingledose.Price:$86.10;subcutaneouslyassingledose.Re-administeredevery3-5yearsRe-administeredevery3

24、-5years Agegroups:Agegroups:NotNotunder2and11-12yearsoldunder2and11-12yearsoldVaccine:S.Pneumoniaen nBacteriacontainspolysaccharidecapsuleBacteriacontainspolysaccharidecapsulen n lactamresistanceiscommon,resistancetolactamresistanceiscommon,resistancetomultipleclassesofdrugsareincreasing.multiplecla

25、ssesofdrugsareincreasing.n n23-valentpolysaccharidevaccine(Prevnar)-NEW23-valentpolysaccharidevaccine(Prevnar)-NEW$80.00perdose$80.00perdose UnderusedUnderused SuppliesareinadequateSuppliesareinadequaten nNewurinaryantigentestmaybeusefulinadultsNewurinaryantigentestmaybeusefulinadultstoidentifyifS.p

26、neumoniaeispresent.toidentifyifS.pneumoniaeispresent.Research for Papern nMechanismthatcausesthesideeffectsandsymptomsofbacterialmeningitisandtheirroleincytokineresponse.n nMechanismofantibioticstospecificbacteriaandmechanismsofresistancebybacteriatoantibioticsn nInterviewPeterHicks,Epidemiologistat

27、theCDC.Shock:Sepsis ProtocolSummary:An Approach to theAdult Patient withSuspected BacterialMeningitisFrom supplement to:Van de Beek D.Community-acquired bacterial meningitis in adults.N Engl J Med.2006;354:44-53Shock:Sepsis ProtocolSummary:An Approach to theAdult Patient withSuspected BacterialMenin

28、gitisFrom supplement to:Van de Beek D.Community-acquired bacterial meningitis in adults.N Engl J Med.2006;354:44-53Shock:Sepsis ProtocolSummary:An Approach to theAdult Patient withSuspected BacterialMeningitisCorticosteroidsCorticosteroidsGivedexamethasoneIVGivedexamethasoneIVbeforeorwith1beforeorwi

29、th1ststdosedoseofantibioticsofantibioticsContraindicationsContraindicationsAntibioticsw/in48hrsAntibioticsw/in48hrsShuntShuntHeadtraumaHeadtraumaFrom supplement to:Van de Beek D.Community-acquired bacterial meningitis in adults.N Engl J Med.2006;354:44-53Shock:Sepsis ProtocolSummary:An Approach to t

30、heAdult Patient withSuspected BacterialMeningitisFrom supplement to:Van de Beek D.Community-acquired bacterial meningitis in adults.N Engl J Med.2006;354:44-53ContraindicationstoContraindicationstoLPLPRecentseizureRecentseizureSignsofherniationatSignsofherniationatanytimeanytimeGCS11orrapidlyGCS 0.1

31、25 mg/L,vancomycin or rifampicin plus either cefotaxime or ceftriaxone.For penicillin-susceptible strains(MIC 6hrs6hrs 深静脉穿刺深静脉穿刺amphotericin Bn n鞘注鞘注 逐渐加量：逐渐加量：最大单次剂量：最大单次剂量：1mg1mg 最大累计剂量：最大累计剂量：20mg20mg Biw-QodBiw-Qod 注射用水稀释注射用水稀释+DXM+DXM CSFCSF反复稀释推注反复稀释推注20min20min左右左右amphotericin Bn n注意事项监测血监测血

32、/尿常规、肝肾功能电解质，注意尿量变尿常规、肝肾功能电解质，注意尿量变化，必要时测血气化，必要时测血气深静脉穿刺护理深静脉穿刺护理鞘注的不良反应：头鞘注的不良反应：头/恶恶/吐、放射性痛、尿潴吐、放射性痛、尿潴留、下肢感觉丧失、轻瘫留、下肢感觉丧失、轻瘫cryptococcus neoformans结核性脑膜炎结核性脑膜炎 近年结核病发病率有上升之势，原因为近年结核病发病率有上升之势，原因为近年结核病发病率有上升之势，原因为近年结核病发病率有上升之势，原因为:-爱滋病传播促进了结核病在全球的回升爱滋病传播促进了结核病在全球的回升爱滋病传播促进了结核病在全球的回升爱滋病传播促进了结核病在全球的回

33、升 -结核杆菌的多药抗药性结核杆菌的多药抗药性结核杆菌的多药抗药性结核杆菌的多药抗药性 -治疗延误或者不完全治疗延误或者不完全治疗延误或者不完全治疗延误或者不完全概述概述结核性脑膜炎-结核杆菌引起的非化脓性脑膜炎结核杆菌引起的非化脓性脑膜炎-最常见的、最严重的肺外结核病之一，占肺最常见的、最严重的肺外结核病之一，占肺外结核外结核5%-15%5%-15%-细胞免疫低下者发病率高细胞免疫低下者发病率高-成人、儿童发生率各占成人、儿童发生率各占50%50%-临床表现多样化、脑脊液不典型临床表现多样化、脑脊液不典型-死亡率或严重的神经系统后遗症达死亡率或严重的神经系统后遗症达50%50%发病机理及病理

34、发病机理及病理PATHOPHYSIOLOGYPATHOPHYSIOLOGY结核性脑膜炎是结核菌全身血行播散的结果。结核性脑膜炎是结核菌全身血行播散的结果。结核性脑膜炎是结核菌全身血行播散的结果。结核性脑膜炎是结核菌全身血行播散的结果。直接蔓延直接蔓延直接蔓延直接蔓延蛛网膜下腔蛛网膜下腔蛛网膜下腔蛛网膜下腔脑膜脑膜脑膜脑膜 原发病灶原发病灶原发病灶原发病灶血血 脑实质、脑膜形成隐匿病灶脑实质、脑膜形成隐匿病灶脑实质、脑膜形成隐匿病灶脑实质、脑膜形成隐匿病灶破溃破溃破溃破溃 外伤外伤疾病疾病（麻疹、百日咳（麻疹、百日咳）病病 理理 PATHOLOGICALPATHOLOGICAL脑膜脑膜脑膜脑膜弥

35、漫性充血、水肿、炎性渗出、形成结核弥漫性充血、水肿、炎性渗出、形成结核弥漫性充血、水肿、炎性渗出、形成结核弥漫性充血、水肿、炎性渗出、形成结核 结节结节结节结节蛛网膜下腔蛛网膜下腔蛛网膜下腔蛛网膜下腔 大量渗出物在颅底聚集，其次在大量渗出物在颅底聚集，其次在大量渗出物在颅底聚集，其次在大量渗出物在颅底聚集，其次在神经交叉、桥脑、延髓、大脑外侧裂。最神经交叉、桥脑、延髓、大脑外侧裂。最神经交叉、桥脑、延髓、大脑外侧裂。最神经交叉、桥脑、延髓、大脑外侧裂。最容易造成颅神经损害如容易造成颅神经损害如容易造成颅神经损害如容易造成颅神经损害如VIIVII、IIIIII、IVIV结核性脑膜炎的颅底渗出结核

36、性脑膜炎的颅底渗出脑实质脑实质脑实质脑实质室管膜及脉络丛受累，出现脑室管室管膜及脉络丛受累，出现脑室管室管膜及脉络丛受累，出现脑室管室管膜及脉络丛受累，出现脑室管膜炎，脊髓膜、脊髓、脊神经根受膜炎，脊髓膜、脊髓、脊神经根受膜炎，脊髓膜、脊髓、脊神经根受膜炎，脊髓膜、脊髓、脊神经根受累出现截瘫等累出现截瘫等累出现截瘫等累出现截瘫等脑血管脑血管脑血管脑血管早期急性动脉炎早期急性动脉炎早期急性动脉炎早期急性动脉炎晚期动脉内膜炎晚期动脉内膜炎晚期动脉内膜炎晚期动脉内膜炎 管腔闭塞管腔闭塞管腔闭塞管腔闭塞脑室质软化脑室质软化脑室质软化脑室质软化 脉络膜充血脉络膜充血脉络膜充血脉络膜充血脑脊液生成增加（早

37、期）脑脊液生成增加（早期）脑脊液生成增加（早期）脑脊液生成增加（早期）脑膜炎症粘连脑膜炎症粘连脑膜炎症粘连脑膜炎症粘连脑脊液回吸收减少脑脊液回吸收减少脑脊液回吸收减少脑脊液回吸收减少 大脑导水管及第大脑导水管及第大脑导水管及第大脑导水管及第交通性脑积水交通性脑积水交通性脑积水交通性脑积水四脑室以上阻塞四脑室以上阻塞四脑室以上阻塞四脑室以上阻塞 阻塞性脑积水阻塞性脑积水阻塞性脑积水阻塞性脑积水 左、右侧脑室脉络丛左、右侧脑室脉络丛左、右侧脑室脉络丛左、右侧脑室脉络丛左、右侧脑室左、右侧脑室左、右侧脑室左、右侧脑室 血血血血浆浆浆浆室间孔室间孔室间孔室间孔 第三脑室第三脑室第三脑室第三脑室第三脑室

38、第三脑室第三脑室第三脑室血血血血脉络丛脉络丛脉络丛脉络丛液液液液循循循循中脑导水管中脑导水管中脑导水管中脑导水管环环环环系系系系统统统统第四脑室脉络丛第四脑室脉络丛第四脑室脉络丛第四脑室脉络丛第四脑室第四脑室第四脑室第四脑室 脑脑脑脑部部部部左侧孔左侧孔左侧孔左侧孔中央孔中央孔中央孔中央孔 右侧孔右侧孔右侧孔右侧孔静静静静脉脉脉脉窦窦窦窦脑蛛网膜粒脑蛛网膜粒脑蛛网膜粒脑蛛网膜粒脑与脊髓蛛网膜下腔脑与脊髓蛛网膜下腔脑与脊髓蛛网膜下腔脑与脊髓蛛网膜下腔脑脊液循环图Figure.Axial Section of a Brain from a Patient with Tuberculous Meni

39、ngitis.Figure.Axial Section of a Brain from a Patient with Tuberculous Meningitis.Ventricular dilatationVentricular dilatation is present(asterisks),as well as is present(asterisks),as well as inflammatory exudateinflammatory exudate in the ambient in the ambient cistern(black arrows)and multiple fo

40、ci of vasculitis-associated subacute,cistern(black arrows)and multiple foci of vasculitis-associated subacute,ischemic ischemic necrosis(white arrows).necrosis(white arrows).临床表现临床表现n n典型表现n n非典型表现-以精神异常为突出表现以精神异常为突出表现-以急性化脓性脑膜炎为首发症状以急性化脓性脑膜炎为首发症状-以头痛为首发症状以头痛为首发症状86%86%有头痛，有头痛，20%20%无发热无发热-脑实质受损为首发症

41、状脑实质受损为首发症状-脑神经受损为首发症状脑神经受损为首发症状-以脑血管病为首发症状以脑血管病为首发症状-以癫痫发作为首发症状以癫痫发作为首发症状诊断诊断n n细菌学诊断细菌学诊断-阳性率低阳性率低 涂片涂片涂片涂片10%10%10%10%，培养，培养，培养，培养20-30%20-30%20-30%20-30%，与病期、取材部，与病期、取材部，与病期、取材部，与病期、取材部位、位、位、位、CSFCSFCSFCSF量、检查方法、次数等因素有关量、检查方法、次数等因素有关量、检查方法、次数等因素有关量、检查方法、次数等因素有关。-快速培养：阳性率高，时间缩短快速培养：阳性率高，时间缩短 BACT

42、EC-TB460BACTEC-TB460BACTEC-TB460BACTEC-TB460或或或或960960960960以及以及以及以及BacT ALERT 3DBacT ALERT 3DBacT ALERT 3DBacT ALERT 3D诊诊 断断n n免疫学诊断免疫学诊断-结核抗体测定：结核抗体测定：结核抗体测定：结核抗体测定：结核杆菌结核杆菌结核杆菌结核杆菌38Kda38Kda38Kda38Kda抗原抗原抗原抗原、膜蛋白抗原、膜蛋白抗原、膜蛋白抗原、膜蛋白抗原、PPDPPDPPDPPD抗原对结脑抗原对结脑抗原对结脑抗原对结脑的诊断价值，敏感性分别为的诊断价值，敏感性分别为的诊断价值，敏感

43、性分别为的诊断价值，敏感性分别为51.8%51.8%51.8%51.8%、53.6%53.6%53.6%53.6%、55.4%55.4%55.4%55.4%；特异性分别为特异性分别为特异性分别为特异性分别为100%,100%100%,100%100%,100%100%,100%和和和和94%94%94%94%。假阳性率在假阳性率在假阳性率在假阳性率在2-15%2-15%，假阴性率在，假阴性率在，假阴性率在，假阴性率在5-45%5-45%。-结核抗原测定结核抗原测定结核抗原测定结核抗原测定：BASBASBASBAS放射免疫法放射免疫法放射免疫法放射免疫法 反相被动血凝试验反相被动血凝试验反相被动

44、血凝试验反相被动血凝试验诊诊 断断n n免疫复合物测定免疫复合物测定免疫复合物测定免疫复合物测定-GuptaGupta等等等等 采用采用采用采用ELISAELISAELISAELISA测定了测定了测定了测定了33333333例临床诊断的结脑患者和例临床诊断的结脑患者和例临床诊断的结脑患者和例临床诊断的结脑患者和34343434例其它脑例其它脑例其它脑例其它脑膜炎患者膜炎患者膜炎患者膜炎患者CSFCSFCSFCSF中的中的中的中的抗抗抗抗BCG-IgGBCG-IgGBCG-IgGBCG-IgG免疫复合物免疫复合物免疫复合物免疫复合物，并与，并与，并与，并与3 3 3 3种类型的种类型的种类型的种

45、类型的结核抗体测定结果比较。结果结脑组结核抗体测定结果比较。结果结脑组结核抗体测定结果比较。结果结脑组结核抗体测定结果比较。结果结脑组CSFCSFCSFCSF特异性免疫复合物特异性免疫复合物特异性免疫复合物特异性免疫复合物阳性阳性阳性阳性21212121例，例，例，例，阳性率阳性率阳性率阳性率64%64%64%64%，而其它疾病患者假阳性而其它疾病患者假阳性而其它疾病患者假阳性而其它疾病患者假阳性3 3 3 3例，例，例，例，假阳假阳假阳假阳性率性率性率性率9%9%9%9%免疫复合物可辅助判断疗效和病人预后免疫复合物可辅助判断疗效和病人预后免疫复合物可辅助判断疗效和病人预后免疫复合物可辅助判断

46、疗效和病人预后n n生化检查方法生化检查方法-腺苷脱氨酶腺苷脱氨酶(ADA(ADA）：）：敏感度敏感度 50%-50%-90%90%-结核杆菌硬脂酸结核杆菌硬脂酸(TSA)(TSA)：特异性：特异性 100%100%n n基因诊断基因诊断诊诊 断断诊诊 断断n nCTCTCTCT、MRMRMRMR检查检查检查检查-基底池渗出：明显强化，呈绒线样、斑片、团快、基底池渗出：明显强化，呈绒线样、斑片、团快、基底池渗出：明显强化，呈绒线样、斑片、团快、基底池渗出：明显强化，呈绒线样、斑片、团快、串珠、结节样或环形强化串珠、结节样或环形强化串珠、结节样或环形强化串珠、结节样或环形强化-颅内结核瘤形成颅内

47、结核瘤形成颅内结核瘤形成颅内结核瘤形成诊诊 断断治疗治疗n n化学治疗化学治疗化学治疗化学治疗第一线抗结核药第一线抗结核药第一线抗结核药第一线抗结核药：IHNIHNIHNIHN、RFPRFPRFPRFP、EMBEMBEMBEMB、PZAPZAPZAPZA、SMSMSMSM等。等。等。等。第二线抗结核药第二线抗结核药第二线抗结核药第二线抗结核药：PASPASPASPAS、丁胺卡那、丁胺卡那、丁胺卡那、丁胺卡那第三线抗结核药第三线抗结核药第三线抗结核药第三线抗结核药：胺硫脲、环丝氨酸等：胺硫脲、环丝氨酸等：胺硫脲、环丝氨酸等：胺硫脲、环丝氨酸等透过透过透过透过BBB BBB BBB BBB：INH

48、INHINHINH、RFPRFPRFPRFP、PZAPZAPZAPZA、环丝氨酸、环丝氨酸、环丝氨酸、环丝氨酸有条件透过有条件透过有条件透过有条件透过BBBBBBBBBBBB：SMSMSMSM、EMBEMBEMBEMB、PASPASPASPAS杀菌药：杀菌药：杀菌药：杀菌药：INHINHINHINH、RFPRFPRFPRFP条件杀菌药条件杀菌药条件杀菌药条件杀菌药：PZAPZAPZAPZA、SMSMSMSM抑菌药：抑菌药：抑菌药：抑菌药：EMBEMBEMBEMB、PZAPZAPZAPZA、丁胺卡那、丁胺卡那、丁胺卡那、丁胺卡那治疗治疗n n化学治疗化学治疗 遵循遵循遵循遵循“早期、联合、长期、

49、足量早期、联合、长期、足量早期、联合、长期、足量早期、联合、长期、足量”原则原则原则原则 早期：越早越好早期：越早越好早期：越早越好早期：越早越好 联合：强化治疗期（联合：强化治疗期（联合：强化治疗期（联合：强化治疗期（2-3M2-3M2-3M2-3M），），），），3-43-43-43-4种易透过种易透过种易透过种易透过BBBBBBBBBBBB的杀菌剂或的杀菌剂或的杀菌剂或的杀菌剂或 加加加加1 1 1 1个抑菌剂个抑菌剂个抑菌剂个抑菌剂 巩固治疗期（巩固治疗期（巩固治疗期（巩固治疗期（10-24M10-24M10-24M10-24M），至少），至少），至少），至少1 1 1 1种杀菌剂或加

50、种杀菌剂或加种杀菌剂或加种杀菌剂或加1 1 1 1个抑菌剂个抑菌剂个抑菌剂个抑菌剂 适量、规则、全程：适量、规则、全程：适量、规则、全程：适量、规则、全程：IHNIHNIHNIHN：1200mg/d 3m;900mg/d 1200mg/d 3m;900mg/d 1200mg/d 3m;900mg/d 1200mg/d 3m;900mg/d 6m;600mg/d 12m;300mg/d 6m;600mg/d 12m;300mg/d 6m;600mg/d 12m;300mg/d 6m;600mg/d 12m;300mg/d 维持治疗维持治疗维持治疗维持治疗治治 疗疗n n糖皮质激素的辅助治疗糖皮质