儿童结核性脑膜炎继发癫痫的临床特征及影响因素分析

doi:10.19982/j.issn.1000-6621.20230183

摘要/Abstract

摘要：

目的: 分析儿童结核性脑膜炎(TBM)继发癫痫的临床特征及相关影响因素。方法: 采用回顾性研究方法,纳入2018年1月至2022年1月南华大学附属长沙中心医院儿童结核科收治的136例诊断为TBM的患儿为研究对象。采用单因素和多因素logistic回归模型分析不同临床指标对TBM患儿继发癫痫的影响。结果: 136例TBM患儿中,20例继发癫痫,发生率为14.7%。单因素分析显示,继发癫痫患儿在神经系统局灶症状[30.0% (6/20)]、意识改变[65.0% (13/20)]、脑积水[50.0% (10/20)]、脑梗塞[30.0% (6/20)]、伴发结核瘤[10.0% (2/20)]、TBM Ⅲ期[50.0% (10/20)]、脑脊液蛋白[1.66 (0.02, 5.60)g/L]、脑脊液腺苷脱氨酶(ADA)[12.74 (1.22, 63.50)U/L]、血钠[(127.35±3.73)mmol/L]等方面与未继发癫痫患儿[分别为6.9% (8/116)、30.2% (35/116)、17.2% (20/116)、9.5% (11/116)、1.7% (2/116)、11.2% (13/116)、1.01 (0.02, 5.60)g/L、3.79 (0.00, 94.00)U/L和(132.91±5.40)mmol/L]差异均有统计学意义(χ²=9.860,P=0.007;χ²=9.060,P=0.004;χ²=13.820,P=0.001;χ²=6.566,P=0.021;χ²=13.511,P=0.004;χ²=19.478,P=0.000;Z=-2.120,P=0.034;Z=-5.005,P=0.000;t=-4.424,P=0.000)。多因素logistic回归分析显示,发生脑梗塞[OR(95%CI)=4.397(1.152~5.837),P=0.014]、脑脊液ADA升高[OR(95%CI)=1.044(1.021~1.297),P=0.033]、低钠血症[OR(95%CI)=0.814(0.672~0.909),P=0.003]均是TBM继发癫痫的危险因素。结论: TBM患儿继发癫痫的比例较高,临床应高度重视,尤其是发生脑梗塞、脑脊液ADA升高、低钠血症可能是儿童TBM继发癫痫的重要预警指标,积极规范抗癫痫药物治疗对控制继发癫痫具有一定的价值。

关键词: 结核,脑膜, 儿童, 癫痫, 因素分析, 统计学

Abstract:

Objective: To analyze the clinical features and influencing factors of epilepsy secondary to tuberculous meningitis (TBM) in children. Methods: One hundred and thirty-six children diagnosed with TBM during Jan. 2018 to Jan. 2022 in Changsha Central Hospital Affiliated to the University of South China were enrolled for retrospective analysis. Univariate and multivariate logistic regression models were used to analyze the influence of clinical characteristics on secondary epilepsy in children with TBM. Results: Among 136 children with TBM, 20 (14.7%) had secondary epilepsy. Univariate analysis showed that focal symptoms in the nervous system (30.0% (6/20)), changes in consciousness (65.0% (13/20)), hydrocephalus(50.0% (10/20)), cerebral infarction (30.0% (6/20)), accompanied by tuberculoma (10.0% (2/20)), TBM phase Ⅲ (50.0% (10/20)), cerebrospinal fluid protein (1.66 (0.02, 5.60) g/L), cerebrospinal fluid adenosine deaminase (ADA)(12.74 (1.22, 63.50) U/L), blood sodium ((127.35±3.73) mmol/L) in children with secondary epilepsy were significant different from that in children without secondary epilepsy (6.9% (8/116), 30.2% (35/116), 17.2% (20/116), 9.5% (11/116), 1.7% (2/116), 11.2% (13/116), 1.01 (0.02, 5.60) g/L, 3.79 (0.00, 94.00) U/L and (132.91±5.40) mmol/L)(χ²=9.860, P=0.007; χ²=9.060, P=0.004; χ²=13.820, P=0.001; χ²=6.566, P=0.021; χ²=13.511, P=0.004; χ²=19.478, P=0.000; Z=-2.120, P=0.034; Z=-5.005, P=0.000; t=-4.424, P=0.000). Multivariate logistic regression analysis showed that cerebral infarction (OR (95%CI)=4.397 (1.152-5.837), P=0.014), increased ADA in cerebrospinal fluid (OR (95%CI)=1.044 (1.021-1.297), P=0.033), and hyponatremia (OR (95%CI)=0.814 (0.672-0.909), P=0.003) were risk factors for secondary epilepsy to TBM. Conclusion: The proportion of secondary epilepsy in children with TBM is high, which should be paid great attention in clinic. The occurrence of cerebral infarction, increase of ADA in cerebrospinal fluid and hyponatremia may be important early predictive indicators of secondary epilepsy in children with TBM. Active and standardized anti-epileptic treatment has certain value in controlling secondary epilepsy.

Key words: Tuberculosis, meningeal, Child, Epilepsy, Factor analysis, statistical

中图分类号:

R529.3
R748

石家云, 周海依, 危松青, 江杰, 吴蕾. 儿童结核性脑膜炎继发癫痫的临床特征及影响因素分析[J]. 中国防痨杂志, 2023, 45(11): 1090-1096. doi: 10.19982/j.issn.1000-6621.20230183

Shi Jiayun, Zhou Haiyi, Wei Songqing, Jiang Jie, Wu Lei. Analysis of clinical features and influencing factors of epilepsy secondary to tuberculosis meningitis in children[J]. Chinese Journal of Antituberculosis, 2023, 45(11): 1090-1096. doi: 10.19982/j.issn.1000-6621.20230183

图/表 4

表1

表2

结核性脑膜炎患儿继发癫痫与未继发癫痫组实验室相关指标分布情况

实验室检查	继发组	未继发组	统计检验值	P值
脑脊液检查[M(Q₁,Q₃)]
压力	227.50(70.00,400.00)	191.90(55.00,400.00)	Z=-1.708	0.185
细胞计数(×10⁶/L)	156.00(4.00,1273.00)	142.54(5.00,877.00)	Z=-0.172	0.863
蛋白质(g/L)	1.66(0.02,5.60)	1.01(0.02,5.60)	Z=-2.120	0.034
葡萄糖(mmol/L)	1.82(0.31,3.40)	1.72(0.23,4.60)	Z=-1.309	0.191
氯化物(mmol/L)	111.85(99.00,131.00)	112.03(97.00,138.00)	Z=-1.343	0.179
腺苷脱氨酶(U/L)	12.74(1.22,63.50)	3.79(0.00,94.00)	Z=-5.005	0.000
血液检查
白细胞[×10⁹/L, M(Q₁,Q₃)]	11.28(3.85,24.30)	12.30(1.50,27.30)	Z=-0.151	0.880
血红蛋白(g/L, $x ˉ$ ±s)	106.21±6.16	105.25±22.56	t=-0.155	0.863
C反应蛋白[mg/L, M(Q₁,Q₃)]	13.81(0.50,42.00)	26.63(0.00,243.00)	Z=-0.691	0.489
血红细胞沉降率[mm/1h, M(Q₁,Q₃)]	37.80(0.00,96.00)	32.12(0.00,96.00)	Z=-0.759	0.448
血钠(mmol/L, $x ˉ$ ±s)	127.35±3.73	132.91±5.40	t=-4.424	0.000
血氯(mmol/L, $x ˉ$ ±s)	98.33±12.04	98.61±9.23	t=0.123	0.903

表2

表3

表4

结核性脑膜炎患儿继发癫痫影响因素的多因素logistic回归分析

变量	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
神经系统局灶症状	0.079	0.936	0.007	0.933	1.082(0.173~6.783)
意识改变	0.524	0.949	0.305	0.581	1.689(0.263~10.842)
脑积水	0.878	0.826	1.130	0.880	2.406(0.082~3.097)
结核瘤	1.997	1.094	3.333	0.068	7.367(0.016~10.158)
脑梗塞	1.481	0.754	5.892	0.014	4.397(1.152~5.837)
结核性胸膜炎分期	0.623	0.781	0.636	0.425	1.864(0.404~8.605)
脑脊液蛋白	0.206	0.349	0.350	0.554	1.229(0.411~1.612)
脑脊液腺苷脱氨酶	0.043	0.020	4.538	0.033	1.044(1.021~1.297)
血钠	-0.206	0.070	8.768	0.003	0.814(0.672~0.909)

表4

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临床特征	继发组(20例)	未继发组(116例)	χ²值	P值
性别			0.003	0.575
男性	11(55.0)	63(54.3)
女性	9(45.0)	53(45.7)
年龄组(岁)			3.416	0.181
<3	13(65.0)	51(43.9)
3~5	3(15.0)	19(16.4)
>5	4(20.0)	46(39.7)
发热	17(85.0)	105(90.5)	0.337	0.698
抽搐发作	8(40.0)	37(31.9)	0.506	0.607
意识改变	13(65.0)	35(30.2)	9.060	0.004
神经系统局灶症状	6(30.0)	8(6.9)	9.860	0.007
脑神经麻痹	3(15.0)	12(10.3)	0.377	0.539
合并中枢神经系统以外结核病	17(85.0)	93(80.2)	0.944	0.376
头部CT或MRI
脑积水	10(50.0)	20(17.2)	13.820	0.001
基底膜强化	8(40.0)	33(28.4)	1.081	0.429
脑梗塞	6(30.0)	11(9.5)	6.566	0.021
结核瘤	2(10.0)	2(1.7)	13.511	0.004
TBM分期			19.478	0.000
Ⅰ	5(25.0)	68(58.6)
Ⅱ	5(25.0)	28(24.2)
Ⅲ	10(50.0)	20(17.2)
确诊为结核性脑膜炎	3(15.0)	13(11.2)	0.236	0.706

编号	变量	赋值	编号	变量	赋值
X₁	神经系统局灶症状	否=0;是=1	X₆	TBM分期	Ⅰ期=1;Ⅱ期=2;Ⅲ期=3
X₂	意识改变	否=0;是=1	X₇	脑脊液蛋白	定性资料直接纳入数据
X₃	脑积水	否=0;是=1	X₈	脑脊液腺苷脱氨酶	定性资料直接纳入数据
X₄	结核瘤	否=0;是=1	X₉	血钠	定性资料直接纳入数据
X₅	脑梗塞	否=0;是=1	Y	继发癫痫	否=0;是=1