Chinese Journal of Antituberculosis ›› 2019, Vol. 41 ›› Issue (11): 1203-1210.doi: 10.3969/j.issn.1000-6621.2019.11.011
• Original Articles • Previous Articles Next Articles
WANG Man-zhi,CHEN Fang(),WEI Song-qing,ZHOU Hai-yi,HU Jin-yue,XIE He-bin,ZHANG Xiao-fo,LI Jia,SHI Jia-yun,WU Lei
Received:
2019-06-17
Online:
2019-11-10
Published:
2019-12-05
WANG Man-zhi,CHEN Fang,WEI Song-qing,ZHOU Hai-yi,HU Jin-yue,XIE He-bin,ZHANG Xiao-fo,LI Jia,SHI Jia-yun,WU Lei. Analysis of influencing factors for prognosis of tuberculous meningitis patients with consciousness disorder[J]. Chinese Journal of Antituberculosis, 2019, 41(11): 1203-1210. doi: 10.3969/j.issn.1000-6621.2019.11.011
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诊断评分 | 评分 |
---|---|
临床表现 | 该层最高得分6分 |
症状持续≥5d(以下 1 项或多项临床表现:头痛、呕吐、易激惹、发热、颈项强直、癫痫发作、局灶性神经损害症状、意识改变) | 4 |
疑似结核的全身症状(1项或多项以下表现):体质量下降(或儿童体质量增长不良),盗汗、持续咳嗽>2周 | 2 |
过去1年内有结核密切接触史或TST、IGRA阳性者(仅限于10岁以内儿童) | 2 |
局灶神经损伤表现(不包括颅神经麻痹) | 2 |
颅神经麻痹 | 1 |
意识改变 | 1 |
脑脊液评分 | 该层最高得分4分 |
外观清亮 | 1 |
白细胞计数10~500个/μl 淋巴细胞比例>50% | 1 |
蛋白>1g/L | 1 |
脑脊液糖<2.2mol/L或低于血糖的50% | 1 |
头部影像学评分 | 该层最高得分6分 |
脑积液 | 1 |
脑基底膜增厚 | 2 |
脑结核瘤 | 2 |
脑梗死 | 1 |
脑基底部高密度影 | 2 |
其他部位结核证据 | 该层最高得分4分 |
胸片提示可疑的活动性结核灶:结核征象=2;粟粒型结核=4 | 2或4 |
CT/MRI/B超证实存在中枢神经系统外结核 | 2 |
其他标本(如痰、淋巴结、胃液、尿、血)中检测到抗酸杆菌或培养出结核分枝杆菌 | 4 |
中枢神经系统外的标本通过核酸扩增技术(NAAT)检测到结核分枝杆菌 | 4 |
鉴别诊断的排除 | 该层最高得分4分 |
采用微生物学(通过染色、培养、核酸扩增)、血清学(如梅毒)、组织学(如淋巴瘤)等方法来确定鉴别诊断。鉴别诊断列表的制定应考虑到年龄、机体免疫状态以及地理位置,包括:化脓性脑膜炎,隐球菌性脑膜炎,梅毒性脑膜炎,病毒性脑膜炎,脑型疟疾,寄生虫引起的或嗜酸细胞性脑膜炎,脑弓形体病和细菌性脑脓肿,恶性肿瘤(如淋巴瘤) |
患者类型 | 病例数(例) | |
---|---|---|
确诊的TBM | 满足A或B的所有条件 A:满足临床表现评分标准同时至少符合以下1种情况:脑脊液检查发现抗酸杆菌;脑脊液分离培养到结核分枝杆菌;PCR方法检测到结核分枝杆菌 B:在脑或脊髓的组织学中找到结核分枝杆菌,并伴有可疑临床表现、体征或脑脊液改变,或尸检有肉眼可见的结核性脑膜炎改变 | 21 |
高度可能的TBM | 满足临床表现评分标准且总诊断评分≥10分(无脑影像学检查结果时)或者总诊断评分≥12分(有脑影像学检查结果时),同时需排除其他疾病。总得分中至少有2分来自脑脊液或脑影像学检查 | 84 |
可能的TBM | 满足临床表现评分标准且总诊断评分为6~10分(无脑影像学检查结果时)或者总诊断评分6~11分(有脑影像学检查结果时),同时需排除其他疾病。当未做腰椎穿刺或脑影像学检查时,可能的TBM不能被诊断或排除 | 7 |
影响因素 | 预后良好组(48例) | 预后不良组(64例) | 检验值 | P值 | ||||
---|---|---|---|---|---|---|---|---|
年龄[例(构成比,%)] | χ2=0.431 | 0.512 | ||||||
>18岁 | 24(50.0) | 36(56.2) | ||||||
≤18岁 | 24(50.0) | 28(43.8) | ||||||
性别[例(构成比,%)] | χ2=4.043 | 0.044 | ||||||
女 | 24(50.0) | 20(31.2) | ||||||
男 | 24(50.0) | 44(68.8) | ||||||
居住地[例(构成比,%)] | χ2=0.000 | 1.000 | ||||||
农村 | 39(81.2) | 52(81.2) | ||||||
城市 | 9(18.8) | 12(18.8) | ||||||
入院前病程[d, M(Q1,Q3)] | 20.81(10.00,20.00) | 26.22(11.25,30.00) | Z=-1.440 | 0.150 | ||||
住院时间[d, M(Q1,Q3)] | 55.50(41.00,68.25) | 39.00(18.75,69.00) | Z=-1.982 | 0.048 | ||||
疾病分期[例(构成比,%)] | χ2=17.733 | 0.000 | ||||||
Ⅰ期 | 5(10.4) | 2(3.1) | ||||||
Ⅱ期 | 38(79.2) | 32(50.0) | ||||||
Ⅲ期 | 5(10.4) | 30(46.9) | ||||||
抽搐[例(构成比,%)] | χ2=8.054 | 0.005 | ||||||
无 | 41(85.4) | 39(60.9) | ||||||
有 | 7(14.6) | 25(39.1) | ||||||
颅神经损伤[例(构成比,%)] | χ2=2.154 | 0.142 | ||||||
无 | 42(87.5) | 49(76.6) | ||||||
有 | 6(12.5) | 15(23.4) | ||||||
颈强直[例(构成比,%)] | χ2=0.239 | 0.625 | ||||||
无 | 8(16.7) | 13(20.3) | ||||||
有 | 40(83.3) | 51(79.7) | ||||||
病理征阳性[例(构成比,%)] | χ2=2.187 | 0.139 | ||||||
无 | 30(62.5) | 31(48.4) | ||||||
有 | 18(37.5) | 33(51.6) | ||||||
并发症[例(构成比,%)] | ||||||||
肺炎 | χ2=1.899 | 0.168 | ||||||
无 | 31(64.6) | 33(51.6) | ||||||
有 | 17(35.4) | 31(48.4) | ||||||
贫血 | χ2=2.172 | 0.141 | ||||||
无 | 21(43.8) | 37(57.8) | ||||||
有 | 27(56.2) | 27(42.2) | ||||||
低钠血症 | χ2=9.481 | 0.002 | ||||||
无 | 29(60.4) | 20(31.3) | ||||||
有 | 19(39.6) | 44(68.7) | ||||||
头颅影像学异常[例(构成比,%)] | ||||||||
脑积液 | χ2=5.992 | 0.014 | ||||||
无 | 37(77.1) | 35(54.7) | ||||||
有 | 11(22.9) | 29(45.3) | ||||||
脑水肿 | χ2=4.386 | 0.036 | ||||||
无 | 40(83.3) | 42(65.6) | ||||||
有 | 8(16.7) | 22(34.4) | ||||||
脑梗死 | χ2=0.321 | 0.571 | ||||||
无 | 29(60.4) | 42(65.6) | ||||||
有 | 19(39.6) | 22(34.4) | ||||||
脑脊液检查 | ||||||||
脑脊液压力[cm H2O, M(Q1,Q3)] | 212.50(150.00,350.00) | 250.00(140.00,337.50) | Z=-0.262 | 0.793 | ||||
脑脊液白细胞[×106个/L, M(Q1,Q3)] | 240.00(30.00,320.00) | 185.00(30.00,80.00) | Z=-1.736 | 0.083 | ||||
脑脊液白蛋白[g/L, M(Q1,Q3)] | 1.58(1.06,2.07) | 1.44(0.98,2.46) | Z=-0.050 | 0.960 | ||||
脑脊液糖[mmol/L, M(Q1,Q3)] | 1.99(1.32,2.69) | 1.81(1.14,2.62) | Z=-0.788 | 0.431 | ||||
脑脊液氯(mmo/L, | 112.33±10.43 | 112.01±9.53 | t=0.165 | 0.869 | ||||
血液检查 | ||||||||
白细胞计数[×109个/L, M(Q1,Q3)] | 8.51(6.19,12.15) | 9.99(6.30,12.12) | Z=-0.679 | 0.497 | ||||
中性粒细胞比率(%, | 73.86±16.03 | 76.89±13.64 | t=-1.082 | 0.282 | ||||
淋巴细胞比率[%, M(Q1,Q3)] | 17.68(7.65,24.93) | 15.70(4.78,23.78) | Z=-0.994 | 0.320 | ||||
血小板[×109个/L, M(Q1,Q3)] | 275.50(206.00,392.50) | 275.50(200.25,361.75) | Z=-0.079 | 0.937 | ||||
白蛋白[g/L, M(Q1,Q3)] | 38.54(34.70,43.15) | 40.29(30.50,41.08) | Z=-1.943 | 0.052 | ||||
球蛋白(g/L, | 28.16±5.91 | 28.84±7.19 | t=-0.534 | 0.594 | ||||
白蛋白/球蛋白( | 1.43±0.37 | 1.31±0.42 | t=1.507 | 0.135 | ||||
ESR[mm/1h, M(Q1,Q3)] | 34.65(14.00,44.00) | 31.69(12.25,40.00) | Z=-0.579 | 0.562 |
变量 | β值 | s | Wald χ2值 | P值 | OR值 | 95%CI值 |
---|---|---|---|---|---|---|
低钠血症 | 1.024 | 0.505 | 4.103 | 0.043 | 2.784 | 1.034~7.495 |
脑水肿 | 1.250 | 0.575 | 4.734 | 0.030 | 3.491 | 1.132~10.768 |
性别 | -0.961 | 0.517 | 3.462 | 0.063 | 0.382 | 0.139~1.053 |
住院时间 | -0.230 | 0.008 | 8.325 | 0.004 | 0.977 | 0.961~0.993 |
抽搐 | 1.150 | 0.587 | 3.841 | 0.050 | 3.157 | 1.000~9.971 |
疾病分期 | 10.709 | 0.005 | ||||
疾病分期(Ⅱ) | -0.790 | 1.062 | 0.553 | 0.457 | 0.454 | 0.057~3.641 |
疾病分期(Ⅲ) | 1.925 | 0.628 | 9.392 | 0.002 | 6.855 | 2.001~23.480 |
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