成人结核性脑膜炎诊疗指南(2026年版)

doi:10.19982/j.issn.1000-6621.20260279

摘要/Abstract

摘要：

结核性脑膜炎是最严重和最难诊断的结核病类型,容易延迟诊断和治疗,影响患者预后。中国防痨协会结核病临床专业分会、首都医科大学附属北京胸科医院、江西省胸科医院和长春市传染病医院借鉴国内外相关指南,补充新的临床研究证据,结合我国结核性脑膜炎诊治实践,制定《成人结核性脑膜炎诊疗指南(2026年版)》。本指南系统总结了结核性脑膜炎诊断方法的最新证据,更新了治疗方案的推荐意见,并对特殊情况下结核性脑膜炎的诊治给出建议,为全国各级医疗机构进一步完善和优化结核性脑膜炎诊治提供循证证据和临床实践指引。

关键词: 结核,脑膜, 诊断, 治疗, 指南

Abstract:

Tuberculous meningitis is the most severe form of tuberculosis, in addition to being the most difficult to diagnose. It is prone to delayed diagnosis and treatment, which negatively influence the prognosis of patients. The Clinical Tuberculosis Branch of the Chinese Antituberculosis Association, Beijing Chest Hospital, Capital Medical University, Jiangxi Chest Hospital and Changchun Infectious Disease Hospital, drawing on relevant domestic and international guidelines and supplementing them with new research evidence, combined with the clinical practice of tuberculous meningitis diagnosis and treatment in China, have developed the guidelines for the diagnosis and treatment of adult tuberculous meningitis (2026 edition). The guideline systematically summarizes the recommendations for diagnostic methods for tuberculous meningitis, updates the recommendations for treatment regimens, and provides recommendations for the management of tuberculous meningitis under special circumstances, offering evidence-based clinical practice guidance for further improving and optimizing the management of tuberculous meningitis in national and regional medical institutions.

Key words: Tuberculosis, meninges, Diagnosis, Treatment, Guideline

中图分类号:

R529.3

中国防痨协会结核病临床专业分会, 首都医科大学附属北京胸科医院, 江西省胸科医院, 长春市传染病医院. 成人结核性脑膜炎诊疗指南(2026年版)[J]. 中国防痨杂志, 2026, 48(10): 1457-1470. doi: 10.19982/j.issn.1000-6621.20260279

Clinical Tuberculosis Branch of the Chinese Antituberculosis Association, Beijing Chest Hospital, Capital Medical University, Jiangxi Chest Hospital, Changchun Infectious Disease Hospital. Guidelines for the diagnosis and treatment of adult tuberculous meningitis (2026 edition)[J]. Chinese Journal of Antituberculosis, 2026, 48(10): 1457-1470. doi: 10.19982/j.issn.1000-6621.20260279

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参考文献 86

[1]	World Health Organization. Global tuberculosis report 2025[R]. Geneva: World Health Organization, 2025.
[2]	Wilkinson R J, Rohlwink U, Misra U K, et al. Tuberculous meningitis[J]. Nat Rev Neurol, 2017, 13(10): 581-598. doi:10.1038/nrneurol.2017.120. pmid: 28884751
[3]	Bishburg E, Sunderam G, Reichman L B, et al. Central nervous system tuberculosis with the acquired immunodeficiency syndrome and its related complex[J]. Ann Intern Med, 1986, 105(2):210-213. doi:10.7326/0003-4819-105-2-210. pmid: 3729203
[4]	Ruslami R, Ganiem A R, Dian S, et al. Intensified regimen containing rifampicin and moxifloxacin for tuberculous meningitis: an open-label, randomised controlled phase 2 trial[J]. Lancet Infect Dis, 2013, 13(1): 27-35. doi:10.1016/S1473-3099(12)70264-5. pmid: 23103177
[5]	Heemskerk A D, Bang N D, Mai N T, et al. Intensified Antituberculosis Therapy in Adults with Tuberculous Meningitis[J]. N Engl J Med, 2016, 374(2): 124-134. doi:10.1056/NEJMoa1507062.
[6]	Marais S, Pepper D J, Marais B J, et al. HIV-associated tuberculous meningitis-diagnostic and therapeutic challenges[J]. Tuberculosis (Edinb), 2010, 90(6): 367-374. doi:10.1016/j.tube.2010.08.006.
[7]	Dodd P J, Osman M, Cresswell F V, et al. The global burden of tuberculous meningitis in adults: A modelling study[J]. PLoS Glob Public Health, 2021, 1(12): e0000069. doi:10.1371/journal.pgph.0000069.
[8]	中华医学会结核病学分会结核性脑膜炎专业委员会. 2019中国中枢神经系统结核病诊疗指南[J]. 中华传染病杂志, 2020, 38(7):400-408. doi:10.3760/cma.j.cn311365-20200606-00645.
[9]	Thwaites G E, Tran T H. Tuberculous meningitis: many questions, too few answers[J]. Lancet Neurol, 2005, 4(3): 160-170. doi:10.1016/S1474-4422(05)01013-6. pmid: 15721826
[10]	Thwaites G E, van Toorn R, Schoeman J. Tuberculous meningitis: more questions, still too few answers[J]. Lancet Neurol, 2013, 12(10): 999-1010. doi:10.1016/S1474-4422(13)70168-6. pmid: 23972913
[11]	Huynh J, Donovan J, Phu N H, et al. Tuberculous meningitis: progress and remaining questions[J]. Lancet Neurol, 2022, 21(5): 450-464. doi:10.1016/S1474-4422(21)00435-X. pmid: 35429482
[12]	Torok M E, Chau T T, Mai P P, et al. Clinical and microbiological features of HIV-associated tuberculous meningitis in Vietnamese adults[J]. PLoS One, 2008, 3(3): e1772. doi:10.1371/journal.pone.0001772.
[13]	Thwaites G, Fisher M, Hemingway C, et al. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children[J]. J Infect, 2009, 59(3): 167-187. doi:10.1016/j.jinf.2009.06.011. pmid: 19643501
[14]	Chiang S S, Khan F A, Milstein M B, et al. Treatment outcomes of childhood tuberculous meningitis: a systematic review and meta-analysis[J]. Lancet Infect Dis, 2014, 14(10): 947-957. doi:10.1016/S1473-3099(14)70852-7. pmid: 25108337
[15]	Feng G D, Shi M, Ma L, et al. Diagnostic accuracy of intracellular mycobacterium tuberculosis detection for tuberculous meningitis[J]. Am J Respir Crit Care Med, 2014, 189(4):475-481. doi:10.1164/rccm.201309-1686OC.
[16]	Patel V B, Theron G, Lenders L, et al. Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous meningitis in a high burden setting: a prospective study[J]. PLoS Med, 2013, 10(10): e1001536. doi:10.1371/journal.pmed.1001536.
[17]	Bahr N C, Nuwagira E, Evans E E, et al. Diagnostic accuracy of Xpert MTB/RIF Ultra for tuberculous meningitis in HIV-infected adults: a prospective cohort study[J]. Lancet Infect Dis, 2018, 18(1): 68-75. doi:10.1016/S1473-3099(17)30474-7. pmid: 28919338
[18]	Pradhan N N, Paradkar M S, Kagal A, et al. Performance of Xpert((R)) MTB/RIF and Xpert((R)) Ultra for the diagnosis of tuberculous meningitis in children[J]. Int J Tuberc Lung Dis, 2022, 26(4): 317-325. doi:10.5588/ijtld.21.0388. pmid: 35351236
[19]	Cresswell F V, Tugume L, Bahr N C, et al. Xpert MTB/RIF Ultra for the diagnosis of HIV-associated tuberculous meningitis: a prospective validation study[J]. Lancet Infect Dis, 2020, 20(3): 308-317. doi:10.1016/S1473-3099(19)30550-X. pmid: 31924549
[20]	Donovan J, Thu D D A, Phu N H, et al. Xpert MTB/RIF Ultra versus Xpert MTB/RIF for the diagnosis of tuberculous meningitis: a prospective, randomised, diagnostic accuracy study[J]. Lancet Infect Dis, 2020, 20(3): 299-307. doi:10.1016/S1473-3099(19)30649-8. pmid: 31924551
[21]	World Health Organization. Module 3, Diagnosis: rapid diagnostics for tuberculosis detection[R]. 3rd ed. Geneva: World Health Organization, 2024.
[22]	Donovan J, Cresswell F V, Tucker E W, et al. A clinical practice guideline for tuberculous meningitis[J]. Lancet Infect Dis,2025:S1473-3099(25)00364-0. doi:10.1016/S1473-3099(25)00364-0.
[23]	Shao L, Qiu C, Zheng L, et al. Comparison of diagnostic accuracy of the GeneXpert Ultra and cell-free nucleic acid assay for tuberculous meningitis: A multicentre prospective study[J]. Int J Infect Dis, 2020, 98: 441-446. doi:10.1016/j.ijid.2020.06.076. pmid: 32599283
[24]	Tho D Q, Torok M E, Yen N T, et al. Influence of antituberculosis drug resistance and Mycobacterium tuberculosis lineage on outcome in HIV-associated tuberculous meningitis[J]. Antimicrob Agents Chemother, 2012, 56(6): 3074-3079. doi:10.1128/AAC.00319-12.
[25]	Heemskerk A D, Donovan J, Thu D D A, et al. Improving the microbiological diagnosis of tuberculous meningitis: A prospective, international, multicentre comparison of conventional and modified Ziehl-Neelsen stain, GeneXpert, and culture of cerebrospinal fluid[J]. J Infect, 2018, 77(6): 509-515. doi:10.1016/j.jinf.2018.09.003. pmid: 30217659
[26]	Thwaites G E, Chau T T, Farrar J J. Improving the bacteriological diagnosis of tuberculous meningitis[J]. J Clin Microbiol, 2004, 42(1): 378-379. doi:10.1128/JCM.42.1.378-379.2004.
[27]	Nair P P, Kalita J, Kumar S, et al. MRI pattern of infarcts in basal ganglia region in patients with tuberculous meningitis[J]. Neuroradiology, 2009, 51(4):221-225. doi:10.1007/s00234-009-0495-x. pmid: 19156405
[28]	Thwaites G E, Macmullen-Price J, Tran T H, et al. Serial MRI to determine the effect of dexamethasone on the cerebral pathology of tuberculous meningitis: an observational study[J]. Lancet Neurol, 2007, 6(3): 230-236. doi:10.1016/S1474-4422(07)70034-0. pmid: 17303529
[29]	Terry A R, Kahle K T, Larvie M, et al. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 5-2016. A 43-Year-Old Man with Altered Mental Status and a History of Alcohol Use[J]. N Engl J Med, 2016, 374(7): 671-680. doi:10.1056/NEJMcpc1509361.
[30]	Marais S, Thwaites G, Schoeman J F, et al. Tuberculous meningitis: a uniform case definition for use in clinical research[J]. Lancet Infect Dis, 2010, 10(11): 803-812. doi:10.1016/S1473-3099(10)70138-9.
[31]	Marais S, Pepper D J, Schutz C, et al. Presentation and outcome of tuberculous meningitis in a high HIV prevalence setting[J]. PLoS One, 2011, 6(5): e20077. doi:10.1371/journal.pone.0020077.
[32]	Solomons R S, Wessels M, Visser D H, et al. Uniform research case definition criteria differentiate tuberculous and bacterial meningitis in children[J]. Clin Infect Dis, 2014, 59(11): 1574-1578. doi:10.1093/cid/ciu665. pmid: 25139968
[33]	Humphries M. The management of tuberculous meningitis[J]. Thorax, 1992, 47(8):577-581. doi:10.1136/thx.47.8.577. pmid: 1412110
[34]	Kennedy D H, Fallon R J. Tuberculous meningitis[J]. JAMA, 1979, 241(3):264-268. doi: 10.1001/jama.1979.03290290032021 URL
[35]	Clarke P, Glick S, Reilly B M. Clinical problem-solving. On the threshold-a diagnosis of exclusion[J]. N Engl J Med, 2005, 352(9):919-924. doi:10.1056/NEJMcps040804.
[36]	Poonnoose S I, Rajshekhar V. Rate of resolution of histologically verified intracranial tuberculomas[J]. Neurosurgery, 2003, 53(4):873-879. doi:10.1227/01.neu.0000083553.25421.6f. pmid: 14519219
[37]	Svensson E M, Dian S, Te Brake L, et al. Model-Based Meta-analysis of Rifampicin Exposure and Mortality in Indonesian Tuberculous Meningitis Trials[J]. Clin Infect Dis, 2020, 71(8): 1817-1823. doi:10.1093/cid/ciz1071. pmid: 31665299
[38]	Wasserman S, Donovan J, Kestelyn E, et al. Advancing the chemotherapy of tuberculous meningitis: a consensus view[J]. Lancet Infect Dis, 2025, 25(1):e47-e58. doi:10.1016/S1473-3099(24)00512-7.
[39]	Meya D B, Cresswell F V, Dai B, et al. Trial of High-Dose Oral Rifampin in Adults with Tuberculous Meningitis[J]. N Engl J Med, 2025, 393(24): 2434-2446. doi:10.1056/NEJMoa2502866.
[40]	Heemskerk A D, Nguyen M T H, Dang H T M, et al. Clinical Outcomes of Patients With Drug-Resistant Tuberculous Meningitis Treated With an Intensified Antituberculosis Regimen[J]. Clin Infect Dis, 2017, 65(1):20-28. doi:10.1093/cid/cix230. pmid: 28472255
[41]	Sahib A, Bhatia R, Srivastava M V P, et al. Escalate: Linezolid as an add on treatment in the intensive phase of tubercular meningitis. A randomized controlled pilot trial[J]. Tuberculosis (Edinb), 2023, 142: 102351. doi:10.1016/j.tube.2023.102351.
[42]	Chow F C, Kafeero P, Nakimbugwe M, et al. Safety and Tolerability of a Short Course of Linezolid for the Treatment of Predominantly Moderate to Severe Tuberculous Meningitis in Adults With Human Immunodeficiency Virus[J]. J Infect Dis, 2025, 231(6): e1034-e1044. doi:10.1093/infdis/jiaf089.
[43]	Abdelgawad N, Wasserman S, Abdelwahab M T, et al. Linezolid Population Pharmacokinetic Model in Plasma and Cerebrospinal Fluid Among Patients With Tuberculosis Meningitis[J]. J Infect Dis, 2024, 229(4):1200-1208. doi:10.1093/infdis/jiad413.
[44]	Litjens C H C, Aarnoutse R E, Te Brake L H M. Preclinical models to optimize treatment of tuberculous meningitis-A systematic review[J]. Tuberculosis (Edinb), 2020, 122: 101924. doi:10.1016/j.tube.2020.101924.
[45]	Tucker E W, Guglieri-Lopez B, Ordonez A A, et al. Noninvasive (11)C-rifampin positron emission tomography reveals drug biodistribution in tuberculous meningitis[J]. Sci Transl Med, 2018, 10(470):eaau0965. doi:10.1126/scitranslmed.aau0965.
[46]	Chen X, Arun B, Nino-Meza O J, et al. Dynamic PET reveals compartmentalized brain and lung tissue antibiotic exposures of tuberculosis drugs[J]. Nat Commun, 2024, 15(1):6657. doi:10.1038/s41467-024-50989-4. pmid: 39143055
[47]	Mota F, Ruiz-Bedoya C A, Tucker E W, et al. Dynamic 18F-Pretomanid PET imaging in animal models of TB meningitis and human studies[J]. Nat Commun, 2022, 13(1):7974. doi:10.1038/s41467-022-35730-3.
[48]	Prasad K, Singh M B, Ryan H. Corticosteroids for managing tuberculous meningitis[J]. Cochrane Database Syst Rev, 2016, 4(4): CD002244. doi:10.1002/14651858.CD002244.pub4.
[49]	Girgis N I, Farid Z, Kilpatrick M E, et al. Dexamethasone adjunctive treatment for tuberculous meningitis[J]. Pediatr Infect Dis J, 1991, 10(3):179-183. doi:10.1097/00006454-199103000-00002. pmid: 2041662
[50]	Schoeman J F, Van Zyl L E, Laubscher J A, et al. Effect of corticosteroids on intracranial pressure, computed tomographic findings, and clinical outcome in young children with tuberculous meningitis[J]. Pediatrics, 1997, 99(2):226-231. doi:10.1542/peds.99.2.226. pmid: 9024451
[51]	Thwaites G E, Nguyen D B, Nguyen H D, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults[J]. N Engl J Med, 2004, 351(17): 1741-1751. doi:10.1056/NEJMoa040573.
[52]	Tobin D M, Roca F J, Oh S F, et al. Host genotype-specific therapies can optimize the inflammatory response to mycobacterial infections[J]. Cell, 2012, 148(3): 434-446. doi:10.1016/j.cell.2011.12.023. pmid: 22304914
[53]	Whitworth L, Coxon J, van Laarhoven A, et al. A Bayesian analysis of the association between Leukotriene A4 Hydrolase genotype and survival in tuberculous meningitis[J]. Elife, 2021, 10:e61722. doi:10.7554/eLife.61722.
[54]	Donovan J, Duc Bang N, Dong H K T, et al. Genotype-stratified adjunctive dexamethasone for tuberculous meningitis in HIV-negative adults: a randomized controlled phase 3 trial[J]. Nat Med, 2026, 32(3):849-858. doi:10.1038/s41591-025-04138-z.
[55]	Donovan J, Bang N D, Imran D, et al. Adjunctive Dexame-thasone for Tuberculous Meningitis in HIV-Positive Adults[J]. N Engl J Med, 2023, 389(15): 1357-1367. doi:10.1056/NEJMoa2216218.
[56]	Davis A G, Wasserman S, Stek C, et al. A Phase 2A Trial of the Safety and Tolerability of Increased Dose Rifampicin and Adjunctive Linezolid, With or Without Aspirin, for Human Immunodeficiency Virus-Associated Tuberculous Meningitis: The LASER-TBM Trial[J]. Clin Infect Dis, 2023, 76(8): 1412-1422. doi:10.1093/cid/ciac932.
[57]	Misra U K, Kalita J, Nair P P. Role of aspirin in tuberculous meningitis: a randomized open label placebo controlled trial[J]. J Neurol Sci, 2010, 293(1/2): 12-17. doi:10.1016/j.jns.2010.03.025.
[58]	Mai N T H, Dobbs N, Phu N H, et al. A randomised double blind placebo controlled phase 2 trial of adjunctive aspirin for tuberculous meningitis in HIV-uninfected adults[J]. Elife, 2018, 7:e33478. doi:10.7554/eLife.33478.
[59]	Schoeman J F, Janse van Rensburg A, Laubscher J A, et al. The role of aspirin in childhood tuberculous meningitis[J]. J Child Neurol, 2011, 26(8): 956-962. doi:10.1177/0883073811398132. pmid: 21628697
[60]	Schoeman J F, Fieggen G, Seller N, et al. Intractable intracranial tuberculous infection responsive to thalidomide: report of four cases[J]. J Child Neurol, 2006, 21(4): 301-308. doi:10.1177/08830738060210040801. pmid: 16900926
[61]	van Toorn R, Solomons R S, Seddon J A, et al. Thalidomide Use for Complicated Central Nervous System Tuberculosis in Children: Insights From an Observational Cohort[J]. Clin Infect Dis, 2021, 72(5): e136-e145. doi:10.1093/cid/ciaa1826. pmid: 33283220
[62]	Abo Y N, Curtis N, Osowicki J, et al. Infliximab for Paradoxical Reactions in Pediatric Central Nervous System Tuberculosis[J]. J Pediatric Infect Dis Soc, 2021, 10(12): 1087-1091. doi:10.1093/jpids/piab094.
[63]	Marais B J, Cheong E, Fernando S, et al. Use of Infliximab to Treat Paradoxical Tuberculous Meningitis Reactions[J]. Open Forum Infect Dis, 2021, 8(1): ofaa604. doi:10.1093/ofid/ofaa604.
[64]	Manesh A, Gautam P, Kumar D S, et al. Effectiveness of Adjunctive High-Dose Infliximab Therapy to Improve Disability-Free Survival Among Patients With Severe Central Nervous System Tuberculosis: A Matched Retrospective Cohort Study[J]. Clin Infect Dis, 2023, 77(10): 1460-1467. doi:10.1093/cid/ciad401. pmid: 37405816
[65]	Donovan J, Figaji A, Imran D, et al. The neurocritical care of tuberculous meningitis[J]. Lancet Neurol, 2019, 18(8): 771-783. doi:10.1016/S1474-4422(19)30154-1. pmid: 31109897
[66]	Aranha A, Choudhary A, Bhaskar S, et al. A Randomized Study Comparing Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in the Management of Hydrocephalus Due to Tuberculous Meningitis[J]. Asian J Neurosurg, 2018, 13(4): 1140-1147. doi:10.4103/ajns.AJNS_107_18. pmid: 30459883
[67]	Goyal P, Srivastava C, Ojha B K, et al. A randomized study of ventriculoperitoneal shunt versus endoscopic third ventriculostomy for the management of tubercular meningitis with hydrocephalus[J]. Childs Nerv Syst, 2014, 30(5): 851-857. doi:10.1007/s00381-014-2371-1.
[68]	Tai M S, Viswanathan S, Rahmat K, et al. Cerebral infarction pattern in tuberculous meningitis[J]. Sci Rep, 2016, 6:38802. doi:10.1038/srep38802.
[69]	Wasay M, Khan M, Farooq S, et al. Frequency and Impact of Cerebral Infarctions in Patients With Tuberculous Meningitis[J]. Stroke, 2018, 49(10): 2288-2293. doi:10.1161/STROKEAHA.118.021301.f. pmid: 30355085
[70]	Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia[J]. Eur J Endocrinol, 2014, 170(3):G1-G47. doi:10.1530/EJE-13-1020.
[71]	Misra U K, Kalita J, Kumar M, et al. Hypovolemia due to cerebral salt wasting may contribute to stroke in tuberculous meningitis[J]. QJM, 2018, 111(7):455-460. doi:10.1093/qjmed/hcy072. pmid: 29635544
[72]	Misra U K, Kalita J, Bhoi S K, et al. A study of hyponatremia in tuberculous meningitis[J]. J Neurol Sci, 2016, 367:152-157. doi:10.1016/j.jns.2016.06.004. pmid: 27423581
[73]	Berning S E, Cherry T A, Iseman M D. Novel treatment of meningitis caused by multidrug-resistant Mycobacterium tuberculosis with intrathecal levofloxacin and amikacin: case report[J]. Clin Infect Dis, 2001, 32(4):643-646. doi:10.1086/318698. pmid: 11181130
[74]	Chen R, Shen Y, Liu H, et al. Intrathecal Isoniazid and Dexamethasone Therapy May Improve Outcomes in Patients with Tuberculous Meningitis: A Two-Center Retrospective Cohort Study[J]. Clin Infect Dis,2026:ciag106. doi:10.1093/cid/ciag106.
[75]	van de Beek D, Drake J M, Tunkel A R. Nosocomial bacterial meningitis[J]. N Engl J Med, 2010, 362(2): 146-154. doi:10.1056/NEJMra0804573.
[76]	Abdool Karim S S, Naidoo K, Grobler A, et al. Integration of antiretroviral therapy with tuberculosis treatment[J]. N Engl J Med, 2011, 365(16): 1492-1501. doi:10.1056/NEJMoa-1014181.
[77]	Blanc F X, Sok T, Laureillard D, et al. Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis[J]. N Engl J Med, 2011, 365(16): 1471-1481. doi:10.1056/NEJMoa1013911.
[78]	Torok M E, Yen N T, Chau T T, et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus (HIV)--associated tuberculous meningitis[J]. Clin Infect Dis, 2011, 52(11): 1374-1383. doi:10.1093/cid/cir230. pmid: 21596680
[79]	Marais S, Meintjes G, Pepper D J, et al. Frequency, severity, and prediction of tuberculous meningitis immune reconstitution inflammatory syndrome[J]. Clin Infect Dis, 2013, 56(3): 450-460. doi:10.1093/cid/cis899. pmid: 23097584
[80]	Meintjes G, Maartens G. HIV-Associated Tuberculosis[J]. N Engl J Med, 2024, 391(4): 343-355. doi:10.1056/NEJMra2308181.
[81]	Bracchi M, van Halsema C, Post F, et al. British HIV Association guidelines for the management of tuberculosis in adults living with HIV 2019[J]. HIV Med, 2019, 20 (Suppl 6):s2-s83. doi:10.1111/hiv.12748.
[82]	World Health Organization. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach[R]. Geneva: World Health Organization, 2021.
[83]	中华医学会感染病学分会艾滋病学组, 中国疾病预防控制中心. 中国艾滋病诊疗指南(2024版)[J]. 中华传染病杂志, 2024, 42(5):257-284. doi:10.3760/cma.j.cn311365-20240328-00081.
[84]	Boulle A, Van Cutsem G, Cohen K, et al. Outcomes of nevirapine- and efavirenz-based antiretroviral therapy when coadministered with rifampicin-based antitubercular therapy[J]. JAMA, 2008, 300(5): 530-539. doi:10.1001/jama.300.5.530. pmid: 18677025
[85]	Dooley K E, Kaplan R, Mwelase N, et al. Dolutegravir-based Antiretroviral Therapy for Patients Coinfected With Tuberculosis and Human Immunodeficiency Virus: A Multicenter, Noncomparative, Open-label, Randomized Trial[J]. Clin Infect Dis, 2020, 70(4):549-556. doi:10.1093/cid/ciz256. pmid: 30918967
[86]	Griesel R, Zhao Y, Simmons B, et al. Standard-dose versus double-dose dolutegravir in HIV-associated tuberculosis in South Africa (RADIANT-TB): a phase 2, non-comparative, randomised controlled trial[J]. Lancet HIV, 2023, 10(7): e433-e441. doi:10.1016/S2352-3018(23)00081-4. pmid: 37230101

证据质量分级	具体描述
高	对观察值非常有把握;观察值接近真实值
中	对观察值有中等程度的把握;观察值有可能接近真实值
低	对观察值的把握有限;观察值可能与真实值有很大区别
极低	对观察值几乎无把握;观察值可能与真实值有极大区别

推荐强度分级	具体描述
强烈推荐	明确显示所推荐的干预措施利大于弊或弊大于利
有条件推荐	已有证据显示利弊不确定或无论质量高低的证据显示利弊相当

指标	发生率或检查结果
症状
头痛	50%~80%
发热	60%~95%
呕吐	30%~60%
畏光	5%~10%
食欲不振/体质量降低	60%~80%
体征
颈强直	40%~80%
意识模糊	10%~30%
昏迷	30%~60%
脑神经麻痹	30%~50%
偏瘫	10%~20%
截瘫	5%~10%
癫痫	5%
脑脊液检查
外观清亮	80%~90%
颅压>250mmH₂O	50%
白细胞计数(×10⁶个/L)	10~1000
蛋白(g/L)	0.45~3.0
脑脊液糖/血糖比值<0.5	95%

标准		评分
临床标准(最高评分=6分)
结核性脑膜炎症状(发热、头痛、呕吐)持续超过5d		4
症状提示结核病(至少一项):体质量下降、盗汗或持续咳嗽超过2周		2
近期有肺结核患者密切接触史,或IGRA阳性/TST强阳性		2
局灶神经损伤(偏瘫、截瘫等)		1
脑神经麻痹		1
意识障碍		1
脑脊液标准(最高评分=4分)
外观清亮		1
细胞数:10~500个/μl		1
淋巴细胞为主(>50%)		1
蛋白含量超过1g/L		1
脑脊液与血浆葡萄糖比值低于50%或脑脊液葡萄糖浓度低于2.2mmol/L		1
颅脑影像检查标准(最高评分=6分)
脑积水(CT或MRI)	1
基底脑膜强化(CT或MRI)	2
结核球(CT或MRI)	2
脑梗死(CT或MRI)	1
增强前基底池高密度(CT)	2
其他部位的结核病证据(最高评分=4分)
胸部影像检查提示活动性肺结核(除粟粒性结核病)	2
胸部影像检查提示粟粒性结核病	4
影像或超声检查提示中枢神经系统结核外的结核病	2
其他部位发现抗酸杆菌或培养发现分枝杆菌(如痰、淋巴结、胃液、尿和血等)	4
神经系统外的标本经商业化结核分枝杆菌核酸扩增方法检测阳性	4

分级	定义
Ⅰ级	清醒、无定向力障碍,且无局部神经损伤
Ⅱ级	Glasgow昏迷指数10~14,伴或不伴局部神经损伤;或Glasgow昏迷指数15伴局部神经损伤
Ⅲ级	Glasgow昏迷指数<10伴或不伴局部神经损伤