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获得性免疫缺陷综合征&新型隐球菌脑膜脑炎1获得性免疫缺陷综合征&新型隐球菌脑膜脑炎1主诉：头痛8天，复视4天，发热意识欠清1天进行性加重头痛颅高压症状视物成双、听力下降颅神经受累症状发热感染症状2主诉：头痛8天，复视4天，发热意识欠清1天进行性加重头痛颅高外院腰穿（2016.4.27）4.27潘式实验（-）脑脊液细胞总数1440*106/L 脑脊液白细胞计数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压力3外院腰穿（2016.4.27）4.27潘式实验（-）脑脊头颅MRI：左侧半卵圆中心点状异常信号，T2Flair序列双顶叶皮层下点状略高信号（2016.4.27）4头颅MRI：左侧半卵圆中心点状异常信号，T2Flair序列双入院后腰穿-略浑浊脑脊液5入院后腰穿-略浑浊脑脊液5入院后腰穿5.15.4潘式实验（1+）（1+）脑脊液RBC210*106/L 420*106/L 脑脊液WBC6*106/L 2*106/L 墨汁染色阳性阳性蛋白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压力778 mmH2O347mmH2O6入院后腰穿5.15.4潘式实验（1+）（1+）脑脊液RBC2脑脊液细胞学成团及散在带荚膜蓝染颗粒Wright-Giemsa染色 放大倍数1：4007脑脊液细胞学成团及散在带荚膜蓝染颗粒Wright-Giem脑脊液培养新生隐球菌报阳时间：48小时8脑脊液培养新生隐球菌8化验白细胞计数及淋巴细胞计数109/L 5/25/35/45/50246810121416182014.5718.8816.3310.591.090.50.690.77白细胞计数淋巴细胞计数9化验白细胞计数及淋巴细胞计数9化验T细胞亚群分类百分比百分比(%)参考范参考范围总T淋巴细胞（CD3+）24.561.085.0T辅助/诱导细胞（Th,CD3+CD4+CD8-）1.834.070.0T抑制/细胞毒细胞（Ts,CD3+CD4-CD8+）93.325.054.0辅助/抑制T淋巴细胞比值0.020.682.4710化验T细胞亚群分类百分比(%)参考范围总T淋巴细胞（CD3AIDS确诊实验11AIDS确诊实验11诊断新型隐球菌脑膜脑炎获得性免疫缺陷综合征12诊断新型隐球菌脑膜脑炎12Clinical Infectious Diseases 2010;50:29132213Clinical Infectious Diseases 2Chin J Mycol,April 2010,Vol 5,No 214Chin J Mycol,April 2010,Vol 5Cryptococcus/隐球菌 Cryptococcus neoformans/新型隐球菌Cryptococcus gattii/格特隐球菌 15Cryptococcus/隐球菌 Cryptococcus1616Incidence 在免疫抑制患者中，隐球菌感染的发病率约为5%10%，在AIDS患者中，隐球菌的感染率可以高达 30%，而在免疫功能正常的人群中，隐球菌的感染率约为十万分之一左右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，隐球菌感染的发病率约为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 populations,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临床表现Chin J Mycol,April 2010,Vol 5,No 219临床表现Chin J Mycol,April 2010,VCSF interpretation for the management of patients with suspected encephalitisJournal of Infection(2012)64,347e37320CSF interpretation for the man艾滋病合并新型隐球菌脑膜脑炎的影像学表现血管周围间隙扩大血管周围间隙扩大胶状假囊（治疗胶状假囊（治疗3个月后）个月后）Radiol Practice，sep 2009，Vol 24，N 0.921艾滋病合并新型隐球菌脑膜脑炎的影像学表现血管周围间隙扩大胶状V-R 间隙（血管周围间隙）扩大血管周围间隙是与软脑膜下隙接续的,是软脑膜随着穿通动脉和流出静脉进出脑实质的延续而成扩大的V-R 间隙意味着大量的隐球菌酵母细胞聚集于血管周围间隙或者部分阻滞了脑脊液的流出22V-R 间隙（血管周围间隙）扩大血管周围间隙是与软脑膜下隙接Three risk groups of cryptococcal Three risk groups of cryptococcal meningoencephalitis meningoencephalitis Human immunodeficiency virus(HIV)infected individualsOrgan transplant recipientsNonHIV infected and nontransplant hosts23Three risk groups of cryptococClinical Infectious Diseases 2010;50:29132224Clinical Infectious Diseases 2Chin J Mycol,April 2010,Vol 5,No 225Chin J Mycol,April 2010,Vol 5Cryptococcosis in a resource-limited health Cryptococcosis in a resource-limited health care environmentcare environmentWith CNS and/or disseminated disease where polyene is not available,induction therapy is fluconazole(800 mg per day orally;1200 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 monitoring 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 PressureElevated CSF PressureIf the CSF pressure is 25 cm of CSF and there are symptoms of increased intracranial pressure during induction therapy,relieve 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 or 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 complete sterilization of CNS,if clinically necessaryClinical Infectious Diseases 2010;50:29132227Elevated CSF PressureIf the CS颅高压处理Chin J Mycol,April 2010,Vol 5,No 228颅高压处理Chin J Mycol,April 2010,292930谢谢各位专家指导！30
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