艾滋病合并新型隐球菌脑膜炎文献回顾课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,获得性免疫缺陷综合征,&,新型隐球菌脑膜脑炎,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,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,2,外院腰穿,（,2016.4.27,）,4.27,潘式实验,（,-,）,脑脊液细胞总数,1440,*,10,6,/L,脑脊液白细胞计数,20,*,10,6,/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,外院腰穿（ 2016.4.27 ）4.27潘式实验（-）脑脊,3,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,）,头颅MRI：左侧半卵圆中心点状异常信号，T2Flair序列双,4,入院后腰穿,-,略浑浊脑脊液,入院后腰穿-略浑浊脑脊液,5,入院后腰穿,5.1,5.4,潘式实验,（,1+,）,（,1+,）,脑脊液,RBC,210,*,10,6,/L,420,*,10,6,/L,脑脊液,WBC,6,*,10,6,/L,2,*,10,6,/L,墨汁染色,阳性,阳性,蛋白,0.4 g/L,0.55 g/L,葡萄糖,1.4 mmol/L,4.7 mmol/L,氯化物,115 mmol/L,123 mmol/L,压力,778 mmH,2,O,347mmH,2,O,入院后腰穿5.15.4潘式实验（1+）（1+）脑脊液RBC2,6,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,：,400,脑脊液细胞学成团及散在带荚膜蓝染颗粒Wright-Giem,7,脑脊液培养,新生隐球菌,报阳时间：,48,小时,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,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,(%),参考范围,总,T,淋巴细胞（,CD3+,）,24.5,61.085.0,T,辅助,/,诱导细胞（,Th,CD3+CD4+CD8-,）,1.8,34.070.0,T,抑制,/,细胞毒细胞（,Ts,CD3+CD4-CD8+,）,93.3,25.054.0,辅助,/,抑制,T,淋巴细胞比值,0.02,0.682.47,化验T细胞亚群分类百分比(%)参考范围总T淋巴细胞（CD3,10,AIDS,确诊实验,AIDS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,诊断新型隐球菌脑膜脑炎,12,Clinical Infectious Diseases 2010; 50:291322,Clinical Infectious Diseases 2,13,Chin J Mycol ,April 2010,Vol 5,No 2,Chin J Mycol ,April 2010,Vol 5,14,Cryptococcus /,隐球菌,Cryptococcus neoformans/,新型隐球菌,Cryptococcus gattii/,格特隐球菌,Cryptococcus /隐球菌 Cryptococcus,15,艾滋病合并新型隐球菌脑膜炎文献回顾课件,16,Incidence,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 worldwide,Clinical Infectious Diseases 2010; 50:291322,Chin J Mycol ,April 2010,Vol 5,No 2,Incidence 在免疫抑制患者中，隐球菌感染的发病率约为,17,Mortality,Despite 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 facilities,Clinical Infectious Diseases 2010; 50:291322,MortalityDespite access to adv,18,临床表现,Chin J Mycol ,April 2010,Vol 5,No 2,临床表现Chin J Mycol ,April 2010,V,19,CSF interpretation for the management of patients with suspected encephalitis,Journal of Infection (2012) 64, 347e373,CSF interpretation for the man,20,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,胶状假囊（治疗,3,个月后）,Radiol Practice,，,sep 2009,，,Vol 24,，,N 0 .9,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,21,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,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,22,Three risk groups of cryptococcal meningoencephalitis,Human immunodeficiency virus (HIV)infected individuals,Organ transplant recipients,NonHIV infected and nontransplant hosts,Three risk groups of cryptococ,23,Clinical Infectious Diseases 2010; 50:291322,Clinical Infectious Diseases 2,24,Chin J Mycol ,April 2010,Vol 5,No 2,Chin J Mycol ,April 2010,Vol 5,25,Cryptococcosis in a resource-limited health care environment,With 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.,Cryptococcosis in a resource-l,26,Elevated CSF Pressure,If 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 necessary,Clinical Infectious Diseases 2010; 50:291322,Elevated CSF PressureIf the CS,27,颅高压处理,Chin J Mycol ,April 2010,Vol 5,No 2,颅高压处理Chin J Mycol ,April 2010,28,艾滋病合并新型隐球菌脑膜炎文献回顾课件,29,谢谢各位专家指导！,谢谢各位专家指导！,30,