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目的探讨原发性广泛耐药结核性脑膜炎的临床表现、诊断方法及治疗方案,提高对原发性广泛耐药结核性脑膜炎的认识。方法对1例确诊原发性广泛耐药结核性脑膜炎患者的临床表现、影像学改变、实验室诊断及治疗结合相关文献进行回顾性分析。结果患者男性,24岁,因“头痛、呕吐5 d,加重伴精神异常10 h”收入院。既往无肺结核病史,胸部X线片未见异常,头颅CT检查提示轻度脑积水、环池轻度狭窄,疑脑膜炎。予异烟肼0.3 g静脉滴注(1次/d),口服异烟肼0.3 g(1次/d),利福平0.45 g(1次/d),吡嗪酰胺1.5 g(1次/d),乙胺丁醇0.75 g(1次/d)抗结核化疗,予地塞米松15 mg减轻结核中毒症状,但患者病情进展迅速,治疗无效死亡。3个月后脑脊液培养提示耐药结核分枝杆菌生长(对异烟肼、利福平、链霉素、环丙沙星、对氨基水杨酸、卡那霉素、丙硫异烟胺耐药),确诊为原发广泛耐药结核性脑膜炎。在万方数据库和Pub Med数据库上检索到广泛耐药结核性脑膜炎相关文献共4篇,共5例,其中2例初治,另外3例未提示为初治还是复治。结论初治原发耐药结核性脑膜炎临床上少见,病情重,进展快,病死率高。临床应加强警惕,尽早获得药敏结果,根据情况调整治疗方案,条件允许情况下应开展分子药敏试验。
Objective To investigate the clinical manifestations, diagnosis and treatment of primary extensively drug resistant tuberculous meningitis and to raise awareness of primary broad-spectrum drug-resistant tuberculous meningitis. Methods Retrospective analysis was performed on the clinical manifestations, imaging changes, laboratory diagnoses and the combination of treatment and treatment of one patient diagnosed with primary drug-resistant tuberculous meningitis. Results Male patient, 24 years old, because of “headache, vomiting 5 d, aggravated with mental disorders 10 h ” income hospital. No past history of pulmonary tuberculosis, chest X-ray showed no abnormalities, head CT examination showed mild hydrocephalus, Central pool mild stenosis, suspected meningitis. To isoniazid 0.3 g intravenous infusion (1 / d), oral isoniazid 0.3 g (1 / d), rifampicin 0.45 g (1 / d), pyrazinamide 1.5 g (1 / d), 0.75 g (1 / d) of ethambutol for anti-tuberculosis chemotherapy and dexamethasone 15 mg to reduce the symptoms of tuberculosis, but the patient’s condition progressed rapidly and the treatment died of ineffectiveness. Cerebrospinal fluid culture at 3 months suggested resistance to M. tuberculosis growth (resistance to isoniazid, rifampicin, streptomycin, ciprofloxacin, paracetamol, kanamycin, prothionamide Medicine), diagnosed as primary broad-spectrum drug-resistant tuberculous meningitis. A total of 4 articles were found in Wanfang database and Pub Med database, including 5 cases of which are mostly drug-resistant and 2 cases of newly diagnosed meningitis. The other 3 cases did not suggest initial treatment or retreatment. Conclusions Primary drug-resistant tuberculous meningitis is rare in clinic, with severe illness, rapid progression and high case fatality rate. Clinical vigilance should be strengthened, as soon as possible drug susceptibility results, according to the situation to adjust the treatment plan, conditions permitting should carry out molecular susceptibility testing.