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目的探讨急诊科早期临床诊断结核性脑膜炎的方法。方法对北京协和医院1995年至2004年10年间出院诊断为结核性脑膜炎的患者进行回顾性分析。对患者有无结核病史、有无合并其他部位结核感染、脑脊液结果及细菌培养等结果进行分析。结果 68例患者中有16例既往有结核病史(24%),有20例结核性脑膜炎发病的同时患有肺结核(30%)、9例患者同时有肺结核以外的颅外结核(13%)。全部患者均进行了结核杆菌培养,其中12例为阳性结果(20%)。阳性率较高的7项临床指标依次是神志改变(100%),发病时间>5 d(99%),脑脊液以淋巴细胞为主(80%),脑脊液糖水平低于血糖水平50%(70%),CT 或 MRI 异常(70%),眼底异常(49%)及合并有其他部位结核(43%)。结论通过68例病例分析可见,结核性脑膜炎常合并其他部位结核感染。脑脊液及血等标本中结核菌培养阳性率低,不宜作为早期诊治的主要依据。建议临床工作中当出现上述7条指标中≥4条时应高度怀疑结核性脑膜炎。
Objective To investigate the early clinical diagnosis of tuberculous meningitis in emergency department. Methods A retrospective analysis was performed on patients diagnosed as having tuberculous meningitis at Peking Union Medical College Hospital from 1995 to 2004. The patient had no history of tuberculosis, with or without other parts of tuberculosis infection, cerebrospinal fluid results and bacterial culture results were analyzed. RESULTS: Sixteen of the 68 patients had a history of tuberculosis (24%), 20 had tuberculous meningitis (30%), and 9 had extracranial tuberculosis (13%) other than tuberculosis . All patients underwent Mycobacterium tuberculosis culture, of which 12 were positive (20%). Seven clinical indicators with high positive rate followed by conscious change (100%), onset time> 5 days (99%), cerebrospinal fluid predominantly by lymphocytes (80%), cerebrospinal fluid glucose level lower than 50% of blood glucose level %), CT or MRI abnormalities (70%), fundus abnormalities (49%), and tuberculosis in other areas (43%). Conclusion According to the analysis of 68 cases, tuberculous meningitis is often associated with tuberculosis in other areas. Cerebrospinal fluid and blood specimens in the positive rate of TB culture is low, not as a major basis for early diagnosis and treatment. Proposed clinical work should be highly suspected of tuberculous meningitis when there are ≥4 out of the above seven indicators.