积极控制颅内高压逆转HIV相关隐球菌性脑膜炎所致严重视力损害一例及文献复习  

Recovery of severe vision impairment with stringent control of intracranial hypertension in HIVassociated Cryptococcal meningitis: a case report and literature review

作　　者：胡志亮[1] 郑立冲 池云[1] 成骢[1] 陈陆馗 魏洪霞[1] 

机构地区：[1]东南大学附属南京市第二医院感染病科,南京市210003 [2]东南大学附属南京市第二医院外科,南京市210003 [3]东南大学附属中大医院神经外科,南京市210009

出　　处：《中华实验和临床感染病杂志（电子版）》2017年第6期617-621,共5页Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition)

基　　金：江苏省"十三五科教强卫工程"青年医学人才项目(No.QNRC2016059)

摘　　要：目的为提高人免疫缺陷病毒(HIV)相关隐球菌性脑膜炎(CM)的救治水平提供理论依据。方法回顾性分析本院2015年收治的1例重症HIV相关CM的临床资料,结合该患者的治疗过程以及国内外文献,对CM相关颅内高压的治疗进行报道。结果该病例具有极高颅内高压(1 200 mm H2O),伴有严重视力损伤近乎失明(双眼仅能感知强光,无法辨别任何物体,对光反射迟钝)。患者先后接受腰大池置管外引流术以及永久性腰大池腹腔分流术以积极控制颅内高压,最终视力恢复至病前水平。通过文献复习发现HIV相关CM颅内高压产生的主要机制是脑脊液重吸收障碍,现有的治疗手段主要包括系列治疗性腰椎穿刺引流,持续性腰大池或是脑室外引流,以及永久性腰大池腹腔或是脑室腹腔分流术。甘露醇虽然在国内应用较为广泛,但国外指南并不推荐。结论 HIV相关CM的治疗应重视颅内高压的控制,并合理选择颅内高压处理方案。当患者出现严重视力损害时,尽早引流或分流脑脊液以严格控制颅内高压或许能阻止患者发展为永久失明。Objective To investigate theoretical basis for improving the management of human immunodeficiency virus （HIV）-associated cryptococcal meningitis （CM）. Methods The clinical data of an HIV-infected patient with severe CM admitted to our hospital in 2015 were analyzed, retrospectively. A literature review was performed to discuss the management of the elevated intracranial pressure （ICP） in HIV- associated CM. Results The reported case had extremely high ICP with severe vision impairment that he could not recognize anything except for a perception of strong light with blunted pupillary light response. The patient sequentially received lumbar drainage and lumboperitoneal shunt to control the elevated ICP that his vision finally returned to premorbid level. A literature view found that elevated ICP in HIV-associated CM was mainly caused by the obstruction to cerebrospinal fluid reabsorption. Current strategies to control the elevated ICP including serial therapeutic lumbar puncture drainages, external lumbar or ventricular drainage, and permanent lumboperitoneal or ventriculoperitoneal shunt. Although mannitol was commonly used in China, it was not recommended in many other countries. Conclusions Stringent control of elevated ICP was very important for the management of HIV-associated CM. When severe vision impairment occurs, early cerebrospinal fluid drainage or shunting to maximally control elevated ICP, may help to prevent permanent vision loss.

关 键 词：视力损伤 隐球菌性脑膜炎 人免疫缺陷病毒 腰大池腹腔分流术 颅内高压 

分 类 号：R512.91[医药卫生—内科学] R519.4[医药卫生—临床医学]