不同剂量两性霉素B鞘内注射联合脑脊液持续引流置换治疗新型隐球菌性脑膜炎的对比  

Comparison of Different Doses of Amphotericin B Intrathecal Injection Combined with Continuous Cerebrospinal Fluid Drainage Replacement in the Treatment of Cryptococcal Meningitis

作　　者：何花 黄瑛 张燕玲 徐俊 李文明 罗云 HE Hua;HUANG Ying;ZHANG Yan-ling;XU Jun;LI Wen-ming;LUO Yun(Dept.of Infectious Disease,The 3rd People’s Hospital of Kunming,Kunming Yunnan 650041,China)

机构地区：[1]昆明市第三人民医院感染二科,云南昆明650041

出　　处：《昆明医科大学学报》2020年第12期112-118,共7页Journal of Kunming Medical University

基　　金：昆明市卫生和计划生育委员会医药卫生科技计划基金资助项目(2018-03-08-001)。

摘　　要：目的探讨不同剂量两性霉素B鞘内注射治疗新型隐球菌性脑膜炎疗效与不良反应。方法按入组条件,收集2017年1月至2019年12月间,昆明市第三人民医院收治的新型隐球菌性脑膜炎病例,按入组标准选择69例,诱导治疗期在静脉注射两性霉素B及口服氟胞嘧啶的基础上,予以腰大池持续引流置换脑脊液,鞘内注射不同剂量的两性霉素B;随机分为4个组,A0、A1、A2每组17例,A3组18例。分别为A1(鞘内注射两性霉素B剂量0.2 mg)、A2(鞘内注射两性霉素B剂量0.3 mg)、A3(鞘内注射两性霉素B剂量0.5 mg)3组;A0为对照组(仅静脉注射两性霉素B及口服氟胞嘧啶,无鞘内注射给药);观察治疗后1周、2周、4周,临床症状改善情况、脑脊液生化指标的变化,脑脊液中病原体的检测、影像学病灶的转归,以及不良反应。结果 A1组不良反应的情况较A2、A3组少,差异有统计学意义(P <0.001);治疗4周后,A2、A3组脑脊液墨汁染色阳性率低于A1,差异有统计学意义(P <0.05);A2、A3组脑脊液墨汁染色阳性率,差异无统计学意义(P> 0.05)。磁共振显示A2组病灶明显吸收人数比率均高于A1、A3组,差异有统计学意义(P <0.05);A1、A3组磁共振显示病灶明显吸收人数比率比较,差异无统计学意义(P> 0.05)。A1组不良反应少,但疗效不及A2、A3组;A2组不良反应较A1组稍高、较A3组低,但A2组疗效最好;A3组因部分病例对不良反应难以耐受,不能每日进行鞘内注射,经治疗后从脑脊液蛋白及糖的恢复情况、影像学检查病灶吸收不及A2组。结论两性霉素B鞘内注射治疗隐球菌性脑膜炎时,若追求快速缓解病情而过快增加剂量,或长期使用较大剂量的两性霉素B鞘内注射带来的不良反应反而影响治疗的进度,干扰后期治疗效果,大部分患者更能接受低、中等剂量的两性霉素B鞘内注射。Objective To investigate the efficacy and side effects of different doses of amphotericin B intrathecal injection in the treatment of cryptococcal meningitis.Methods 69 cases of cryptococcal meningitis admitted in the Third People's Hospital of Kunming city from January 2017 to December 2019,were enrolled in this study.In the induction period,continuous drainage through the lumbar cisterm was performed to replace cerebrospinal fluid on the basis of intravenous amphotericin B and oral fluorocytosine,and different doses of amphotericin B were injected intrathecally.All the cases were randomly divided into 4 groups,17 cases in A0,A1,A2 group respectively,18 cases in A3 group.Experimental groups were A1(amphotericin intrathecal injection B dose 0.2 mg),A2(amphotericin intrathecal injection B dose 0.3 mg)and A3(amphotericin intrathecal injection B dose 0.5 mg).A0 was control group(intravenous amphotericin B and oral fluorocytosine only,no intrathecal injection).Clinical symptoms,cerebrospinal fluid biochemical indicators,pathogens in CSF,imaging,and adverse reactions were observed at 1,2,and 4 weeks after treatment.Results The adverse reactions in group A1 were significantly lower than those in group A2 and A3(P<0.001);After 4 weeks of treatment,the positive rate of CSF ink staining in A2 and A3 groups was significantly lower than that in A1 group(P<0.05);The positive rate of cerebrospinal fluid ink staining in A2 and A3 groups has no statistic significance(P>0.05).MRI showed that the ratio of obvious absorption of lesions in Group A2 was significantly higher than that in group A1 and Group A3(P<0.05);Comparison of the ratio of obvious absorption of lesions in A1 and A3 groups by MRI showed no statistically significant difference(P>0.05).There were fewer adverse reactions in group A1,but the efficacy was not as good as that in group A2 and A3;The adverse reactions in group A2 were slightly higher than that in group A1 and lower than that in group A3,but A2 has the best efficacy.Due to the intolerance of some patients

关 键 词：不同剂量 两性霉素B 鞘内注射 新型隐球菌性脑膜炎 脑脊持续引流及置换 

分 类 号：R512[医药卫生—内科学]