獲得性免疫缺陷綜合征

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新型隱球菌腦膜腦炎1主訴：頭痛8天，復(fù)視4天，發(fā)熱意識(shí)欠清1天進(jìn)行性加重頭痛顱高壓癥狀視物成雙、聽力下降顱神經(jīng)受累癥狀發(fā)熱感染癥狀2外院腰穿（2016.4.27）4.27潘式實(shí)驗(yàn)（-）腦脊液細(xì)胞總數(shù)1440*106/L腦脊液白細(xì)胞計(jì)數(shù)20*106/L墨汁染色蛋白0.184g/L葡萄糖2.6mmol/L氯化物113.0mmol/L壓力3頭顱MRI：左側(cè)半卵圓中心點(diǎn)狀異常信號(hào)，T2Flair序列雙頂葉皮層下點(diǎn)狀略高信號(hào)（2016.4.27）4入院后腰穿--略渾濁腦脊液5入院后腰穿5.15.4潘式實(shí)驗(yàn)（1+）（1+）腦脊液RBC210*106/L420*106/L腦脊液WBC6*106/L2*106/L墨汁染色陽(yáng)性陽(yáng)性蛋白0.4g/L0.55g/L葡萄糖1.4mmol/L4.7mmol/L氯化物115mmol/L123mmol/L壓力778mmH2O347mmH2O6腦脊液細(xì)胞學(xué)—成團(tuán)及散在帶莢膜藍(lán)染顆粒Wright-Giemsa染色放大倍數(shù)1：4007腦脊液培養(yǎng)新生隱球菌報(bào)陽(yáng)時(shí)間：48小時(shí)8化驗(yàn)—白細(xì)胞計(jì)數(shù)及淋巴細(xì)胞計(jì)數(shù)9化驗(yàn)—T細(xì)胞亞群分類百分比(%)參考范圍總T淋巴細(xì)胞（CD3+）24.561.0~85.0T輔助/誘導(dǎo)細(xì)胞（Th,CD3+CD4+CD8-）1.834.0~70.0T抑制/細(xì)胞毒細(xì)胞（Ts,CD3+CD4-CD8+）93.325.0~54.0輔助/抑制T淋巴細(xì)胞比值0.020.68~2.4710AIDS確診實(shí)驗(yàn)11診斷新型隱球菌腦膜腦炎獲得性免疫缺陷綜合征12ClinicalInfectiousDiseases2010;50:291–32213ChinJMycol,April2010,Vol5,No214Cryptococcus/隱球菌

Cryptococcusneoformans/新型隱球菌Cryptococcusgattii/格特隱球菌

1516Incidence在免疫抑制患者中，隱球菌感染的發(fā)病率約為5%~10%，在AIDS患者中，隱球菌的感染率可以高達(dá)30%，而在免疫功能正常的人群中，隱球菌的感染率約為十萬(wàn)分之一左右ItisestimatedthattheglobalburdenofHIV-associatedcryptococcosisapproximates1millioncasesannuallyworldwide

ClinicalInfectiousDiseases2010;50:291–322ChinJMycol,April2010,Vol5,No217MortalityDespiteaccesstoadvancedmedicalcareandtheavailabilityofHAART,the3-monthmortalityrateduringmanagementofacutecryptococcalmeningoencephalitisapproximates20%Furthermore,withoutspecificantifungaltreatmentforcryptococcalmeningoencephalitisincertainHIV-infectedpopulations,mortalityratesof100%havebeenreportedwithin2weeksafterclinicalpresentationtohealthcarefacilities

ClinicalInfectiousDiseases2010;50:291–32218臨床表現(xiàn)ChinJMycol,April2010,Vol5,No219CSFinterpretationforthemanagementofpatientswithsuspectedencephalitisJournalofInfection(2012)64,347e37320艾滋病合并新型隱球菌腦膜腦炎的影像學(xué)表現(xiàn)血管周圍間隙擴(kuò)大膠狀假囊（治療3個(gè)月后）RadiolPractice，sep2009，Vol24，N0.921V-R間隙（血管周圍間隙）擴(kuò)大血管周圍間隙是與軟腦膜下隙接續(xù)的,是軟腦膜隨著穿通動(dòng)脈和流出靜脈進(jìn)出腦實(shí)質(zhì)的延續(xù)而成擴(kuò)大的V-R間隙意味著大量的隱球菌酵母細(xì)胞聚集于血管周圍間隙或者部分阻滯了腦脊液的流出22ThreeriskgroupsofcryptococcalmeningoencephalitisHumanimmunodeficiencyvirus(HIV)–infectedindividualsOrgantransplantrecipientsNon–HIVinfectedandnontransplanthosts23ClinicalInfectiousDiseases2010;50:291–32224ChinJMycol,April2010,Vol5,No225Cryptococcosisinaresource-limitedhealthcareenvironmentWithCNSand/ordisseminateddiseasewherepolyeneisnotavailable,inductiontherapyisfluconazole(800mgperdayorally;1200mgperdayisfavored)foratleast10weeksoruntilCSFcultureresultsarenegative,followedbymaintenancetherapywithfluconazole(200–400mgperdayorally)WhereAmBdisnotavailableoraffordable,wherefacilitiesforadmissionandIVtherapydonotexist,orwhererenalandpotassiummonitoringarenotsufficientlyrapidorreliabletoallowsafeuseofAmBd,fluconazoleisoftentheonlytreatmentoption.26ElevatedCSFPressureIftheCSFpressureis>25cmofCSFandtherearesymptomsofincreasedintracranialpressureduringinductiontherapy,relievebyCSFdrainage(bylumbarpuncture,reducetheopeningpressureby50%ifitisextremelyhighortoanormalpressureof<20cmofCSFIfthereispersistentpressureelevation>25cmofCSFandsymptoms,repeatlumbarpuncturedailyuntiltheCSFpressureandsymptomshavebeenstabilizedfor12daysandconsidertemporarypercutaneouslumbardrainsorventriculostomyforpersonswhorequirerepeateddailylumbarpuncturesPermanentVPshuntsshouldbeplacedonlyifthepatientisreceivingorhasreceivedappropriateantifungaltherapyandifmoreconservativemeasurestocontrolincreasedintracranialpressurehavefailed.Ifthepatientisreceivinganappropriateantifungalregimen,VPshuntscanbe