摘要目的 分析非AIDS相关隐球菌脑膜炎(隐脑)患者的临床特征及疗效.方法 回顾性分析复旦大学附属华山医院1997年至2007年住院治疗的154例隐脑病例,总结其临床特征,并对不同初始治疗方案的疗效及转归作进一步分析.连续变量采用t检验,离散变量采用卡方检验或Fisher确切概率检验.根据不同治疗方案的疗效,绘制Kaplan-Meier生存曲线,并行log-rank检验.结果 154例患者中51例有一种或一种以上基础疾病,头痛、发热、脑膜刺激征、呕吐和意识障碍为病程中最为常见的临床表现.脑脊液涂片和培养阳性率分别为88.44%和78.95%,而脑脊液隐球菌荚膜多糖抗原检测阳性率高达100%.154例患者中共有12例治疗未满7 d而未纳入疗效评估,其中9例死亡,2例病情恶化自动出院,1例自动出院后失访.对其余142例患者进行疗效评估,两性霉素B组、氟康唑组、两性霉素B联合氟康唑组的有效率分别为78.3%(36/46例)、33.3%(8/24例)和76.0%(38/50例),两性霉素B组、两性霉素B联合氟康唑组的疗效显著优于氟康唑组(X~2=13.6354,12.5509;均P＜0.01).随访1年,有11例失访,余143例患者的归因病死率为19.58%,全因病死率为28.67%,两性霉素B组、两性霉素B联合氟康唑组的1年生存率显著高于氟康唑组.结论 非AIDS相关隐脑的病死率仍较高,且与初始治疗方案的选择密切相关,其中以两性霉素B单用或联合氟胞嘧啶疗效最佳,而采用氟康唑单用或联合氟胞嘧啶初始治疗的疗效较差.

abstractsObjective To study the clinical features and antifungal therapeutic effects in nonacquired immune deficiency syndrome(AIDS)patients with cryptococcal meningitis. Methods One hundred and fifty-four non-AIDS patients with cryptococcal meningitis admitted to Huashan Hospital, Fudan University from 1997 to 2007 were reviewed retrospectively. Clinical characteristics, initial antifungal therapies and outcome of these patients were analyzed. Continuous variables were analyzed using t test and categorical variables were compared by X~2 test or Fisher's exact test. Kaplan-Meier survival curves of different therapies were compared with log-rank test. Results Fifty-one patients (33.12%)had one or more predisposing factors. Headache, fever, meningeal irritation, vomiting and altered mental status were common clinical symptoms and signs during the course of diseases. The positive rates of cerebrospinal fluid(CSF)smear, CSF culture and detection of CSF cryptococcal capsular polysaccharide antigen were 88.44%,78.95%and 100.00%,respectively.Twelve cases were excluded because treatment durations were less than 7 days, including 9 died,2 discharged against medical advice due to illness exacerbation and 1 lost after against medical advice discharge. The remaining 142 patients were evaluated for therapeutic effects. The effective rates in amphotericin B (AmB)group, fluconazole group and AmB plus fluconazole group were 78.3%(36/46),33.3%(8/24)and 76.0%(38/50),respectively. The therapeutic effects in AmB group and AmB plus fluconazole group were superior to fluconazole group(X~2=13.6354,12.5509;P＜0.01).Eleven patients were lost during 1-year follow-up. The attributable and overall mortality in the remaining 143 patients were 19.58% and 28.67%,respectively.The 1-year survival rates in AmB group and AmB plus fluconazole group were significantly higher than that in fluconazole group. Conclusions The mortality of non-AIDS cryptococcal meningitis is still high,which is closely correlated with initial antifungal therapies. AmB alone or combined with flucytosine is related to both higher successful response and higher survival rate, while the efficacy of initial fluconazole alone or combined with flucytosine is poor.