Elazary R, Kalish Y
Medical Dept., Hadassah University Hospital, Ein Karem, Jerusalem.
Harefuah. 2001 Feb;140(2):115-7, 191, 190.
The increase in prevalence of tuberculous meningitis during the past decade has been attributed in part to the increase of AIDS. Failure to diagnose HIV can cause irreversible damage and even death. We describe a man with AIDS admitted through the emergency room because of high fever and headaches for more than a month, He was cachectic and had nuchal rigidity without major neurological deficit. Brain imaging was normal and lumbar puncture showed neutrophils, lymphocytes, hypochloremia, elevated protein, and decreased glucose; cryptococcal antigen was negative but acid-fast staining was positive. Anti-TB chemotherapy was started using 4 drugs and dexamethasone was also given. Considerable improvement in his general condition followed rapidly. Use of corticosteroids in tuberculous meningitis has been a major issue. They are added to antimicrobial agents in order to decrease reactivity of inflammatory mediators and thus reduce central nervous system damage. We review several controlled studies in which steroids were added to treat tuberculous meningitis. The conclusions of most were that they decrease morbidity and mortality, especially of those moderately to severely ill. Most considered as ungrounded the possibility of exacerbating latent tuberculous, or any other opportunistic infection outside the central nervous system. However, it is currently recommended to add prednisone, 1 mg/kg/d for 2-4 weeks when initiating anti-tuberculous treatment.
在过去十年中，结核性脑膜炎患病率的上升部分归因于艾滋病的增加。未能诊断出艾滋病毒会导致不可逆转的损害甚至死亡。我们描述了一名因持续一个多月的高热和头痛通过急诊室收治的艾滋病患者。他消瘦，有颈部强直，但无明显神经功能缺损。脑部影像学检查正常，腰椎穿刺显示有中性粒细胞、淋巴细胞，低氯血症，蛋白升高，葡萄糖降低；隐球菌抗原阴性，但抗酸染色阳性。开始使用4种药物进行抗结核化疗，并给予地塞米松。随后他的一般状况迅速有了显著改善。在结核性脑膜炎中使用皮质类固醇一直是一个主要问题。将它们添加到抗菌药物中是为了降低炎症介质的反应性，从而减少中枢神经系统损伤。我们回顾了几项在治疗结核性脑膜炎时添加类固醇的对照研究。大多数研究的结论是，它们可降低发病率和死亡率，尤其是对中度至重度患者。大多数人认为，加重潜在结核病或中枢神经系统以外的任何其他机会性感染的可能性没有依据。然而，目前建议在开始抗结核治疗时添加泼尼松，剂量为1mg/kg/天，持续2 - 4周。
