Takahashi Teruyuki, Ogawa Katsuhiko, Sawada Shigemasa, Nakayama Tomohiro, Mizutani Tomohiko
Department of Neurology, Nihon University Nerima-Hikarigaoka Hospital.
Rinsho Shinkeigaku. 2003 Jan-Feb;43(1-2):20-5.
We report a case of refractory tuberculous meningitis which was markedly improved by intrathecal administration of isoniazid (INH). The patient was a 35-year-old woman diagnosed with systemic lupus erythematosus (SLE) at age 25, who was being managed with steroid therapy. She was admitted to another hospital due to miliary tuberculosis at age 34, and after discharge continued with a regimen of 2 anti-tuberculosis drugs (INH. Rifampicin (RFP)). She was admitted to our hospital with severe headache and fever on June 18, 2001. She showed severe meningeal irritation, and cerebrospinal fluid (CSF) examination revealed cell counts of 207/microliter (72% polynuclear cells), protein level of 300 mg/dl, glucose level of 13 mg/dl, chloride (Cl) level of 104 mEq/l, adenosine deaminase (ADA) level of 10.0 IU/l. The CSF culture was negative for Mycobacterium tuberculosis (M. tuberculosis) and direct polymerase chain reaction (PCR) for M. tuberculosis DNA was negative, but nested PCR was positive in preserved CSF samples. Marked leptomeningeal enhancement at the basilar meninges was noted by cranial MRI on gadolinium (Gd)-DTPA enhanced T1-weighted images. We diagnosed her condition as tuberculous meningitis and administered a total of 5 anti-tuberculosis drugs over about 2 months. However, during this period, both her clinical and CSF findings worsened, and she developed severe consciousness disturbance showing marked hydrocephalus on cranial MRI in August 2001. Therefore, we initiated intrathecal administration of INH 100 mg 3 times a week for progressive tuberculous meningitis. After the initiation of intrathecal therapy, both her consciousness disturbance and CSF findings were improved almost immediately. Ventriculo-peritoneal shunt operation was performed for hydrocephalus on September 26, 2001, and her clinical symptoms were further improved. To our knowledge, this is the first reported case of refractory tuberculous meningitis markedly improved by intrathecal administration of INH. Our findings suggested that intrathecal administration of INH was useful for refractory tuberculous meningitis.
我们报告了一例难治性结核性脑膜炎患者，通过鞘内注射异烟肼（INH）病情显著改善。患者为一名35岁女性，25岁时被诊断为系统性红斑狼疮（SLE），一直在接受类固醇治疗。34岁时因粟粒性肺结核入住另一家医院，出院后继续使用两种抗结核药物（INH、利福平（RFP））治疗方案。2001年6月18日，她因严重头痛和发热入住我院。她表现出严重的脑膜刺激征，脑脊液（CSF）检查显示细胞计数为207/微升（72%为多形核细胞），蛋白水平为300毫克/分升，葡萄糖水平为13毫克/分升，氯（Cl）水平为104毫当量/升，腺苷脱氨酶（ADA）水平为10.0国际单位/升。脑脊液培养结核分枝杆菌（M. tuberculosis）阴性，结核分枝杆菌DNA的直接聚合酶链反应（PCR）阴性，但保存的脑脊液样本巢式PCR呈阳性。钆（Gd）-二乙三胺五乙酸（DTPA）增强T1加权像的头颅磁共振成像（MRI）显示基底脑膜有明显的软脑膜强化。我们将她的病情诊断为结核性脑膜炎，并在大约2个月内总共使用了5种抗结核药物。然而，在此期间，她的临床症状和脑脊液检查结果均恶化，2001年8月头颅MRI显示她出现严重意识障碍并伴有明显脑积水。因此，对于进展性结核性脑膜炎，我们开始每周3次鞘内注射100毫克INH。鞘内治疗开始后，她的意识障碍和脑脊液检查结果几乎立即得到改善。2001年9月26日因脑积水进行了脑室-腹腔分流手术，她的临床症状进一步改善。据我们所知，这是首例经鞘内注射INH后显著改善的难治性结核性脑膜炎病例。我们的研究结果表明，鞘内注射INH对难治性结核性脑膜炎有效。
