Department of Central Clinical Laboratory, Teikyo University Hospital, Tokyo, Japan.
J Infect Chemother. 2012 Dec;18(6):931-6. doi: 10.1007/s10156-012-0382-y. Epub 2012 Apr 5.
A 32-year-old man was admitted to our hospital because of fever, headache, and loss of consciousness. Four days before admission, he had had difficulty speaking. On the day of admission, his colleague had found him to be unconscious and lying on his back. He was admitted to our hospital. The temperature at the eardrum was 35.2°C. Neurologic evaluation was negative. Computed tomography (CT) scan of the brain showed slight ventricular enlargement bilaterally. An X-ray film of the chest showed no abnormality. On the second hospital day, neck stiffness was noted. The cerebrospinal fluid (CSF) contained 870 white cells/μl, most of which were neutrophils; the glucose level in the CSF was 10 mg/dl, and the protein level was 140 mg/dl. Stained smears of the CSF, including Gram staining and India-ink preparations, disclosed no microorganisms. Capsular antigen tests for several bacteria were negative. Antimicrobial agents were started. However, by changing the microscope focus slightly while viewing Gram stains of the CSF, we could see brightened and Gram-positive bacilli that had been phagocytosed by neutrophils. This finding suggested the presence of Mycobacterium tuberculosis. Ziehl-Neelsen staining of the CSF and gastric juice revealed anti-acid bacilli. Polymerase chain reaction for M. tuberculosis in the gastric juice was positive. This case showed that Gram staining could be useful as an initial adjunct for the diagnosis of tuberculous meningitis, particularly when the CSF shows predominantly neutrocytic pleocytosis, but no other evidence of bacterial meningitis.
一位 32 岁男性因发热、头痛和意识丧失而入院。入院前 4 天，他出现言语困难。入院当天，同事发现他昏迷并仰卧。患者体温为 35.2°C。神经评估未见异常。脑 CT 扫描显示双侧脑室轻度扩大。胸部 X 光片未见异常。入院第二天，出现颈项强直。CSF 中含有 870 个白细胞/μl，其中大多数为中性粒细胞；CSF 中的葡萄糖水平为 10mg/dl，蛋白水平为 140mg/dl。CSF 的染色涂片，包括革兰氏染色和印度墨水准备，均未发现微生物。几种细菌的囊膜抗原检测均为阴性。开始使用抗生素。然而，通过在观察 CSF 的革兰氏染色时稍微改变显微镜焦点，我们可以看到被中性粒细胞吞噬的明亮革兰氏阳性杆菌。这一发现提示存在结核分枝杆菌。CSF 和胃液的齐尔-尼尔森染色显示抗酸杆菌。胃液中结核分枝杆菌的聚合酶链反应呈阳性。本病例表明，革兰氏染色可作为结核性脑膜炎诊断的初始辅助手段，特别是当 CSF 显示主要为中性粒细胞增多，但没有其他细菌性脑膜炎的证据时。
