静脉导管留置及胸腔注射尿激酶治疗结核性胸腔积液影响

探讨中心静脉导管胸腔穿刺留置抽液联合胸腔内注入尿激酶(urokinase,UK)治疗结核性渗出性胸膜炎对胸膜肥厚、粘连的预防作用。方法:将52例收治的结核性渗出性胸膜炎所致大量胸腔积液患者随机分为治疗组(27例)和对照组(25例),对照组给于常规抗结核以及传统单纯胸腔穿刺抽液(每周3次)等治疗;全身结核中毒症状严重者,予口服泼尼松30mg．d-1,每周减量5～10mg,疗程约4～6周。在以上药物治疗同时,治疗组第一次穿刺时使用一次性中心静脉导管代替传统胸穿针穿刺置入并保留于胸腔,抽液后从导管注入尿激酶10～20万U,保留24小时后再次抽液;可以再次或多次使用尿激酶10万u注入胸腔;此后不定时抽液,经B超证实抽尽胸水后拔除导管。结果:治疗组住院时间(12．3±6．6)天,住院费用(2219．5±1171．9)元,治疗后第三个月的胸膜厚度(1．00±0．23)mm,无病例发生胸膜增厚、粘连及包裹性胸腔积液。对照组住院时间(20．4±7．9)天,住院费用(2721．9±1711．7)元,治疗后第三个月胸膜厚度(2．1±0．31)mm,另有3例发生胸膜增厚、粘连,2例形成包裹性胸腔积液。各项指标对比差异有显著性。结论:中心静脉导管胸腔穿刺留置抽液及尿激酶胸腔内保留注射治疗结核性胸腔积液具有简便、安全、创伤少、疗效确切;缩短住院时间,降低住院费用;且能有效预防胸膜肥厚和粘连发生。值得临床推广应用。     

Immunodiagnosis of tuberculous meningitis: rapid detection of mycobacterial antigens in cerebrospinal fluid by reverse passive hemagglutination assay and their characterization by Western blotting

Tuberculous meningitis (TBM) is one of the commonest chronic infections of the central nervous system (CNS). Diagnosis of TBM has been a problem as it causes various clinical manifestations which can be confused with those of other chronic infections of the CNS such as neurocysticercosis (NCC), neurobrucellosis and cryptococcal meningitis, that are prevalent in many underdeveloped and developing countries. Differential diagnosis of TBM can be made by detecting circulating mycobacterial antigens in CSF by immunoassays. In this study, a reverse passive hemagglutination (RPHA) has been developed using rabbit antimycobacterial IgG for detection of circulating mycobacterial antigens in CSFs from chronic infections of the CNS in order to develop a rapid, simple, sensitive and cost-effective method. Circulating mycobacterial antigens were characterized by immunoblot assay. The sensitivity limit of RPHA was 400 ng ml(-1). RPHA was specific as antimycobacterial IgG did not show any reaction with porcine Cysticercus cellulosae which was used as a control antigen. RPHA could detect mycobacterial antigens in CSF at a sensitivity level of 94.11% with a specificity of 99.0%. Immunoblot analysis of RPHA positive CSFs revealed predominantly 30-32 kDa and 71 kDa antigens whilst 6, 86, 120, 96 and 110 kDa showed varied degree of reactivity. Antigens of masses 30-32 and 71 kDa were absent in culture filtrate of Mycobacterium tuberculosis H37Rv grown in Proskeur-Beck liquid medium. RPHA is a rapid, simple and sensitive immunological method with a long shelf life of 6-8 weeks if stabilized coated erythrocytes are stored at +4 degrees C. RPHA could be used as an additional immunodiagnostic tool in both differential diagnosis and prognosis of TBM. Immunoblot results indicate that 30-32 kDa and 71 kDa antigens are cell wall derived.     

Assessment of antibody responses to antigens of Mycobacterium tuberculosis and Cysticercus cellulosae in cerebrospinal fluid of chronic meningitis patients for definitive diagnosis as TBM/NCC by passive hemagglutination and immunoblot assays

Tanned sheep erythrocytes stabilized with pyruvic aldehyde and glutaraldehyde, called double-aldehyde-stabilized cells, were used to standardize passive hemagglutination assay (PHA) for detection of antibody responses to sonicate extract of Mycobacterium tuberculosis and Cysticercus cellulosae soluble antigens. PHA was performed in the following groups of cerebrospinal fluid (CSF) samples: group I - chronic infections of the central nervous system with the possible diagnosis of tuberculous meningitis (TBM), tuberculoma and neurocysticercosis (NCC) (n=88), and group II - controls which included (a) non-infectious non-neurological conditions (n=30), (b) infectious neurological conditions (n=21) and (c) non-infectious neurological conditions (n=133). PHA could detect anti-mycobacterial antibodies at the sensitivity level of 80.76% with a specificity of 92.4% and anti-cysticercal antibodies with a sensitivity of 100% and specificity of 92.94%. However, in 6.33% (i.e. 14/221) of group I and group II (c) CSFs both anti-mycobacterial and anti-cysticercal antibodies were detected. Immunoblot analysis of CSFs derived from TBM patients reacted predominantly to 120-kDa, 96-kDa, 65-kDa, 38-kDa, 26-kDa, 23-kDa, 19-kDa and 12-14-kDa and 4-6-kDa antigens of M. tuberculosis sonicate extract (MTSE), whilst CSFs of proven NCC reacted to >110-kDa, 96-kDa, 80-kDa, 66-68-kDa, 52-kDa and 26-28-kDa antigens of porcine whole cyst sonicate extract (PCSE). On immunoblot analysis, some of the CSFs of TBM patients were PHA positive for both MTSE and PCSE showed antibody reactivity to 70-kDa and 10-kDa antigens of C. cellulosae. Similarly CSF antibody of some Guillain Barre syndrome and myeloradiculopathy patients reacted with cysticercal antigens. But per se no cross-reactivity between MTSE and anti-cysticercal antibodies and vice-versa were observed. However, findings of this study should alert laboratory personnel especially in endemic areas to be extra careful in interpretation of antibody detection results.     

耐药性结核性脑膜炎研究进展

结核性脑膜炎是由结核杆菌引起的中枢感染性疾病,是肺外结核病中最严重的一种,其多侵袭脑膜,有时可累及脑实质、脊髓,有很高的致死率。结核病在发展中国家中的感染趋势尤为突出。我国为人口大国,抗结核治疗和预防的形势异常严峻。随着抗结核药物的广泛使用,耐药性结核性脑膜炎患者数量增加,严重影响了结核性脑膜炎的预后。在耐药性结核性脑膜炎患者的治疗中,早期诊断、经验性治疗、调整治疗方案对患者的预后尤为重要。本文对耐药性结核性脑膜炎的分布、临床诊断、基因检测、治疗方案及预后进行系统性的总结。     

尿激酶胸腔注入治疗结核包囊性胸腔积液

目的寻求治疗结核包囊性胸腔积液的新方法。方法胸膜活检确诊为结核性胸腔积液并经Ｂ超或胸部Ｘ线证实有粘连包囊的病人１５例,经胸腔内注入尿激酶每次１０万单位,用６０ｍｌ生理盐水稀释,每８～１２ｈ重复,连续５次,每次记录抽取胸水总量,并复查Ｂ超观察粘连包囊情况。对照组为单纯用抗结核治疗及间断抽胸水１５例。结果实验组１３例有效,总有效率８６．７％。对照组２例有效,有效率１３．３％,疗效明显优于对照组（Ｐ＜０．０５）。结论尿激酶胸腔内注入是治疗结核性粘连包囊性胸腔积液的一种安全可靠的新方法。     

结核性脑膜脑炎并结核性脊髓炎的2例临床分析

目的：总结结核性脑膜脑炎并结核性脊髓炎的临床特点、治疗方法及预后。方法：对2例结核性脑膜脑炎并结核性脊髓炎患者的临床资料、实验室检查、影像学资料、组织病理学、治疗方法及预后进行分析。结果：2例患者均有头痛、颅神经麻痹、脑膜刺激征、双下肢乏力、感觉障碍;脑脊液中蛋白明显升高;MRI检查显示有脑膜强化、颅内强化灶及相应节段脊髓肿胀;全身抗痨联合鞘内注射异烟肼和地塞米松治疗有效。结论：结核性脑膜脑炎患者如出现脊髓受损表现或脑脊液蛋白明显增高,而腰穿压力正常或降低等应考虑合并结核性脊髓炎的可能性。早期全身抗痨联合鞘内给药疗效确切。     

Implication of glucocorticoid in anti-inflammatory effects of Ro5-4864 in mouse pleurisy induced by carrageenan

Mouse pleurisy induced by carrageenan is used to determine the mechanism of anti-inflammatory action of 7-chloro-5-(4-chlorophenyl)-1,3-dihydro-1-methyl-2-H-1,4-benzodiazepin-2 (Ro5-4864). Pre-treatment with Ro5-4864 inhibits different inflammatory parameters, such as neutrophil influx, MPO activity and NO levels in the early phase (4 h), as well as mononuclear cells and ADA activity in the late phase (48 h) of pleurisy. dl-Aminoglutethimide, inhibitor of steroidal synthesis, reverted the effect of Ro5-4864 on these different inflammatory parameters. Our results suggest that anti-inflammatory action of Ro5-4864 may be partly due to its capacity to inhibit leukocyte migration, as well as leukocyte activation and formation of NO by a mechanism dependent on glucocorticoids.     

Comparison of loop-mediated isothermal amplification and real-time PCR for the diagnosis of tuberculous pleurisy

Aims: Tuberculous pleurisy is an important cause of pleural effusions in areas with a high incidence of tuberculosis. In this study, we developed an IS1081‐based LAMP for the detection of Mycobacterium tuberculosis complex and investigated its usefulness in the diagnosis of tuberculous pleurisy. Methods and Results: Investigation of pleural effusion samples from patients with tuberculous pleurisy, majority of them smear‐/culture‐negative, and control individuals with non‐TB diseases showed that the LAMP assay with incubation time of 60 min has much higher specificity and the LAMP assay with incubation time of 90 min has significantly higher sensitivity in the diagnosis of tuberculous pleurisy, as compared with fluorescent real‐time PCR. Conclusions: The MTBC–LAMP is a useful assay for the diagnosis of tuberculous pleurisy, especially in pleural effusion smear‐/culture‐negative patients. Significance and Impact of the Study: Tuberculous pleural effusion usually contains low number of mycobacteria, which leads to low diagnostic sensitivity of acid‐fast staining and mycobacterial culture methods. In this study, we developed a simple and sensitive LAMP assay for the diagnosis of tuberculous pleurisy. This assay should have broad application in resource‐limited settings.     

Correlates of protective immune response in tuberculous pleuritis

Tuberculous pleuritis (TB) provides a good model to study the correlates of protective immune response at the site of infection. To study the in vivo correlates of immunity, cell subset profile and cytokine assay in plasma (BL) and pleural fluid (PF) of 82 patients were done. Lymphocyte proliferation and cytokine response to mycobacterial antigens were measured in 32 subjects to understand the in vitro correlates. Increase in CD4(+) cells and CD4(+)/CD8(+) ratio with selective concentration of interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha and interleukin (IL)-12 in PF suggests that the CD4(+) population may be of TH1 type. We observed an accelerated lymphoproliferative response to purified protein derivative (PPD) and heat killed Mycobacterium tuberculosis (MTB) in PF cells of both TB and non-TB (NTB) subjects. Interestingly, in in vitro studies, IL-4 levels together with IFN-gamma were significantly increased in the supernatants of PF mononuclear cells (PFMC) of TB patients and showed a shift in immune response towards TH0/TH2 type. PPD and MTB antigens induced an enhanced proliferation of PFMC and also increased in vitro IL-4 response together with apoptosis, thus eliciting a dual response.