摘要： 目的 分析结核性脑膜炎患者临床表现、早期脑脊液细胞学改变及演变过程，提高对其早期识别能力及诊疗效果的判断。方法 回顾分析60 例结核性脑膜炎患者的临床特征、病原学检查及脑脊液生化尤其是细胞学动态变化资料。结果 60例患者中58例（96.67%）以发热、头痛发病，1周内并发意识障碍者9 例（15.00%），伴抽搐5 例（8.33%）、眼动障碍8 例（13.33%）、偏瘫7 例（11.67%），44 例（73.33%）既往有肺结核病史。实验室检查脑脊液浓缩集菌抗酸染色阳性8 例（13.33%）、结核分枝杆菌培养阳性5 例（8.62%）、脑脊液结核分枝杆菌DNA 阳性5 例（8.77%）。脑脊液改变以颅内压、蛋白定量升高、葡萄糖降低为主；细胞学变化呈现以淋巴细胞增多为主的混合细胞学反应，发病早期脑脊液中性粒细胞比例< 0.40，经抗结核药物治疗后细胞总数及中性粒细胞比例短期内（最长随访2 个月）可无明显改变。经正规抗结核药物治疗，44 例患者好转、11 例迁延不愈并出院或转院、5 例死亡；发病3 周内接受抗结核药物治疗的患者预后明显优于发病3 周后接受治疗者。结论 结核性脑膜炎患者临床表现无特异性，病原学阳性检出率极低，早期诊断困难。肺结核病变对明确诊断具有辅助价值，脑脊液混合细胞学反应可高度提示诊断。经抗结核药物治疗后脑脊液细胞学演变缓慢，可长期呈混合细胞学反应，不能以此为据推翻结核性脑膜炎的诊断。治疗时机很大程度上决定治疗效果。

关键词: 结核, 脑膜, 脑脊髓液, 白细胞计数, 细胞诊断学

Abstract: Objective To analyze the clinical and cerebrospinal fluid (CSF) cytological features of patients with tuberculous meningitis (TBM), to improve early diagnostic accuracy and treatment of TBM. Methods Clinical presentations, etiology and biochemical and cytological features of CSF were analyzed retrospectively among 60 adult cases with TBM hospitalized at Neurology Department of General Hospital of Ningxia Medical University from January 2005 to May 2011. Results Most patients (58/60, 96.67%) had fever and headache at onset. In some patients, disturbance of consciousness (9/60, 15.00%), seizure (5/60, 8.33%) occurred in 1 week and focal neurological signs developed during the course. Forty?four patients (73.33%) had pulmonary tuberculosis history. In CSF examination, acid?fast bacillus positive was found in 8 patients. Positive acid ? fast myobacterium tuberculous culture was detected in 5 patients and positive myobacterium tuberculosis DNA were seen in 5 patients. The main changes of CSF were intracranial hypertension, increase of protein, and decrease of glucose. CSF presented mixed cellular response with predominace in the increasing of leucocytes. During early stage the mean percentage of neutrophil in CSF was less than 40%. After short term (as long as 2 months) of regular antituberculotic therapy no significant changes in total cell count and the proportion of neutrophils were seen. In 60 patients, 44 patients were ameliorated, 11 were not healed or were discharged or transferred to other hospital and 5 were dead. Prognosis of patients treated within 3 weeks after onsets was superiorly to those treated at more than 3 weeks after onset. Conclusion There are no specific clinical features in TBM and it is hard to perform early diagnosis for TBM, particularly, existing of low efficiency in pathogenic detection, but pulmonary tuberculosis is of accessary value to diagnose TBM. Whereas mixed cellular response may complementarily provide the diagnosis of TBM in early stage. Cytologic changes of CSF can be very slow even after therapy. Therefore persistent mixed cellular response in CSF cannot exclude TBM. The time of treatment will determine the therapeutic effectiveness in a great degree.

Key words: Tuberculosis, meningeal, Cerebrospinal fluid, Leukocyte count, Cytodiagnosis