| Objective:To analyze the causes of misdiagnosis and missed diagnosis in patient with tuberculous meningitis for early clinical diagnosis and treatment.Methods:Retrospective analysis from February 1,2013 to December 31,2017 in the hospital affiliated hospital of zunyi medical college for misdiagnosis and missed diagnosis of tuberculous meningitis in 122 cases of patients with the causes of missed diagnosis and misdiagnosis and clinical data which included clinical manifestations,physical signs,laboratory and auxiliary examinations,diagnosis and treatment and so on.Results:The general situation:A total of 122 cases of tuberculous meningitis were misdiagnosed and missed,73 cases were male,49 were female.Their ages ranged from 15 to 82 years,and the average age was 50 years old(the median).There were 54 cases of acute onset of disease(accounting for 44.26%),49 cases of subacute onset(accounting for 40.16%)and 19 cases of chronic onset(accounting for 15.57%).The hospital stay ranged from 4 to 84 days,and the average time was 27.44 days(the median).The onset time ranged from 10 hours to 365 days,and the average time was 10 days(the median).Among the 122 cases,simple tuberculous meningitis accounted for 12.30%(15/122),extracranial tuberculosis accounted for 87.7%(107/122),tuberculosis accounted for 86.07%(105/122),among which hematogenous disseminated pulmonary tuberculosis accounted for 37.14%(39/105).Major clinical manifestations:Symptoms were most common with fever(accounting for 85.25%),nausea and vomiting(accounting for 72.95%)and headache(accounting for 71.31%).Positive signs of nervous system were meningeal irritation(44/122),abnormal muscle or muscle tone(22/122)and abnormal tendon reflex(10/122)and paresthesia(numbness or abnormal deep feeling or shallow feeling,10/122).Cerebrospinal fluid assay was performed in 120 of the 122 patients.They all had abnormal changes,among which 77 cases increased intracranial pressure(accounting for 64.17%),99 cases increased leukocyte(accounting for 82.5%),the protein content in 115 cases increased(accounting for 95.83%),the glucose in 78 cases were reduced(accounting for 65%),the chloride in 87 cases were reduced(accounting for 72.5%),the level of ADA in 21 cases increased(accounting for 17.5%),the level of LDH in 70 cases increased(accounting for 58.33%).All of the 120 patients had cerebrospinal fluid acid-resistant smear,and the results were negative.The cerebrospinal fluid of 31 patients was cultured with mycobacterium tuberculosis,and 5 cases were positive(accounting for 16.13%).The cerebrospinal fluid of 5 patients was examined by GeneXpert MTB/RIF,and one case was positive.Examination of the pathogen of sputum:The sputum of 67 patients was smeared with acid-proof bacillus,of which 12 cases were positive(accounting for 17.91%).The sputum of 23 patients was cultured with mycobacterium tuberculosis,of which 8 cases were positive(accounting for 34.78%).The sputum of 4 patients was examined by GeneXpert MTB/RIF,and one case was positive.The sputum of 3 patients was examined by loop-mediated isothermal amplification(LAMP),and the results were all positive.Interferon-? release assay(IGRA):A total of 49 patients in this study were examined by enzyme-linked immunsorbent assay(ELISA),of which 40 cases were positive(accounting for 81.63%).31 patients were examined by enzyme link spot(ELISPOT),of which 28 were positive(accounting for 90.32%).Iconography:Among the 122 cases,105 were combined with tuberculosis.36 cases underwent chest X-ray examination,27 cases of which were abnormal(accounting for 75%).103 cases underwent chest CT examination,of which their results were all abnormal(accounting for 100%).The head CT examination was performed in 93 patients(including the outer court),and 61 cases were abnormal(accounting for 65.59%).101 cases underwent MRI examination,and 88 cases were abnormal(accounting for 87.13%).Misdiagnosis and missed diagnosis: 943 patients with tuberculous meningitis were discharged during the same Period(including the dead),of which 79 were misdiagnosed and the misdiagnosis rate was 8.38%(79/943).The time of misdiagnosis ranged from 1 day to 391 days,and the average time was 9 days(the median).The most common misdiagnosed disease was viral meningitis or encephalitis,and other diseases included intracranial infection,cerebral infarction,hydrocephalus,infectious headache,etc.43 patients were missed and the rate of missed diagnosis was 4.56%(43/943).The missed time ranged from 5 days to 245 days,and the average time was 16 days(the median).Treatment:The number of patients with initial treatment was 116 and 6 cases were retreated with pulmonary tuberculosis in 122 cases.Individualized anti-tb drug therapy was performed based on the patient's height,weight,age,tolerance level and the combination of the underlying disease.All of them were treated with isoniazid,rifampicin,pyrazinamide and ethambutol,adding streptomycin or levofloxacin,injecting isoniazid and dexamethasone by intrathecal.If there were no contraindications for the use of hormones,all patients were treated with glucocorticoid,in order to reduce the symptoms of TB poisoning,relieve the leakage of the meninges and prevent the adhesion of the meninges.At the same time,all patients were treated with dehydration treatment,nutritional support and so on.After active treatment,69 cases showed significant effect,42 cases were effective,8 cases were invalid and 3 patients died.The effective rate was 90.98%.Adverse reactions were most common in blood uric acid elevation(accounting for 36.07%)and liver damage(accounting for 35.25%).Conclusion:It is easy for misdiagnosis and missed diagnosis of tuberculous meningitis,early.There are five main reasons:1.Clinical symptoms and signs are often atypical and lack specificity.2.Manifestations of cerebrospinal fluid and head imaging are atypical.3.It is difficult to find the etiology.4.There are many complications and complex states of an illness.5.Clinicians lack a high level of diagnostic awareness. |
PDF Full Text Request