一例儿童患者中可能存在的临床-测压颅内压分离的隐球菌性脑膜脑炎

文献信息

中文摘要

背景： 一名既往健康的12岁女孩，未发现免疫缺陷，因25天头痛、呕吐和严重乏力就诊。脑脊液（CSF）分析证实为格特隐球菌脑膜脑炎。尽管连续腰椎穿刺的颅内压（ICP）读数始终正常（均低于20 cmH2O），患者仍出现提示颅内压升高的临床体征，进展为意识下降，需入住ICU并接受经口气管插管。脑MRI显示交通性脑积水、软脑膜强化以及视神经鞘和颅神经VII、VIII的神经周围对比增强。治疗包括放置腰大池外引流管进行CSF引流，并根据2024年ECMM/ISHAM/ASM非HIV中枢神经系统隐球菌病全球指南，采用脂质体两性霉素B联合氟胞嘧啶进行抗真菌诱导治疗。尽管接受了治疗，患者仍出现不可逆的黑矇和双侧感音神经性听力损失，归因于神经周围软脑膜播散，并经MRI证实。本病例说明了儿童隐球菌性脑膜脑炎中可能存在的临床-测压ICP分离现象——该现象可能反映粘连性蛛网膜炎伴脊髓CSF腔室化，而非真正的ICP升高——并强调了在此情况下超越间歇性测压进行多模式评估的重要性。

英文摘要

A 12-year-old previously healthy girl without an identified immunodeficiency presented with a 25-day history of headache, vomiting, and severe asthenia. Cerebrospinal fluid (CSF) analysis confirmed Cryptococcus gattii meningoencephalitis. Despite consistently normal intracranial pressure (ICP) readings on serial lumbar punctures (all below 20 cm H2O), the patient developed clinical signs suggestive of raised intracranial pressure, progressing to decreased consciousness requiring ICU admission and orotracheal intubation. Brain MRI demonstrated communicating hydrocephalus, leptomeningeal enhancement, and perineural contrast enhancement of the optic nerve sheath and of cranial nerves VII and VIII. Management included an external lumbar subarachnoid drain for CSF drainage and antifungal induction with liposomal Amphotericin B combined with Flucytosine, in accordance with the 2024 ECMM/ISHAM/ASM Global Guideline for non-HIV CNS cryptococcosis. Notwithstanding treatment, the patient developed irreversible amaurosis and bilateral sensorineural hearing loss attributed to perineural leptomeningeal dissemination, confirmed on MRI. This case illustrates a possible clinical-manometric ICP dissociation in pediatric cryptococcal meningoencephalitis-a phenomenon that may reflect adhesive arachnoiditis with spinal CSF compartmentalization rather than true ICP elevation-and underscores the importance of multimodal assessment beyond intermittent manometry in this setting.