TOXOPLASMIC ENCEPHALITIS IN PATIENTS WITH THE ACQUIRED-IMMUNODEFICIENCY-SYNDROME
TOXOPLASMIC ENCEPHALITIS IN PATIENTS WITH THE ACQUIRED-IMMUNODEFICIENCY-SYNDROME
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DOI：
10.1056/nejm199309303291403
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发表时间：
1993-09-30
影响因子：
158.5
通讯作者：
REMINGTON, JS
中科院分区：
文献类型：
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作者：
LUFT, BJ;HAFNER, R;REMINGTON, JS
背景资料。在获得性免疫缺陷综合征(AIDS)患者中，弓形体脑炎通常是基于临床表现、抗弓形虫抗体滴度阳性和特征性神经放射学异常而被推定的诊断。对特定治疗的反应有助于确认诊断，但尚不清楚这种反应应该有多快。我们研究了急性弓形虫脑炎患者的治疗过程，并评估了这一经验性诊断的客观临床标准。采用可量化的神经学评估方法，前瞻性评价口服克林霉素(600 mg/d，4次/d)和乙胺嘧啶(75 mg/d)治疗6周的艾滋病合并弓形虫脑炎患者的临床疗效。49名患者中有35名(71%)对治疗有反应，其中30名(86%)在第7天有改善。有反应者中有32名(91%)在第14天时至少改善了基线异常的一半。治疗开始后7至14天内神经异常的改善与6周时的神经反应密切相关。治疗失败的四名患者和两名淋巴瘤患者在治疗的前12天内出现了进行性神经异常或新的异常。无论临床结果如何，非局部性异常(头痛和癫痫)均有所改善。口服克林霉素和乙胺嘧啶是治疗弓形体脑炎的有效方法。尽管接受治疗但早期神经功能恶化的患者，或在适当的抗弓形虫治疗10至14天后神经功能没有改善的患者，应考虑接受脑活组织检查。
Background. In patients with the acquired immunodeficiency syndrome (AIDS), toxoplasmic encephalitis is usually a presumptive diagnosis based on the clinical manifestations, a positive antitoxoplasma-antibody titer, and characteristic neuroradiologic abnormalities. A response to specific therapy helps to confirm the diagnosis, but it is unclear how rapid the response should be. We studied the course of patients treated for acute toxoplasmic encephalitis and evaluated objective clinical criteria for this empirical diagnosis.Methods. A quantifiable neurologic assessment was used prospectively to evaluate the clinical outcome of patients with AIDS and toxoplasmic encephalitis who were treated with oral clindamycin (600 mg four times a day) and pyrimethamine (75 mg every day) for six weeks.Results. Thirty-five of 49 patients (71 percent) responded to therapy, and 30 of these (86 percent) had improvement by day 7. Thirty-two of those with a response (91 percent) improved with respect to at least half of their base-line abnormalities by day 14. Improvement in neurologic abnormalities within 7 to 14 days after the start of therapy was strongly associated with the neurologic response at 6 weeks. The four patients in whom treatment failed and the two patients with lymphoma had progressing neurologic abnormalities or new abnormalities during the first 12 days of therapy. Nonlocalizing abnormalities (headache and seizure) improved regardless of the clinical outcome.Conclusions. Oral clindamycin and pyrimethamine are an effective treatment for toxoplasmic encephalitis. Patients who have early neurologic deterioration despite treatment or who do not improve neurologically after 10 to 14 days of appropriate antitoxoplasma therapy should be considered candidates for brain biopsy.