結核性腦膜炎/心包炎患者能使用激素嗎？—— 1例14歲患者的循證治療_《中國循證醫學雜志》

作者：

譚建龍 , 王雙 , 廖再波

四川大學華西醫院老年病科（成都 610041）;

關鍵詞：

結核性腦膜炎結核性心包炎肺結核糖皮質激素循證治療

DOI：

10.7507/1672-2531.20080242

視頻：

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目的　肺及肺外結核患者是否能使用激素是目前頗有爭議的臨床問題，結合1 例肺結核合并結核性心包炎和結核性腦膜炎患者的病情，用循證臨床實踐的方法，就是否使用激素進行床旁循證治療。
方法　計算機檢索Cochrane圖書館、OVID、MEDLINE、www.guideline.org，查找和評價高質量臨床證據，并根據患者意愿為患者制定治療方案。
結果　共納入11 個RCT，2 個Cochrane 系統評價，9 個指南。證據表明：① 糖皮質激素能降低結核性腦膜炎患者的死亡風險，也能降低神經系統功能缺損的風險；② 潑尼松龍使結核性心包炎患者總體死亡率降低（P=0.044），同時使心包炎所致的死亡風險也顯著降低（P=0.004）；③ 激素能否使肺結核患者獲益仍有爭議。結合患者病情和意愿，在抗癆治療的基礎上加用地塞米松等治療7 周后，患者腦脊液基本恢復正常，心包積液消失。
結論　對于結核性腦膜炎和結核性心包炎患者應常規使用糖皮質激素治療，但如何選擇糖皮質激素類藥物以及治療療程仍未達成一致。

引用本文： 譚建龍,王雙,廖再波. 結核性腦膜炎/心包炎患者能使用激素嗎？—— 1例14歲患者的循證治療. 中國循證醫學雜志, 2008, 08(12): 1122-1125. doi: 10.7507/1672-2531.20080242 復制

1.	Kumarvelu S, Prasad K, Khosla A, et al. Randomized controlled trial of dexamethasone in tuberculous meningitis. Tuber Lung Dis, 1994, 75(3): 203-207.
2.	Toppet M, Malfroot A, Derde MP, et al. Corticosteroids in primary tuberculosis with bronchial obstruction. Arch Dis Child, 1990, 65(11): 1222-1226.
3.	Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology, 1997, 2(4): 275-281.
4.	Anonymous. Study of chemotherapy regimens of 5 and 7 months’ duration and the role of corticosteroids in the treatment of sputumpositive patients with pulmonary tuberculosis in South India. Tubercle, 1983, 64(2): 73-91.
5.	Bilaceroglu S, Perim K, Buyuksirin M, et al. Prednisolone: a beneficial and safe adjunct to antituberculosis treatment? A random-ized controlled trial. Int J Tuberc Lung Dis, 1999, 3(1): 47-54.
6.	Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet, 1987, 2(8573): 1418-1422.
7.	Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet, 1988, 2(8614): 759-764.
8.	Mayosi BM, Ntsekhe M, Volmink JA, et al. Interventions for treating tuberculous pericarditis. Cochrane Database of Systematic Reviews 2002, Issue 4.
9.	Hakim J, Ternouth I, Mushangi E, et al. A. Double blind randomised placebo controlled trial of adjuvant prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. Heart, 2000, 84: 183-188.
10.	Strang JI, Nunn AJ, Johnson DA, et al. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up. QJM, 2004 , 97(8): 525-535.
11.	Girgis NI, Farid Z, Kilpatrick ME, et al. Dexamethasone adjunctive treatment for tuberculous meningitis. Pediatr Infect Dis J, 1991, 10(3): 179-183.
12.	Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med, 2004, 351(17): 1741-1751.
13.	O’Toole RD, Thornton GF, Mukherjee MK, et al. Dexamethasone in tuberculous meningitis. Relationship of cerebrospinal fluid effects to therapeutic efficacy. Ann Intern Med, 1969, 70(1): 39-47.
14.	Schoeman JF, Van Zyl LE, Laubscher JA, et al. Effect of corticosteroids on intracranial pressure, computed tomographic findings, and clinical outcome in young children with tuberculous meningitis. Pediatrics, 1997, 99(2): 226-231.
15.	Kumarvelu 1994 [published and unpublished data] Kumarvelu S, Prasad K, KhoslaA, et al. Randomized controlled trial of dexamethasone in tuberculous meningitis. Tuber Lung Dis, 1994, 75(3): 203-207.
16.	Prasad K, SinghMB. Corticosteroids for managing tuberculous meningitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art.
17.	Centers for Disease Control and Prevention. Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003; 52 (No. RR-11): [inclusive page numbers].
18.	National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London (UK): Royal College of Physicians; 2006. 215.

1. Kumarvelu S, Prasad K, Khosla A, et al. Randomized controlled trial of dexamethasone in tuberculous meningitis. Tuber Lung Dis, 1994, 75(3): 203-207.
2. Toppet M, Malfroot A, Derde MP, et al. Corticosteroids in primary tuberculosis with bronchial obstruction. Arch Dis Child, 1990, 65(11): 1222-1226.
3. Park IW, Choi BW, Hue SH. Prospective study of corticosteroid as an adjunct in the treatment of endobronchial tuberculosis in adults. Respirology, 1997, 2(4): 275-281.
4. Anonymous. Study of chemotherapy regimens of 5 and 7 months’ duration and the role of corticosteroids in the treatment of sputumpositive patients with pulmonary tuberculosis in South India. Tubercle, 1983, 64(2): 73-91.
5. Bilaceroglu S, Perim K, Buyuksirin M, et al. Prednisolone: a beneficial and safe adjunct to antituberculosis treatment? A random-ized controlled trial. Int J Tuberc Lung Dis, 1999, 3(1): 47-54.
6. Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled trial of prednisolone as adjuvant in treatment of tuberculous constrictive pericarditis in Transkei. Lancet, 1987, 2(8573): 1418-1422.
7. Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial effusion in Transkei. Lancet, 1988, 2(8614): 759-764.
8. Mayosi BM, Ntsekhe M, Volmink JA, et al. Interventions for treating tuberculous pericarditis. Cochrane Database of Systematic Reviews 2002, Issue 4.
9. Hakim J, Ternouth I, Mushangi E, et al. A. Double blind randomised placebo controlled trial of adjuvant prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. Heart, 2000, 84: 183-188.
10. Strang JI, Nunn AJ, Johnson DA, et al. Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up. QJM, 2004 , 97(8): 525-535.
11. Girgis NI, Farid Z, Kilpatrick ME, et al. Dexamethasone adjunctive treatment for tuberculous meningitis. Pediatr Infect Dis J, 1991, 10(3): 179-183.
12. Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med, 2004, 351(17): 1741-1751.
13. O’Toole RD, Thornton GF, Mukherjee MK, et al. Dexamethasone in tuberculous meningitis. Relationship of cerebrospinal fluid effects to therapeutic efficacy. Ann Intern Med, 1969, 70(1): 39-47.
14. Schoeman JF, Van Zyl LE, Laubscher JA, et al. Effect of corticosteroids on intracranial pressure, computed tomographic findings, and clinical outcome in young children with tuberculous meningitis. Pediatrics, 1997, 99(2): 226-231.
15. Kumarvelu 1994 [published and unpublished data] Kumarvelu S, Prasad K, KhoslaA, et al. Randomized controlled trial of dexamethasone in tuberculous meningitis. Tuber Lung Dis, 1994, 75(3): 203-207.
16. Prasad K, SinghMB. Corticosteroids for managing tuberculous meningitis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art.
17. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003; 52 (No. RR-11): [inclusive page numbers].
18. National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London (UK): Royal College of Physicians; 2006. 215.

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結核性腦膜炎/心包炎患者能使用激素嗎？—— 1例14歲患者的循證治療

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結核性腦膜炎/心包炎患者能使用激素嗎？—— 1例14歲患者的循證治療

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