隐球菌性脑膜炎抗真菌治疗.pptx

隐球菌性脑膜炎抗真菌治疗第1页/共46页 Challenge for Cryptococcal MeningitisCryptococcus neoformans is the most common cause of fungal meningitis in HIV and non-HIV-infected patientsFound in 7%-10% patients with AIDSRemain high mortality rate (10%-44%), especially in immunocompromised patients第2页/共46页 Case Study第3页/共46页 Present HistoryA 46-year-old man was admitted to our hospital because of fevers and headache for over 2 monthsLumbar puncture showed a WBC count of 58×106/L with 0.94 monocytes, protein was 176mg/dL, and glucose was 1.5mmol/LFailed for treating with broad spectrum antibiotics including ceftazidime, levofloxacin, etc.His temperature continued to climb up to 39?C, and his headache developed into an intolerable one. He was then transferred to our hospital第4页/共46页 Lab ExaminationsCSF: WBC28×106/L，multinucleated cells 15/28，monocytes 13/28，protein 1169mg/L，glucose1.3mmol/LCSF smear for fungi was negativeCSF culture was positive for Cryptococcus neoformansCSF cryptococcal antigen titres 1:160第5页/共46页 Cranial MRI第6页/共46页 Past History of Hepatitis BIn 2002 he was diagnosed with decompensated hepatitis B cirrhosis, presenting with fatigue, anorexia and bloatingHBVM: HBsAg(+), HBeAg(+), HBcAB(+)HBV DNA was 2.2×107 copies/mL第7页/共46页 Past History of Hepatitis BHe took Lamivudine 100mg/d，and witnessed a reduction of viral load to 3.8×103 copies/mL. 15 months later he developed YMDD mutation and viral load rebounded to 1.0×107copies/mLSince then he had several episodes of jaundice, liver enzyme elevation, ascites and spontaneous bacterial peritonitis. Symptoms were relieved each time after anti-infective and supportive therapyHBV DNA was 6.19×108 copies/mL in July 2005. Adefovir 10mg/d was added to lamivudine第8页/共46页 Liver CT第9页/共46页 How can I initially treat this patient?AmBL-AmBFluconazoleItraconazolePosaconazoleFlucytosine 第10页/共46页 RoadmapClinical studies in the pre-HIV EraClinical studies in the AIDS EraRecent studies for cryptococcal meningitis第11页/共46页 Clinical studies in t