Clinical analysis of misdiagnosis in adult central nervous system infections due to Listeria monocytogenes
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摘要:
背景 中枢神经系统单核细胞增生李斯特菌感染(Listeria monocytogenes infection，LMI)常与多种疾病临床表现类似，极易误诊。 目的 结合文献分析我中心成年人中枢神经系统LMI的临床特点和误诊原因，提高诊断率。 方法 回顾性分析2018-2022年我中心收治的成年人中枢神经系统LMI患者，总结患者的误诊情况并分析原因，并通过文献复习，总结国内外成年人中枢神经系统LMI误诊患者临床资料。 结果 我中心共收治7例中枢神经系统LMI患者，均以发热、头痛为主诉就诊，部分患者伴呼吸衰竭和意识障碍。7例均通过病原学检测确诊，但早期均被误诊。其中误诊为上呼吸道感染5例，病毒性脑膜炎3例，结核性脑膜炎4例，误诊时间为(9.4 ± 4.8) d。患者多采用利福平 + 喹诺酮 + 磺胺类药物治疗，5例完全恢复，2例遗留后遗症。文献复习发现目前国内外共47例较完整的误诊患者资料，绝大多数患者通过脑脊液培养确诊。关于误诊疾病的类型，文献中以颅内感染最常见，其次为内科系统疾病和其他类型疾病，误诊中位时间11(1.5 ~ 95) d，给予青霉素等药物治疗后多数患者预后良好。 结论 中枢神经系统LMI临床表现和辅助检查常不典型，临床医生应提高认识，减少或避免误诊。 -
关键词:
- 中枢神经系统感染 /
- 单核细胞增生李斯特菌 /
- 误诊 /
- 颅内感染 /
- 脑脊液培养
Abstract:Background The manifestations of central nervous system Listeria monocytogenes infection (LMI) are often similar to those of various diseases and are easily to be misdiagnosed. Objective To analyze the clinical characteristics and misdiagnosed causes of adult central nervous system LMI in our hospital and reported in literatures, in order to improve the diagnostic accuracy. Methods A retrospective analysis on clinical data about adult patients with central nervous system LMI who were admitted to our hospital from 2018 to 2022 was conducted to summarize the information of misdiagnosed patients and analyze the causes. Clinical profiles of misdiagnosed adult central nervous system LMI patients were summarized by database retrieval. Results A total of 7 patients with central nervous system LMI were admitted to our hospital, all of whom presented with fever and headache as the chief complaint, and some of them suffered from respiratory failure and consciousness disorder. The patients were diagnosed by microbiological tests. All of them were misdiagnosed at the early stage of the disease, of which 5 cases were diagnosed as upper respiratory tract infection, 3 cases as viral meningitis and 4 cases as tuberculous meningitis. The duration of misdiagnosis was (9.4 ± 4.8) d. Patients were mainly treated with rifampicin, quinolone and sulfanilamide. Five patients were recovered completely, two patients had sequelae. Totally 47 cases of misdiagnosed patients were found in literature reports, and most of them were diagnosed by cerebrospinal fluid culture. As for the types of misdiagnosed diseases, intracranial infection was the most common, followed by internal medicine diseases and other types of diseases. The median number of misdiagnosis days was 11(1.5-95) d. Most patients had a good prognosis after treatment with penicillin and other drugs. Conclusion The clinical manifestations and auxiliary examinations of LMI in central nervous system are often atypical. Clinicians should improve the understanding of the disease and reduce or avoid the misdiagnosis. -
表 1 中枢神经系统单核细胞增生李斯特菌感染患者临床资料
Table 1. Clinical data about patients with central nervous system infections due to Listeria monocytogenes
临床特点 患者1 患者2 患者3 患者4 患者5 患者6 患者7 年龄/岁 52 59 68 47 56 31 46 性别 女 男 男 男 女 女 男 既往史 体健 陈旧性肺结核 高血压 高血压，冠心病 多发性肌炎a 系统性红斑狼疮a 高血压 诱发因素 无 不洁饮食 受凉 无 无 无 无 病程/d 8 6 17 3 11 8 8 临床表现 发热，头痛，
恶心，呕吐发热，头痛，
恶心，呕吐发热，头痛，意识
障碍，呼吸衰竭，
精神症状发热，头痛 发热，头痛，
恶心，呕吐发热，头痛，
抽搐，呼吸衰竭发热，头痛，恶心，
呕吐，意识障碍，
精神症状，耳鸣神经系统查体
阳性体征脑膜刺激征 脑膜刺激征 昏迷，肌力下降，
病理征，脑膜刺激征脑膜刺激征 听力下降，肌力下降 失语，凝视，右侧CNⅦ
麻痹，肌力下降，病理征昏迷，眼球震颤，左侧
CNⅢ、Ⅴ、Ⅶ麻痹，
脑膜刺激征最高体温/℃ 40 38 39.5 38.5 40 39 39.5 诊断 Lm脑膜炎 Lm脑膜炎 Lm脑膜脑炎，脑室脓肿 Lm脑膜炎 Lm脑膜炎 Lm脑脓肿 Lm脑膜脑炎，脑室脓肿 误诊疾病 URI，VM，TBM URI，TBM VM，肺部感染 VM URI，TBM URI URI，TBM 外院是否腰穿 是 是 是 否 否 是 否 治疗 QN，RIF，SMX QN，RIF，SMX QN，RIF，SMX QN，RIF，SMX LZD，RIF QN，SMX，LZD LZD，QN，RIF a患者长期服用激素和免疫抑制剂；CN：脑神经；Lm：单核细胞增生李斯特菌；URI：上呼吸道感染；VM：病毒性脑膜炎；TBM：结核性脑膜炎；QN：喹诺酮；RIF：利福平；SMX：复方新诺明；LZD：利奈唑胺。 
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表 2 中枢神经系统单核细胞增生李斯特菌感染患者主要化验结果
Table 2. Main laboratory results of patients with central nervous system infections due to Listeria monocytogenes
实验室检查 患者1 患者2 患者3 患者4 患者5 患者6 患者7 $\bar x \pm s $/Md 白细胞/(L-1，×109) 8.32 26.9 8.14 19.37 10.03 19.5 6.94 14.2 ± 7.7 IL-6/(pg·mL-1) 6.27 521 15.88 344.1 70.65 125.7 20.48 70.65 CRP/(mg·dL-1) 4.35 21.98 2.36 11.14 14.86 17.44 2.87 10.7 ± 7.8 血沉/(mm·h-1) 78 48 45 64 73 10 115 61.9 ± 32.6 降钙素原/(ng·mL-1) 未查 0.049 未查 0.617 1.03 0.394 4.7 0.617 低钠血症 是 否 否 否 否 是 是 - 颅内压/mmH2O ＞330 ＞330 270 ＞330 300 ＞330 240 ＞330 脑脊液白细胞/(L-1，×106) 17 210 310 460 1266 1530 2 010 829 ± 766.5 脑脊液葡萄糖/(mmol·L-1) 0.79 0.5 2.3 1.8 4.4 2.9 1.39 2.0 ± 1.3 脑脊液氯化物/(mmol·L-1) 113 106.6 108.28 99 104.1 110.1 120.7 108.8 ± 6.9 脑脊液蛋白/(g·L-1) 2.38 2.59 2.74 1.72 1.97 1.57 0.72 2.0 ± 0.7 微生物病原学 阳性ab 阳性a 阳性ac 阳性ab 阳性a 阳性abc 阳性a - IL-6：白细胞介素-6；CRP：C-反应蛋白；a脑脊液二代测序；b脑脊液培养；c血培养。
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