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中华实验和临床感染病杂志(电子版)

中华实验和临床感染病杂志(电子版) ›› 2020, Vol. 14 ›› Issue (04) : 331 -335. doi: 10.3877/cma.j.issn.1674-1358.2020.04.012

所属专题： 经典病例； 经典病例； 文献；

短篇论著

以听力下降为主要表现的7例神经型布鲁氏菌病患者的临床特点
房高丽1, 葛子若2, 钱芳2, 侯静1, 张立松1, 马爱民1, 孙挥宇1, 陈志海2,†()   
  1. 1. 100015　北京，首都医科大学附属北京地坛医院耳鼻喉科
    2. 首都医科大学附属北京地坛医院感染性疾病诊疗中心、新发突发传染病研究北京市重点实验室、感染病科国家临床重点专科
  • 收稿日期:2019-08-05 出版日期:2020-08-15
  • 通信作者: 陈志海
  • 基金资助:
    国家科技重大专项(No. 2018ZX09711003)

Clinical features of 7 cases of hearing loss associated with neurobrucellosis

Gaoli Fang1, Ziruo Ge2, Fang Qian2, Jing Hou1, Lisong Zhang1, Aimin Ma1, Huiyu Sun1, Zhihai Chen2,†()   

  1. 1. Departments of Otolaryngology, the National Clinical Key Department of Infectious Diseases, Beijing Key Laboratory Emerging Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
    2. Department of Infectious Diseases, the National Clinical Key Department of Infectious Diseases, Beijing Key Laboratory Emerging Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
  • Received:2019-08-05 Published:2020-08-15
  • Corresponding author: Zhihai Chen
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房高丽, 葛子若, 钱芳, 侯静, 张立松, 马爱民, 孙挥宇, 陈志海. 以听力下降为主要表现的7例神经型布鲁氏菌病患者的临床特点[J]. 中华实验和临床感染病杂志(电子版), 2020, 14(04): 331-335.

Gaoli Fang, Ziruo Ge, Fang Qian, Jing Hou, Lisong Zhang, Aimin Ma, Huiyu Sun, Zhihai Chen. Clinical features of 7 cases of hearing loss associated with neurobrucellosis[J]. Chinese Journal of Experimental and Clinical Infectious Diseases(Electronic Edition), 2020, 14(04): 331-335.

目的

探讨以听力下降为主要表现的神经型布鲁氏菌病患者的临床特点及转归。

方法

选取2008年10月至2019年9月于首都医科大学附属北京地坛医院住院的7例神经型布鲁氏菌病合并听力下降的患者作为研究对象，收集其流行病学史、临床表现、病原学特异性检查、脑脊液分析、耳部查体、纯音测听、影像学表现等资料，并结合国内外文献进行分析和讨论。

结果

7例患者中，男性5例、女性2例，年龄22～70岁，平均39.29岁。7例患者均有明确的流行病学接触史，早期表现出布鲁氏菌病的典型症状：发热、多汗、肌肉和关节疼痛、乏力、头痛等。听力下降表现为感音神经性聋，出现在发病早期2例、治疗过程中3例、停药后2例。单侧发病者2例，双侧发病者5例。突发性聋者2例，渐进性听力下降5例。听力下降病程小于3个月者4例，听力改善者4例；长于3个月者3例，听力改善者0例。轻、中度患者5例，重度、极重度患者2例。腰椎穿刺检查提示入组患者颅内压轻度升高（平均为197 mmH2O），脑脊液中白细胞升高（平均为104个/μl），且以单核细胞为主（90.7%），脑脊液蛋白206.1 mg/dl，脑脊液糖1.95 mmol/L，脑脊液氯化物118.7 mmol/L。

结论

神经型布鲁氏菌病合并听力损害并不少见，相较于其他典型症状缺乏特异性，极易误诊及漏诊。早发现、早诊断、早期治疗能有效降低相关后遗症。

关键词: 神经型布鲁氏菌病, 听力下降, 听神经炎, 颅内压升高
Objective

To investigate the clinical characteristics and outcome of neurobrucellosis patients with hearing loss as the major clinical manifestation.

Methods

From October 2008 to September 2019, 7 cases of neurobrucellosis with hearing loss in Beijing Ditan hospital, Capital Medical University were selected, and their clinical data including epidemiological history, clinical manifestations, etiological specificity, cerebrospinal fluid analysis, ear examination, pure tone audiometry, imaging findings were analyzed, respectively. Analysis and discussion were performed based on domestic and foreign literature.

Results

Among the 7 neurobrucellosis patients with hearing loss, 5 were male and 2 were female, aged 22-70 years old, with the average age as 39.29 years old. All of the 7 patients had definite epidemiological history, early presentation of typical symptoms of brucellosis: fever, hyperhidrosis, muscle and joint pain, fatigue and headache, etc. Hearing loss was manifested as sensorineural deafness, 2 cases in the early stage, 3 cases in the course of treatment and 2 cases after drug withdrawal. There were 2 cases with unilateral hearing loss and 5 cases with binaural diseases. There were 2 cases with sudden deafness and 5 cases with progressive hearing loss. There were 4 cases with the course of hearing loss < 3 months, whose hearing capabilities were all improved after treatment; there were 3 cases with the course of hearing loss > 3 months but no case occured hearing improvement after treatment. There were 5 cases with mild and moderate deafness, 2 cases with severe and extremely severe deafness. Lumbar puncture showed a slight increase in intracranial pressure, with an average of 197 mmH2O, elevated white blood cells in cerebrospinal fluid, with an average of 104 cells/μl [monocytes dominated (90.7%)], cerebrospinal fluid protein as 206.1 mg/dl, cerebrospinal fluid sugar as 1.95 mmol/L, cerebrospinal fluid chloride as 118.7 mmol/L.

Conclusions

Hearing loss associated with neurobrucellosis was not rare. Because of its relatively lack of specific clinical manifestations, it was easy to misdiagnose and missed diagnosis. Early detection, diagnosis and treatment could decrease sequelae.

Key words: Neurobrucellosis, Hearing loss, Acoustic neuritis, Intracranial pressure
表1 7例布鲁氏菌病患者的临床资料
病例编号 性别 年龄 流行病学接触史 主要症状 布鲁氏菌相关检查 药物治疗
1 女 70 牛羊养殖 发热、腰痛、出汗3年，加重伴左耳听力下降2周 （血）RBT（+） 多西环素+利福平+左氧氟沙星+头孢噻肟舒巴坦钠
2 男 29 牛羊屠宰 发热、听力下降、腰痛、视物模糊、下肢关节痛，排便排尿障碍3个月 （血）RBT（+） 头孢曲松+利福平+莫西沙星；2周后改为复方新诺明+利福平+多西环素
3 男 28 牛羊屠宰 发热、头痛、排尿困难、双耳听力下降1年半 （血）SAT 1︰25（4+），（血）RBT （+） 多西环素+利福平+左氧氟沙星+复方新诺明+头孢曲松
4 男 35 牛羊养殖 双下肢无力、腰痛、发热8年，2年前左耳突聋 （CSF）基因检测布鲁氏菌（+）；（血）RBT（-） 多西环素+利福平+左氧氟沙星+头孢曲松，奥拉西坦营养神经治疗
5 男 22 牛羊运输 发热、关节痛、头痛、癫痫2年，双耳听力下降2个月 （血、CSF）RBT（+） 多西环素+利福平+左氧氟沙星+头孢曲松+复方新诺明，腺苷钴胺营养神经
6 男 38 牛羊养殖 发热、头痛、双下肢无力伴疼痛2年半、双耳听力下降2年 （血、CSF）RBT （+），（CSF）SAT 1︰100，（CSF）布鲁氏菌IgG抗体（+） 美他环素+利福平+左氧氟沙星，腺苷钴胺营养神经，曾应用强的松6周
7 女 53 牛羊肉贩卖 乏力、出汗、关节痛，头痛8个月，复视、听力下降1月 （CSF）布鲁氏菌高通量测序（+），（血）RBT（+） 头孢曲松+利福平+多西环素+复方新诺明
表2 7例神经型布鲁氏菌病患者合并听力下降的临床表现、影像学检查和疗效
病例编号 听力下降病程（月） 听力损失类型 治疗前PTA（dB） 治疗后PTA（dB） 影像学检查 疗效评价
1 0.5 左耳SNHL（中度） L：50
R：20		 L：30
R：20		 MRI：脑白质脱髓鞘改变 有效
2 3 双耳SNHL（中度） L：55
R：60		 L：35
R：40		 MRI：脑桥、延髓、马尾等部位异常强化，双侧额叶脑软化灶 有效
3 18 双耳SNHL（中度） L：45
R：43		 L：28
R：30		 MRI：脑白质脱髓鞘改变 无效
4 24 左耳全聋 L：90
R：25		 L：85
R：25		 MRI：脑白质脱髓鞘改变 无效
5 2 双耳SNHL（中度） L：50
R：52		 L：33
R：30		 MRI：幕上脑室轻度扩大 有效
6 24 双耳全聋 L：90
R：90		 L：88
R：90		 MRI：小脑软脑膜强化 无效
7 1 双耳SNHL（中度） L：48
R：53		 L：25
R：30		 MRI：未见异常 有效
表3 7例患者的脑脊液指标
病例编号 腰椎穿刺压力（80～180 mmH2O） CSF白细胞数（个/μl） CSF单核细胞（%） CSF多核细胞（%） CSF蛋白（8～43 mg/dl） CSF糖（2.5～4.5 mmol/L） CSF氯化物（120～132 mmol/L）
1 180 35 90 10 43.0 3.87 125.4
2 250 213 95 5 290.4 2.20 110.5
3 190 26 70 30 27.1 2.55 129.1
4 180 123 97 3 317.0 0.70 117.0
5 160 129 90 10 283.4 1.54 116.5
6 250 190 93 7 267.2 1.88 115.6
7 170 10 100 0 214.3 0.89 117.1
图1 病例5治疗过程中脑脊液指标
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