艾滋病合并进行性多灶性脑白质病的MRI表现

doi:10.19871/j.cnki.xfcrbzz.2023.02.005

摘要/Abstract

摘要： 目的探讨艾滋病合并进行性多灶性脑白质病（PML）的MRI特征,以期提升对其诊断及鉴别诊断的水平。方法回顾分析2015年5月至2022年3月在首都医科大学附属北京佑安医院经病理证实或临床确诊的27例艾滋病合并PML患者资料,总结分析其MRI表现。结果艾滋病合并PML患者共27例,均为男性,平均年龄（38±9）岁。27例患者MRI表现为皮质下多发病灶,其中26例（96.3%）为不对称分布,累及脑皮质者1例（3.7%）。幕上病灶23例（85.19%）、幕下病灶14例（51.85%）、同时受累10例（37.04%）。幕上病灶主要位于顶叶18例（66.67%）、额叶17例（62.96%）、颞叶12例（44.44%）、枕叶6例（22.22%）、胼胝体压部3例（11.11%）,幕上受累病例均为多叶受累。幕下病灶,小脑受累8例（29.63%）、脑桥4例（14.81%）、延髓3例（11.11%）和桥臂2例（7.41%）。T₂WI上显示为“银河征”或“扇贝征”18例（66.67%）,DWI上病灶边缘高信号17例（62.96％）;27例均无占位效应;脑萎缩2例（7.41%）;MRI增强扫描19例,仅1例（5.26%）强化,呈点状、线样强化。结论艾滋病合并PML以双侧额叶、顶叶、枕叶皮质下多发及不对称的脱髓鞘病变多见,特征性的表现为T₂WI上“银河征”,病变的分布范围与脑血管的分布区不一致,DWI上病灶边缘为高信号,无占位效应,增强多无强化。因此,MRI检查结合患者临床病史、体征及实验室检查,可显著提升其诊断的正确率。

关键词: 获得性免疫缺陷综合征, 进行性多灶性白质脑病, 磁共振成像, 诊断, 鉴别诊断

Abstract: Objective To improve diagnosis level based on MRI features of progressive multifocal leukoencephalopathy (PML) in AIDS patients. Method Retrospective analysis of 27 AIDS patients with PML confirmed by pathology or clinical diagnosis in Beijing You'an Hospital, Capital Medical University from May 2015 to March 2022. We analyzed MRI features of PML in AIDS patients to explore the characteristic features. Result All of 27 patients of PML in AIDS patients in our study were male with average age of (38 ± 9) years. All of 27 patients of PML in AIDS patients in our study equipped multiple lesions in subcortical. 26 (96.3%) lesions of PML in AIDS patients were asymmetrically distributed, and 1 (3.7%) involved cerebral cortex. There were 23 (85.19%) cases of supratentorial lesions, 14 (51.85%) cases of infratentorial lesions, and 10 (37.04%) cases of supratentorial and infratentorial lesions. Among patients with supratentorial lesions, many brain areas were involved, including 18 (66.67%) in the parietal lobe, 17 (62.96%) in the frontal lobe, 12 (44.44%) in the temporal lobe, 6 (22.22%) in the occipital lobe, 3 (11.11%) cases in splenium of corpus callosum. The cases with supratentorial lesions were multilobed. Regarding patients with infratentorial lesions, 8 (29.63%) cases were involved in the cerebellum, 4 cases (14.81%) in the pons, 3 cases (11.11%) in the medulla oblongata, 2 (7.41%) cases in the pontine arm. All patients equipped multiple lesions [27 cases (100%)] which were asymmetrically located in subcortical [26 cases (96.3%)]. 18 cases (66.67%) showed “Milky way sign” on T₂WI. 17 cases (62.96%) showed high signal at the edge of the lesion on DWI. 27 cases were no space occupying effect, and brain atrophy in 2 cases (7.41%). 19 cases had MRI enhancement scan, only 1 case (5.26%) was enhanced, showing punctate and linear enhancement. Conclusion PML in AIDS patients mainly presented multiple and asymmetric demyelinating lesions under the bilateral frontal parietal occipital cortex. “Milky way sign” on T₂WI was a characteristic feature of PML in AIDS patients. The distribution range of lesions was inconsistent with the distribution area of cerebral vessels. The edge of lesions on DWI can show high signal. But there was not obvious diffusion limitation, and space occupying effect of lesions, and enhanced signal in enhancement phases. MRI examination combines with the clinical history, physical sign and laboratory examination of patients, it can obviously improve the diagnostic accuracy.

Key words: Acquired immunodeficiency syndrome, Progressive multifocal leukoencephalopathy, Magnetic resonance imaging, Diagnosis, Differential diagnosis

中图分类号:

R512.91

任美吉, 李莉, 赵晶, 齐石, 李宏军. 艾滋病合并进行性多灶性脑白质病的MRI表现[J]. 新发传染病电子杂志, 2023, 8(2): 23-27.

Ren Meiji, Li Li, Zhao Jing, Qi Shi, Li Hongjun. MRI features of AIDS complicated with progressive multifocal leukoencephalopathy[J]. Electronic Journal of Emerging Infectious Diseases, 2023, 8(2): 23-27.

参考文献

[1] 石秀东, 黄诗雯, 施裕新. 磁共振诊断HIV相关进行性多灶性脑白质病的研究进展[J]. 中国临床医学, 2017, 24(1): 141-144.
[2] 李嘉姝, 聂莹雪. 艾滋病所致的进行性多灶性白质脑病研究进展[J/CD].中华临床医师杂志(电子版), 2012, 6(22): 7352-7354.
[3] CINQUE P, KORALNIK IJ, GEREVINI S, et al.Progressive multifocal leukoencephalopathy in HIV-1 infection[J]. Lancet Infect Dis, 2009, 9(10): 625-636.
[4] 黄华, 陆普选. 艾滋病合并进行性多灶性脑白质病的影像学表现及鉴别诊断[J]. 中国医学影像技术, 2009, 25(7): 1316-1318.
[5] 刘正琴, 徐大飞, 殷剑, 等. 艾滋病伴发进行性多灶性白质脑病1例报道并文献复习[J]. 中国神经免疫学和神经病学杂志, 2011, 8(4): 261-263.
[6] NETRAVATHI M, MAHADEVAN A, SATISHCHANDRA P, et al.Progressive multifocal leukoencephalopathy (PML) associated with HIV Clade C--is not uncommon[J]. J Neurovirol, 2013, 19(3): 198-208.
[8] LIMA MA, DRISLANE FW, KORALNIK IJ.Seizures and their outcome in progressive multifocal leukoencephalopathy[J]. Neurology, 2006, 6(2): 262-264.
[7] 中华医学会感染病学分会艾滋病丙型肝炎学组, 中国疾病预防控制中心. 中国艾滋病诊疗指南(2021年版)[J].中国艾滋病性病,2021,27(11): 1182-1201.
[9] KHANNA N, WOLBERS M.JC virus-specific immune responses in human immunodeficiency virus type 1 patients with progressive multifocal leukoencephalopathy[J]. J Virol, 2009, 83(9): 4404-4411.
[10] BERGER JR, CONCHA M.Progressive multifocal leukoencephalopathy: the evolution of a disease once considered rare[J]. J Neurovirol,1995,1(1): 5-18.
[11] 思治广. AIDS合并进行性多灶性脑白质病的MRI诊断[J].医学影像学杂志, 2018, 28(5): 710-713.
[12] ARNAUD FX, HISSENE A, MÉTIVIER D. Gadolinium enhancement in brain magnetic resonance imaging in progressive multifocal leukoencephalopathy after natalizumab monotherapy: Is it really atypical[J]. J Neuroradiol, 2012, 39(4): 267-270.
[13] Antinori A, Cingolani A, Lorenzini P. Clinical epidemiology and survival of progressive multifocal leukoencephalopathy in the era of highly active antiretroviral therapy: data from the Italian Registry Investigative Neuro AIDS(IRINA)[J]. J Neurovirol, 2003, 9 Suppl 1: 47-53.
[14] WHITE MK,KHALILI K.Pathogenesis of progressive multifocal leukoenlcephalopathy-revisited[J].J Infect Dis,2011,203(5): 578-586.
[15] PIZA F, FINK MC, NOGUEIRA GS, et al.JC virus-associated central nervous system diseases in HIV-infected patients in Brazil: clinical presentations, associated factors with mortality and outcome[J]. Braz J Infect Dis, 2012, 16(2):153-156.
[16] FALCÓ V, OLMO M, DEL SAZ SV, et al.Influence of HAART on the clinical course of HIV-1-infected patients with progressive multifocal leukoencephalopathy: results of an observational multicenter study[J]. J Acquir Immune Defic Syndr, 2008, 49(1): 26-31.
[17] PADMANABHAN S, CHERIAN A, IYPE T, et al.Hot cross bun sign in HIV-related progressive multifocal leukoencephalopathy[J]. Ann Indian Acad Neurol, 2013, 16(4): 672-673.
[18] BAG AK, CURÉ JK, CHAPMAN PR, et al.JC virus infection of the brain. AJNR Am J Neuroradiol, 2010, 31(9): 1564-1576.
[19] SHAHANI L, SHAH M, TAVAKOLI-TABASI S.Immune reconstitution inflammatory syndrome in a patient with progressive multifocal leukoencephalopathy[J]. BMJ Case Rep, 2015, 10, 2014207325.
[20] TAN K, RODA R, OSTROW L, et a1. PML-IRIS in patients with HIV infection: clinical manifestations and treatment with steroids[J]. Neurology, 2009, 72(17): 1458-1464.
[21] 冯逢. 多发性硬化的常见MRI征象分析[J]. 磁共振成像, 2011, 2(4): 309-313.
[22] 闫铄, 李晶晶, 谢汝明. 艾滋病合并弓形虫脑病MRI表现及其预后预测价值[J/CD]. 新发传染病电子杂志, 2016, 1(1): 27-30.