144.3 🩺 內科專科考前版

144.3.0.1 1️⃣ 22E 更新

• GeneXpert MTB/Ultra (2017+): increased sensitivity in CSF
• CrAg lateral flow assay (LFA) (Immy): rapid, point-of-care; CSF & serum
• Mycobacterial culture replaced by molecular when fast diagnosis critical
• Single high-dose liposomal AmB (10 mg/kg) + flucytosine + fluconazole for cryptococcal meningitis in HIV — AMBITION trial 2022, non-inferior to 2-week AmB + 5-FC (Africa-focused)

144.3.0.2 2️⃣ Practical Workup

144.3.0.2.1 Stepwise

1. History: travel, immunization, animal/tick, drug, HIV risk, prior meningitis episodes
2. HIV test mandatory
3. CSF essential:
   • Multiple LPs (volume for cultures, cytology, serology)
   • 病人 1 次 LP yield 不夠
4. Bloods: HIV, syphilis, IGRA, ACE, ANA, Lyme, Cocci, Histo, Blasto serology
5. Imaging: MRI + contrast — basal enhancement (TB), leptomeningeal nodular (carcinomatous), tuberculomas
6. Meningeal biopsy: refractory undiagnosed

144.3.0.3 3️⃣ 台灣 context

• TB meningitis: endemic 高發, 不能漏
• Cryptococcal: HIV epidemic + immunocompromised (post-transplant)
• 健保 amphotericin B, flucytosine, fluconazole 給付完整
• GeneXpert MTB available at major hospitals
• ID consult routine for chronic meningitis

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