化膿性腦膜炎 (6)課件

化膿性腦膜炎62569PurulentMeningitis化膿性腦膜炎62569Purposeanddemand:Tofamiliarizethepathogenyofpurulentmeningitis.Tounderstandthemechanismandpathologychange.Tograsptheclinicalmanifestation,diagnosis,differentialdiagnosisandtreatment.Toself-studytheaccessoryexaminationofneuralsystem.化膿性腦膜炎62569ContentsInductionEtiology&pathogenesisManifestationsComplicationsLaboratoryfindingsDiagnosis&differentialdiagnosisTreatment&prevention化膿性腦膜炎62569Introduction

Acuteinfectionofcentralnervoussystem(CNS).75%ofcasesoccurintheageof2yr.Theinflammationofmeningescausedbyvarioumonfeaturesinclinicalpracticesinclude:fever,headache,vomit,convulsions,disturbanceofconsciousness,increasedintracranialpressure,meningealirritation.

Oneofthemostpotentiallyseriousinfections,associatedwithhighmortality(about10%)andmorbidity.化膿性腦膜炎62569Etiology1.Pathogens:Mainpathogens:Neissriameningitidis,streptoccuspneumoniae,Haemophilusinfluenzae.2/3ofpurulentmeningitisarecausedbythesepathogens

化膿性腦膜炎625691.Pathogens(Pathogensinspecialpopulations)neonate&＜3moinfants:EscherichiacoliStreptococcushaemolyticusgroupBStaphlococcusaureus＞3moinfants:HaemophilusinfluenzaegroupB

StreptococcuspneumoniaeNeisseriameningitidis＞5yrchildren:NeisseriameningitidisStreptococcuspneumoniaeEtiology化膿性腦膜炎62569Etiology2.MajorriskfactorsformeningitisImmatureimmunologicfunctionandattenuatedimmunologicresponsetopathogensLowlevelofimmunoglobulin,defectsofcomplementImmatureorimpairedblood-brain-barrier(BBB)

ImmatureBBBfunction:maturationatabout1yrImpairedBBB:Congenialoracquireddefectsacrossmucocutaneousbarrier化膿性腦膜炎62569AccessofbacteriainvasionTypicalaccess---hematogenousdissemination

BacteriacolonizingthemucousmembranesofthenasopharynxinvasionintolocaltissuebacteremiathroughBBSmainlyeffectonarachnoidandleptomeningesModeoftransmission:Persontopersoncontactthroughrespiratorytractsecretionsordroplets化膿性腦膜炎62569AccessofbacteriainvasionInvasionfromparameningealorgans:suchasparanasalsinusesormiddleearBacteriaspreadtothemeningesdirectly:throughanatomicdefectsintheskullorheadtrauma化膿性腦膜炎62569

Structureofmeninges化膿性腦膜炎62569PathologyCharacterizedbyleptomeningealandperivascularinfiltrationwithpolymorphonuclearleukocytesandaninflammatoryexudate.Exudatewhichmaybedistributedfromconvexityofbraintobasalregionofcranium.Exudateismorethicknessduetostreptococcuspneumoniaethanotherpathogens.化膿性腦膜炎62569ClinicalmanifestationsProdrome:acuteonset,precedebyseveraldaysofupperrespiratoryinfectionsorgastrointestinalsymptomsfulminantonset:epidemiccerebrospinalmeningitismanifestations:progressingshockbleedingspotsintheskinorecchymosisdisseminatedintravascularcoagulationdisturbanceofcentralnervoussystem.化膿性腦膜炎62569ClinicalmanifestationsCommonfeaturesofmeningitis:

signsofsystemicinfection:

fever,headache,fatigue,weakness,anorexia,bleedingspotsintheskin,ecchymosis,alterationofmentalstatusandconsciousness化膿性腦膜炎62569ClinicalmanifestationsCommonfeaturesofmeningitis:

neurologicalsigns:

meningealirritation:nuchalrigidity,kernigsign,brudzinskisign

increasedintracranialpressure:headache,vomiting,herniation

Seizure(20-30%)FocalorgeneralizedDuetocerebritis,infarction,electrolytedisturbancesFrequentlynotedwithHinfluenzae&Spneumococcalmeningitis化膿性腦膜炎62569Whenflexingthehip90degreesandthenextendingtheleg,thepatientfeelssubsequentpain化膿性腦膜炎62569Whenpassivelyflexingtheneckwhilesupine,patientinvoluntarilyflexeshiskneesandhips.化膿性腦膜炎62569ClinicalmanifestationsCommonfeaturesofmeningitis:

neurologicalsigns:

alterationofmentalstatusandconsciousnessincluding:irritability,lethargy,somnolence,confusion,stuppor,comaduetoincreasedintracranialpressure,cerebritis

focalsignsⅡ、Ⅲ、Ⅳ、Ⅵ、Ⅶ、Ⅷcranialnervesintrouble,paralysis,sensorydisturbance,mainlycausedbyvascularocclusion化膿性腦膜炎62569Clinicalmanifestations

Thesymptomsandsignsarenotevidentinneonatesandinfantsyoungerthan3moofage;andpatientsalreadyreceivedirregularantibiotictherapy.化膿性腦膜炎62569Comparisonofthemanifestationsofmeningitis

betweendifferentagegroupsSignsofsystemicinfectionIncreasedintracranialpressuremeningealirritationTypical(olderchildren)Fever,alteredconsciousness,seizureHeadache,vomiting,herniationnuchalrigidity,backpain,kernigsign,brudzinskisignAtypical(neonate&<3moinfant)Fever,normaltemperatureorhypothermia;minimorsubtleseizure;poorfeeding;lessactivityScream,frown;bulgingorfullfontanel;wideningofthesuturesNotevident化膿性腦膜炎62569ComplicationsandsequelaeSubduraleffusionDefinitivediagnosis:volumeoffluidinsubduralspace>2ml,protein>0.4g/L,Incidence:developin10-30%ofpatients,asymptomaticin85-90%ofpatients;especiallycommonininfants4-6monthofage(rareinchildrenover1yr);Causativeorganisms:Hinfluenzae,Spneumoniae化膿性腦膜炎62569ComplicationsandsequelaeIndications:NoresponsetoasensitiveantibiotictherapyProlongedfeverorfeverreoccurringafteranafebrileintervalwitheffectivetreatmentBulgingfontanel,wideningofsutures,enlargingheadcircumference,vomit,seizure,alteredconsciousness.ImprovedCSFpromoreseriousclinicalmanifestations化膿性腦膜炎62569Complicationsandsequelae

Diagnosismethods:

Cranialtranslucenttest

BultrasonicexaminationandCTSubduralspacepuncturenormalsubduraleffusion化膿性腦膜炎62569Complicationsandsequelae2.VentriculitisUsuallyoccursinneonatesandinfants(<1yr),withsevereprognosisThemaincauseisdelayeddiagnosisandtreatmentofmeningitis.Diagnosis:Bultrasonicexaminationorneuroimagingstudies(CT,MRI):enlargedlateralventricleLateralventriclepuncture:bacteriaandinflammatorycellsinventricularfluid,WBC>50x106/L,Glucose<1.6mmol/L,orprotein>400mg/L.化膿性腦膜炎62569Complicationsandsequelae3.hydrocephalus:Communicatinghydrocephalus&Obstructivehydrocephalus:Severehydrocephalus:enlargingheadcircumference;bulgingfontanel;sutureseparation;sunseteyes;increasingneuropsychiatricsymptoms4.Cerebralhyponatremia:Thesyndromeofinappropriatesecretionofantidiuretichormone5.others:Deafness,blindness,paralysis,epilepsy,mentalretardation化膿性腦膜炎62569Examinations1.Bloodroutineexamination:WBC&NEUT↑2.Cerebrospinalfluidexaminations:(1)Routineexamination:increasedcerebrospinalpressureappearance:cloudyWBC＞1000*106/L,consistingchieflyofneutdecreasedglucoseconcentration(80%),＜1.1mmol/L;raisedproteinconcentration,＞1g/LFindingbacteriainCSF化膿性腦膜炎62569Examinations2.Cerebrospinalfluidexaminations:(2)specialexamination:①Specificbacterialantigen-detectiontestCountercurrentimmuno-electrophoresis,CIELatexagglutinationImmunofluorescenttest②LDH,lacticacid,CRP,TNF,Ig,NSEdeterminations化膿性腦膜炎62569Examinations3.Otherexaminations(1)bloodculture:beforeantibiotictherapy(2)petechiasmear:epidemiccerebrospinalmeningitis(3)othersecretioncultures:(4)imaging:CT&MRI化膿性腦膜炎62569DiagnosisEarlierdiagnosisandpromptinitiationofeffectiveantibiotictreatmentiscriticalforminimizingsequelaeofpurulentmeningitis.

Suspectedcases:febrileinfantswithseizure,meningealirritation,increasedintracranialpressure,alteredmentalstatusPayattentiontotheatypicalsymptomsandsignsinneonate,infantandpatientalreadyreceivedirregularantibiotictherapy化膿性腦膜炎62569DiagnosisDiagnosisisconfirmedbyanalysisofcerebrospinalfluid(CSF)

Suggestionbacterialmeningitis

Increasedpressure(90%)Appearance:slightlycloudytopurulentRaisedwhitebloodcells,consistingchieflyofpolymorphonuclearleukocytesRaisedproteinconcentration,Decreasedglucoseconcentration(80%)化膿性腦膜炎62569Diagnosis

Confirmationofthediagnosis:isolationfromtheCSFofaspecificbacterialpathogenbymicroscopyorapositivecultureorrapidantigen-detectiontestofCSF

Gram-stainedsmearofCSF:identifythecausativeorganismin70-90%ofcases

CSFculture:positiveinabout80%ofcases.definitivediagnosis,determinationofantibioticsensitivity.PCR:amplifiesbacterialDNA(Hinfluenzae,N.meningitidis)化膿性腦膜炎62569DifferentialdiagnosisViralmeningitis/encephalitis:

Lessseveresystemicinfectioussymptoms

Usuallynotdevelopafter2-3weeks

CSF:normalglucoseTuberculousmeningitis:

Subacuteonsetandprogress

AhistoryofclosecontactwithknowncasesoftuberculosisEvidenceofacuteorhealedtubercularinfectiononchestx-rayTuberculinskintest:OT,PPDCSF化膿性腦膜炎62569DifferentialdiagnosisCryptococcalmeningitis:slowonset,alongcourseofdisease,increasedintracranialpressure→severeheadacheCSFchanges:similarwithtuberculousmeningitisconfirmedbyIndiainkstainingorcultureofCSFMollaret’smeningitis:etiology:unknowclinicalmanifestationsandCSF:recurrent,similartopurulentmeningitisCSF:Mollaret’scellsadrenocorticalhormonetherapy:effective化膿性腦膜炎62569DifferentialdiagnosisBrainabscess:slowonsetCSF:pressure↑↑,cell→normalor↑,protein→↑furtherdiagnosis:CTorMRIAcutetoxicencephalopathy:manifestations:delirium,convulsions,coma,meningealirritation,cerebralpalsyCSF:onlypressure↑化膿性腦膜炎62569壓力kpa外觀潘氏試驗(yàn)白細(xì)胞數(shù)（×106/L）蛋白質(zhì)（g/L)糖（mmol/L）氯化物（mmol/L）其他正常0.69-1.96新生兒0.29-0.78清—0~10小嬰兒0~200.2~0.4新生兒0.2~1.22.8~4.5嬰兒3.9~5.0117~127嬰兒110~122

化腦升高混濁++~+++數(shù)百~數(shù)萬(wàn)，多核為主明顯增加減低正?；驕p低涂片，培養(yǎng)可發(fā)現(xiàn)致病菌

結(jié)腦升高阻塞時(shí)低不太清毛玻璃樣+~+++數(shù)十~數(shù)百，淋巴為主增高，阻塞時(shí)明顯增高降低降低涂片或培養(yǎng)可見(jiàn)抗酸桿菌

病腦正常或升高多數(shù)清±~++正常~數(shù)百。淋巴為主正?；蛏栽龈哒Ｕ２《九囵B(yǎng)有時(shí)陽(yáng)性真菌性腦膜炎高不太清+~+++數(shù)十~數(shù)百，單核為主增高降低降低墨汁染色腦膿腫常升高清或者不太清—~++正常~數(shù)百正?；蛏愿哒ＵＶ卸拘阅X病升高清—~+正常正?；蛏愿哒Ｕ；撔阅X膜炎62569Treatment1.AntibacterialtherapyTherapyprinciples:earlytreatment,antibioticssusceptibletopathogensandwithhighpermeabilitythroughBBB,givenintraveninously,enoughdose,enoughcourseofantibiotictherapy

化膿性腦膜炎62569Treatmentatthetimeofunknownpathogenicbacteria:

Firstchoice:Cefotaxime,Ceftriaxone(3drgenerationofcephalosporins,highpermeabilitythroughBBB,productsofmetabolismalsohaseffect,CSFsterilizationwithin24h)

Otherchoice:Penicillin,Chloramphenicol,(sideeffects:graybabysyndromeandbonemarrowsuppression)atthetimeofknownpathogenicbacteria:refertodrugsensitivitytest化膿性腦膜炎62569Antibiotictherap