1、化脓性脑膜炎专题教育化脓性脑膜炎专题教育Purpose and demand:To familiarize the pathogeny of purulent meningitis.To understand the mechanism and pathology change.To grasp the clinical manifestation,diagnosis,differential diagnosis and treatment.To self-study the accessory examination of neural system.化脓性脑膜炎专题教育2ContentsI
2、nductionEtiology&pathogenesisManifestationsComplicationsLaboratory findingsDiagnosis&differential diagnosisTreatment&prevention化脓性脑膜炎专题教育3Introduction Acute infection of central nervous system(CNS).75%of cases occur in the age of 2yr.The inflammation of meninges caused by various bacteria.Common fea
3、tures in clinical practices include:fever,headache,vomit,convulsions,disturbance of consciousness,increased intracranial pressure,meningeal irritation.One of the most potentially serious infections,associated with high mortality(about 10%)and morbidity.化脓性脑膜炎专题教育4Etiology1.Pathogens:Main pathogens:N
4、eissria meningitidis,streptoccus pneumoniae,Haemophilus influenzae.2/3 of purulent meningitis are caused by these pathogens 化脓性脑膜炎专题教育51.Pathogens(Pathogens in special populations)neonate&3mo infants:Escherichia coli Streptococcus haemolyticus group B Staphlococcus aureus3mo infants:Haemophilus infl
5、uenzae group B Streptococcus pneumoniae Neisseria meningitidis5yr children:Neisseria meningitidis Streptococcus pneumoniaeEtiology化脓性脑膜炎专题教育6Etiology2.Major risk factors for meningitis Immature immunologic function and attenuated immunologic response to pathogens Low level of immunoglobulin,defects
6、of complement Immature or impaired blood-brain-barrier(BBB)Immature BBB function:maturation at about 1yr Impaired BBB:Congenial or acquired defects across mucocutaneous barrier化脓性脑膜炎专题教育7Access of bacteria invasion Typical access-hematogenous dissemination Bacteria colonizing the mucous membranes of
7、 the nasopharynx invasion into local tissue bacteremia through BBS mainly effect on arachnoid and leptomeninges Mode of transmission:Person to person contact through respiratory tract secretions or droplets化脓性脑膜炎专题教育8Access of bacteria invasionInvasion from parameningeal organs:such as paranasal sin
8、uses or middle earBacteria spread to the meninges directly:through anatomic defects in the skull or head trauma化脓性脑膜炎专题教育9 Structure of meninges 化脓性脑膜炎专题教育10Pathology Characterized by leptomeningeal and perivascular infiltration with polymorphonuclear leukocytes and an inflammatory exudate.Exudate w
9、hich may be distributed from convexity of brain to basal region of cranium.Exudate is more thickness due to streptococcus pneumoniae than other pathogens.化脓性脑膜炎专题教育11Clinical manifestationsProdrome:acute onset,precede by several days of upper respiratory infections or gastrointestinal symptoms fulmi
10、nant onset:epidemic cerebrospinal meningitis manifestations:progressing shock bleeding spots in the skin or ecchymosis disseminated intravascular coagulation disturbance of central nervous system.化脓性脑膜炎专题教育12Clinical manifestationsCommon features of meningitis:signs of systemic infection:fever,heada
11、che,fatigue,weakness,anorexia,bleeding spots in the skin,ecchymosis,alteration of mental status and consciousness化脓性脑膜炎专题教育13Clinical manifestationsCommon features of meningitis:neurological signs:meningeal irritation:nuchal rigidity,kernig sign,brudzinski sign increased intracranial pressure:headac
12、he,vomiting,herniation Seizure(20-30%)Focal or generalized Due to cerebritis,infarction,electrolyte disturbances Frequently noted with H influenzae&S pneumococcal meningitis化脓性脑膜炎专题教育14When flexing the hip 90 degrees and then extending the leg,the patient feels subsequent pain化脓性脑膜炎专题教育15When passiv
13、ely flexing the neck while supine,patient involuntarily flexes his knees and hips.化脓性脑膜炎专题教育16Clinical manifestationsCommon features of meningitis:neurological signs:alteration of mental status and consciousnessincluding:irritability,lethargy,somnolence,confusion,stuppor,comadue to increased intracr
14、anial pressure,cerebritis focal signs、cranial nerves in trouble,paralysis,sensory disturbance,mainly caused by vascular occlusion化脓性脑膜炎专题教育17Clinical manifestations The symptoms and signs are not evident in neonates and infants younger than 3mo of age;and patients already received irregular antibiot
15、ic therapy.化脓性脑膜炎专题教育18Comparison of the manifestations of meningitis between different age groupsSigns of systemic infectionIncreased intracranial pressuremeningeal irritationTypical(older children)Fever,altered consciousness,seizureHeadache,vomiting,herniationnuchal rigidity,back pain,kernig sign,
16、brudzinski signAtypical(neonate&2ml,protein0.4g/L,Incidence:develop in 10-30%of patients,asymptomatic in 85-90%of patients;especially common in infants 4-6 month of age(rare in children over 1yr);Causative organisms:H influenzae,S pneumoniae化脓性脑膜炎专题教育20Complications and sequelae Indications:No respo
17、nse to a sensitive antibiotic therapy Prolonged fever or fever reoccurring after an afebrile interval with effective treatment Bulging fontanel,widening of sutures,enlarging head circumference,vomit,seizure,altered consciousness.Improved CSF profile with more serious clinical manifestations化脓性脑膜炎专题教
18、育21Complications and sequelae Diagnosis methods:Cranial translucent test B ultrasonic examination and CT Subdural space puncture normalsubdural effusion化脓性脑膜炎专题教育22Complications and sequelae2.VentriculitisUsually occurs in neonates and infants(50 x106/L,化脓性脑膜炎专题教育23Complications and sequelae3.hydroc
19、ephalus:Communicating hydrocephalus&Obstructive hydrocephalus:Severe hydrocephalus:enlarging head circumference;bulging fontanel;suture separation;sunset eyes;increasing neuropsychiatric symptoms4.Cerebral hyponatremia:The syndrome of inappropriate secretion of antidiuretic hormone5.others:Deafness,
20、blindness,paralysis,epilepsy,mental retardation化脓性脑膜炎专题教育24Examinations2.Cerebrospinal fluid examinations:(2)special examination:Specific bacterial antigen-detection test Countercurrent immuno-electrophoresis,CIE Latex agglutination Immunofluorescent testLDH,lactic acid,CRP,TNF,Ig,NSE determinations
21、化脓性脑膜炎专题教育26Examinations3.Other examinations(1)blood culture:before antibiotic therapy(2)petechia smear:epidemic cerebrospinal meningitis(3)other secretion cultures:(4)imaging:CT&MRI化脓性脑膜炎专题教育27Diagnosis Earlier diagnosis and prompt initiation of effective antibiotic treatment is critical for minimi
22、zing sequelae of purulent meningitis.Suspected cases:febrile infants with seizure,meningeal irritation,increased intracranial pressure,altered mental status Pay attention to the atypical symptoms and signs in neonate,infant and patient already received irregular antibiotic therapy化脓性脑膜炎专题教育28Diagnos
23、is Diagnosis is confirmed by analysis of cerebrospinal fluid(CSF)Suggestion bacterial meningitis Increased pressure(90%)Appearance:slightly cloudy to purulent Raised white blood cells,consisting chiefly of polymorphonuclear leukocytes Raised protein concentration,Decreased glucose concentration(80%)
24、化脓性脑膜炎专题教育29Diagnosis Confirmation of the diagnosis:isolation from the CSF of a specific bacterial pathogen by microscopy or a positive culture or rapid antigen-detection test of CSF Gram-stained smear of CSF:identify the causative organism in 70-90%of cases CSF culture:positive in about 80%of cases
25、.definitive diagnosis,determination of antibiotic sensitivity.PCR:amplifies bacterial DNA(H influenzae,N.meningitidis)化脓性脑膜炎专题教育30Differential diagnosisViral meningitis/encephalitis:Less severe systemic infectious symptoms Usually not develop after 2-3weeks CSF:normal glucoseTuberculous meningitis:S
26、ubacute onset and progress A history of close contact with known cases of tuberculosis Evidence of acute or healed tubercular infection on chest x-ray Tuberculin skin test:OT,PPD CSF化脓性脑膜炎专题教育31Differential diagnosisCryptococcal meningitis:slow onset,a long course of disease,increased intracranial p
27、ressuresevere headacheCSF changes:similar with tuberculous meningitisconfirmed by Indiainkstaining or culture of CSFMollarets meningitis:etiology:unknowclinical manifestations and CSF:recurrent,similar to purulent meningitisCSF:Mollarets cellsadrenocortical hormone therapy:effective化脓性脑膜炎专题教育32Diffe
28、rential diagnosisBrain abscess:slow onsetCSF:pressure,cellnormal or,protein further diagnosis:CT or MRIAcute toxic encephalopathy:manifestations:delirium,convulsions,coma,meningeal irritation,cerebral palsyCSF:only pressure 化脓性脑膜炎专题教育33压力压力kpa外观外观潘氏试潘氏试验验白细胞数白细胞数（106/L）蛋白质蛋白质（g/L)糖（糖（mmol/L）氯化物氯化物（m
29、mol/L）其他其他正常正常0.69-1.96新生儿新生儿0.29-0.78清清010小婴儿小婴儿0200.20.4新生儿新生儿0.21.22.84.5婴儿婴儿3.95.0117127婴儿婴儿110122化脑化脑升高升高混浊混浊+数百数百数万，数万，多核为主多核为主明显增明显增加加减低减低正常或减低正常或减低涂片，涂片，培养可培养可发现致发现致病菌病菌结脑结脑升高升高阻塞时低阻塞时低不太清不太清毛玻璃毛玻璃样样+数十数十数百，数百，淋巴为主淋巴为主增高，增高，阻塞时阻塞时明显增明显增高高降低降低降低降低涂片或涂片或培养可培养可见抗酸见抗酸杆菌杆菌病脑病脑正常或升高正常或升高多数清多数清+正常正
30、常数百。数百。淋巴为主淋巴为主正常或正常或稍增高稍增高正常正常正常正常病毒培病毒培养有时养有时阳性阳性真菌性真菌性脑膜炎脑膜炎高高不太清不太清+数十数十数百，数百，单核为主单核为主增高增高降低降低降低降低墨汁染墨汁染色色脑脓肿脑脓肿常升高常升高清或者清或者不太清不太清+正常正常数百数百正常或正常或稍高稍高正常正常正常正常中毒性中毒性脑病脑病升高升高清清+正常正常正常或正常或稍高稍高正常正常正常正常化脓性脑膜炎专题教育34Treatment1.Antibacterial therapy Therapy principles:early treatment,antibiotics suscepti
31、ble to pathogens and with high permeability through BBB,given intraveninously,enough dose,enough course of antibiotic therapy 化脓性脑膜炎专题教育35Treatment at the time of unknown pathogenic bacteria:First choice:Cefotaxime,Ceftriaxone (3dr generation of cephalosporins,high permeability through BBB,products
32、of metabolism also has effect,CSF sterilization within 24h)Other choice:Penicillin,Chloramphenicol,(side effects:gray baby syndrome and bone marrow suppression)at the time of known pathogenic bacteria:refer to drug sensitivity test 化脓性脑膜炎专题教育36Antibiotic therapy of bacterial meningitisEtiologyStanda
33、rd antibiotics of choiceDuration of therapyH.influenzaeCeftriaxone/ampicillin 2-3weeksS.pneumoniaeCefotaxime/Ceftriaxone 2-3weeksN.meningitidisPenicillin G/Ceftriaxone7-10daysStaphlococcus aureusCloxacillin/Ceftriaxone/Norvancomycin3-4weeksE.coliCefotaxime/Ceftriaxone(or+ampicillin)3-4weeksUnknownCe
34、fotaxime/Ceftriaxone+ampicillin2-3weeks化脓性脑膜炎专题教育37Treatment2.Adrenal cortical hormone:dexamethasone:0.3-0.5mg/kg/day3.Symptomatic treatment&supportive care Increased intracranial pressure:Intravenous mannitol 0.5-1g/kg/every time,q4-6h Convulsions:diazepam&chloral hydrate&phenobarbital Fever:Acetam
35、inophen&ibuprofen Maintenance fluid and thermal energy supplement:fluid administration:60-80ml/kg/day fluid infusion with dehydration therapy 化脓性脑膜炎专题教育38Treatment4.Treatment of complications Subdural effusion Few volume could be absorbed with treatment spontaneously Subdural puncture:take out 20-30ml/each time (unilateral puncture),less than 50-60ml/each time (bilateral puncture),everyday or every other day Ventriculitis:lateral ventricle puncture and injection of antibiotics locally Cerebral hyponatremia:supplement of sodium化脓性脑膜炎专题教育39
