1、化脓性脑膜炎英文版化脓性脑膜炎英文版 Acute infection of central nervous system(CNS).90%of cases occur in the age of 1mo-5yr.The inflammation of meninges caused by various bacteria.Common features in clinical practices include:fever,increased intracranial pressure,meningeal irritation.One of the most potentially serio
2、us infections,associated with high mortality(about 10%)and morbidity.Purulent Meningitis化脓性脑膜炎英文版21.Etiology2.1.1 Pathogens:Main pathogens:Neissria meningitidis,streptoccus pneumoniae,Haemophilus influenzae.(2/3 of purulent meningitis are caused by these pathogens)Pathogens in special populations(ne
3、onate&3mo infants,malnutrition,immunodeficiency):gramnegative enteric bacilli,group B streptococci,staphlococcus aureus 化脓性脑膜炎英文版31.2 Major risk factors for meningitis Immature immunologic function and attenuated immunologic response to pathogens Low level of immunoglobulin,defects of complement and
4、 properdin system Immature or impaired blood-brain-barrier(BBB)Immature BBB function:maturation at about 1yr Impaired BBB:Congenial or acquired defects across mucocutaneous barrier 化脓性脑膜炎英文版4 1.3 Access of bacteria invasion Typical access-hematogenous dissemination Bacteria colonizing the mucous mem
5、branes of the nasopharynx invasion into local tissue bacteremia hematogenous seeding to the subarachnoid space Mode of transmission:Person to person contact through respiratory tract secretions or droplets化脓性脑膜炎英文版5 Bacteria spread to the meninges directly:through anatomic defects in the skull or he
6、ad trauma Invasion from parameningeal organs:such as paranasal sinuses or middle earAccess of bacteria invasion化脓性脑膜炎英文版62.Pathology Structure of meninges 化脓性脑膜炎英文版7 Characterized by leptomeningeal and perivascular infiltration with polymorphonuclear leukocytes and an inflammatory exudate.Exudate wh
7、ich may be distributed from convexity of brain to basal region of cranium.Exudate is more thickness due to streptococcus pneumoniae than other pathogens.Pathology化脓性脑膜炎英文版83.Clinical manifestations The younger the child is,the higher incidence of meningitis will be.-2/3 of cases occur less than 1yr
8、of age.Mode of presentation:Acute or fulminant onset:symptoms and signs of sepsis;meningitis evolve rapidly over a few hours and death within 24 hours;usually infected with Neissria meningitides (N.meningitides).化脓性脑膜炎英文版9 Subacute onset:Precede by several days of upper respiratory tract or gastroin
9、testinal symptoms;difficult to pinpoint the exact onset of meningitis;usually with meningitis due to Haemophilus influenzae (H influenzae)and streptoccus pneumococcus (S pneumococcus).Mode of presentation化脓性脑膜炎英文版10 Common features of meningitis:signs of systemic infection:fever(90-95%),anorexia,sho
10、ck,alteration of mental status and consciousness neurological signs:increased intracranial pressure:headache,vomiting(82%),herniation meningeal irritation:nuchal rigidity(77%),kernig sign,brudzinski sign Clinical manifestations化脓性脑膜炎英文版11brudzinski sign化脓性脑膜炎英文版12 Seizure(20-30%)Focal or generalized
11、 Due to cerebritis,infarction,electrolyte disturbances Frequently noted with H influenzae&S pneumococcal meningitis Persist after 4th day and difficult to treat with poor prognosisClinical manifestations化脓性脑膜炎英文版13 Clinical manifestations Alteration of mental status and consciousness Including:irrit
12、ability,lethargy,stupor obtundation,coma Due to increased intracranial pressure,cerebritis,hypotension Often with pneumococcal or meningococcal meningitis Comatose patients with a poor prognosis化脓性脑膜炎英文版14 The symptoms and signs are not evident in neonates and infants younger than 3mo of age;and pat
13、ients already received irregular antibiotic therapy.Clinical manifestations化脓性脑膜炎英文版15Signs of systemic infectionIncreased intracranial pressuremeningeal irritationTypical(older children)Fever,altered consciousness,seizureHeadache,vomiting,herniationnuchal rigidity,back pain,kernig sign,brudzinski s
14、ignAtypical(neonate&3mo infant)Fever,normal temperature or hypothermia;minim or subtle seizure;poor feeding;less activityScream,frown;bulging or full fontanel;widening of the suturesNot evidentComparison of the manifestations of meningitis between different age groupsClinical manifestations化脓性脑膜炎英文版
15、164.Diagnosis Earlier diagnosis and prompt initiation of effective antibiotic treatment is critical for minimizing sequelae of purulent meningitis.Suspected cases:febrile infants with seizure,meningeal irritability,increased intracranial pressure,altered mental status Pay attention to the atypical s
16、ymptoms and signs in neonate,infant and patient already received irregular antibiotic therapy 化脓性脑膜炎英文版17 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 ch
17、iefly of polymorphonuclear leukocytes Raised protein concentration,decreased glucose concentration(80%)Diagnosis化脓性脑膜炎英文版18 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 sm
18、ear of CSF:identify the causative organism in 70-90%of cases CSF culture:positive in about 80%of cases.definitive diagnosis,determination of antibiotic sensitivity.PCR:amplifies bacterial DNA(H influenzae,N.meningitidis)Diagnosis化脓性脑膜炎英文版195.Differential diagnosis Purulent meningitis caused by diffe
19、rent pathogens Neissria meningitidis:Occur in epidemics(type A,C),which is more common in spring,or sporadic all the year (type B,C,Y)Sudden onset with various cutaneous signs (petechiae,purpura,or an erythematous macular rash)化脓性脑膜炎英文版20 Streptococcus pneumoniae:Young infants(1yr)are most susceptib
20、le population Peak season:spring and winter Easier to have subdural effusion and hydrocephalus Easily have a protracted course and relapseDifferential diagnosis化脓性脑膜炎英文版21 Haemophilus influenzae Occurs predominantly in infants 2mo to 2yr of age Many cases are in winter Higher incidence of subdural e
21、ffusion Others pathogens:staphylococcus aureus,gramnegative enteric bacilli Special susceptible population:neonate,3mo infants,malnutrition,immunodeficiency Severe infection,difficult to treatDifferential diagnosis化脓性脑膜炎英文版22 Meningitis caused by other microorganisms Differential diagnosis化脓性脑膜炎英文版2
22、3Differential diagnosis化脓性脑膜炎英文版24DiseasePressure(Kpa)aspectTotal WBC(x106/L)Protein(g/L)Glucose(mmol/L)smearsculturesnormal0.69-1.96(0.29-0.78)clear0-5(0-20)0.2-0.4(0.2-1.2)2.2-4.4-Purulentmeningitiscloudy(PMN)(1-5)(2.2)Grams stain+TuberculousmeningitisNormal or cloudy(MN)AFB stain+Viral meningitis
23、/encephalitisNormal or Normal Normal or(MN)Normal or(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);化脓性脑膜炎英文版26 Causative organisms:45%of cases of meningitis caused by H influenzae,30
24、%by S pneumoniae,9%by N meningitidissubdural effusion化脓性脑膜炎英文版27 Diagnosis methods:Cranial translucent test B ultrasonic examination and CT Subdural space puncture subdural effusionnormalsubdural effusion化脓性脑膜炎英文版296.2 Ventriculitis6.3 hydrocephalusComplications化脓性脑膜炎英文版30Circulation of cerebrospina
25、l fluid(CSF)化脓性脑膜炎英文版316.2 Ventriculitis Usually occurs in neonates and infants(50 x106/L,Ventriculitis化脓性脑膜炎英文版33Circulation of cerebrospinal fluid(CSF)化脓性脑膜炎英文版346.3 hydrocephalus:Communicating hydrocephalus:adhered or destroyed arachnoid granulation around the cistern at the base of the brain Obs
26、tructive hydrocephalus:following obstructed of the cerebral aqueduct,or the foramina of Magendie and Luschka6.4 others:Deafness,blindness,paralysis,epilepsy,mental retardationComplications化脓性脑膜炎英文版357.Treatment8.7.1 Antibacterial therapy Therapy principles:early treatment,antibiotics susceptible to
27、pathogens and with high permeability through BBB,given intraveninously,enough dose,enough course of antibiotic therapy 化脓性脑膜炎英文版36 Susceptible to pathogens First choice:Cefotaxime,Ceftriaxone (3dr generation of cephalosporins,high permeability through BBB,products of metabolism also has effect,CSF s
28、terilization within 24h)Other choice:Penicillin,Chloromycin,Cefuroxime,Ceftazidime(delayed effect to make CSF sterile,high incidence of relapse and deafness)Antibacterial therapy化脓性脑膜炎英文版37EtiologyStandard antibiotics of choiceDuration of therapyH.influenzaeCefotaxime/Ceftriaxone7-10daysN.meningitid
29、isCefotaxime/Ceftriaxone7daysS.pneumoniaeCefotaxime/Ceftriaxone2-3weeksStaphlococcus aureusSemisynthetic penicillins(Oxacillin sodium,Cloxacillin sodium),Norvancomycin3weeksE.coliCefotaxime/Ceftriaxone(or+ampicillin)3weeksUnknownCefotaxime/Ceftriaxone+ampicillin2-3weeksAntibiotic therapy of bacteria
30、l meningitis化脓性脑膜炎英文版38 Maintenance fluid and thermal energy supplement:Fluid administration:60-80ml/kg/day Fluid infusion with dehydration therapy7.2 Supportive care Treatment化脓性脑膜炎英文版39 increased intracranial pressure Osmotic therapy:intravenous mannitol 0.5-1g/kg/every time,q4-6h Combination with
31、 intravenous dexamethasone:0.3-0.5mg/kg/day Endotracheal intubation and hyperventilation Treatment化脓性脑膜炎英文版40 Subdural effusion Few volume could be absorbed with treatment spontaneously Subdural puncture:take out 15ml/each time (unilateral puncture),less than 30ml/each time (bilateral puncture),everyday or every other day Stripping operation:for the cases not cure after 3-4weeks Treatment化脓性脑膜炎英文版41 Others:Ventriculitis:lateral ventricle puncture and injection of antibiotics locally Epilepsy:AEDsTreatment化脓性脑膜炎英文版42
