1、化脓性脑膜炎 purulent meningitis,Abbreviations PM purulent meningitis CSF cerebrospinal fluid CNS central nervous system ICP intracranial pressure BBB blood-brain barrier WBC white blood cell NC neutrocyte,INTRODUCTION Purulent Meningitis (PM) is one of serious bacterial infection. PM is associated with a
2、 high rate of acute complications and risk of chronic sequelae. PM is quite common CNS disorders in childhood, and it should be included in the differential diagnosis of altered mental status.,概念,由化脓性细菌引起的 中枢神经系统急性感 染性疾病,病原学(1),常见病原 脑膜炎球菌 (meningococcus) 肺炎链球菌 (pneumococcus) 流感嗜血杆菌 (haemophilus infl
3、uenzae) 金黄色葡萄球菌（staphylococcus aureus） 大肠杆菌（escherichia coli）,脑膜炎球菌,肺 炎 球 菌,Common bacteria The first 2 month: escherichia coli ; staphylococcus aureus; 2 month12 yr: Pneumococcus; Meningococcus; Hemophilus influenzae type b.,病原学(2),病原菌与年龄的关系 新生儿 大肠杆菌、绿脓杆菌、金黄色葡萄球菌 儿童 脑膜炎球菌、肺炎球菌、流感嗜血杆菌,发病机制(1),The ri
4、sk factors 1. Lack of immunity: young age, defects of T-lymphocyte, defects of immunoglobulin, defects of the complement system or properdin system 2. Environment Congenital or acquired CSF leak: such as cranial defect or middle ear fistulas, basal skull fracture, lumbosacral dermal sinus, penetrati
5、ng cranial trauma,Meningocele Sinus, 回顾 中枢神经系统脑膜的解剖及脑脊液的循环,PATHOGENESIS Bacteria attack to the mucosal epithelial cell receptors by pili, enter the circulation, penetrate the BBB (blood-brain barrier) to the CSF, colonize and multiply, then incite inflammatory response and polymorphonuclear cell inf
6、iltration, which produce TNF, IL-1, PG-2 and other cytokines.,致病菌入侵途径,致病菌,软脑膜,蛛网膜,表层脑,血流途径,直接通道,临近感染,发病机制(2),决定入侵中枢神经系统的因素 细菌数量 毒力 机体免疫状态 多种细胞因子参与发病 TNF，IL1等,PATHOLOGY Meningeal exudation and varying thickness Vascular changes: vasculitis , thrombosis, necrosis or occlusion of small vascules Cerebra
7、l infarction Increased ICP Ventriculitis Hydrocephalus, communicating Damage of the cerebral cortex,轻症化脑的病理变化 软脑膜及蛛网膜炎、表层脑组织为主的炎 症反应，炎症渗出物主要在大脑顶部表面。 重症化脑的病理变化 除轻症的改变外，还出现血管病变、脑实质损害，脑室管膜炎、颅神经受累。,CLINICAL MANIFESTATIONS,(1) Nonspecific finding: fever; anorexia or poor feeding; symptoms of URI, myalgia
8、s, arthralgias, tachycardia, hypotension, various cutaneous signs,(2) cerebral dysfunction: Seizures: focal or generalized due to cerebritis, infarction, or electrolyte disturbances. After 4 days, persisting seizures are associated with a poor prognosis. Alternations of mental status and reduced lev
9、el of consciounes: irritality, lethargy, stupor, obtundation, coma. Comatose ones have a poor prognosis,(3) Increased ICP: headache, emesis, papilledema (more chronic process). bulging fontanel and widening of the sutures, cranial neurologic paralysis (such as facial, oculomotor, abducens or auditor
10、y nerve paralysis), signs of herniation (tachycardia or bradycardia, apnea or hyperventilation),(4) Meningeal irritation: Nuchal rigidity Back pain Kernig sign Brudrinski sign,临床表现(1),年长儿及成人典型表现,（）感染中毒及急性脑功能障碍症状,兴奋：烦躁、惊厥 抑制：嗜睡、昏睡、浅昏迷、深昏迷,（2）颅高压表现 头痛、呕吐、视乳头水肿,颅高压三联征,颈项强直 （3）体征 ：脑膜刺激征 克氏征阳性 布氏征阳性,4岁女孩
11、患脑膜炎 表现为神志淡漠,4岁女孩患脑膜炎 颈项强直、布氏征阳性,4,4岁女孩患脑膜炎 克氏征阳性,临床表现(),年龄小于3个月的幼婴和新生儿化脑的特点： 1、体温可高可低 2、颅压增高不明显 3、惊厥可不典型 4、脑膜刺激征不明显,COMPLICATIONS,1. Subdural effusion It is the most common complication of PM in childhood. Its incidence is around 3060%, and adding asymptomatic ones, the incidence is 8590%. Most of
12、cases occur in infants. Manifestations: After treating and getting a good effect by antibiotic, then the patients manifest the symptoms and signs of PM again:,fever, seizures, alternation of mental status, bulging fontanel, diastasis of sutures, enlarging head circumference, emesis, positive cranial
13、 transillumination, etc. CT or MRI of brain can make the definite diagnosis.,并发症及后遗症(1),硬膜下积液 2ml，蛋白定量 400 mg/L,2. Ventriculitis It is occurred in the patients who are not treated in time. The symptoms and signs of PM are not improved and even progressed using effective antibiotics,并发症及后遗症(2),脑室管膜炎(
14、见于新生儿、小婴儿) 治疗被延误 强力治疗后仍持续发热、反复抽搐、呼吸衰竭且进行性加重 脑脊液始终不正常 头颅B超、CT可助诊，确诊依靠侧脑室穿刺脑室液,3. SIADH (syndrome of inappropriation ADH-secretion) Occurring in the majority of patients with PM. It is a result of hypothalamic or pituitary dysfunction. Resulting in hyponatremia and reduced serum osmolarity, and exacer
15、bate cerebral edema or directly produce hyponatremic seizures.,并发症及后遗症(3),抗利尿激素异常分泌综合征 病因 炎症累及下丘脑及垂体后叶，引起抗利尿激素过量分泌。 表现 低钠及血浆渗透压降低,others Cranial nerve palsies: such as deafness, blindness Cerebral or cerebellar herniation hydrocephalus,其他并发症及后遗症 脑积水 各种颅神经功能障碍 癫痫,EXAMINATION OF EXPERIMENT,(1) CSF: Wh
16、en PM is suspected, lumbar puncture (LP) should be performed to get CSF. It should be found in CSF: Turbid or purulent High ICP,Elevated leukocyte count: greater than 1000/mm3 (3002000/mm3) and neutrophilic predominance (7595%) elevated protein (100500mg/dl) reduced glucose and chloride concentratio
17、ns Gram stain may be positive with bacteria Bacteria culture may be positive,(2) Other potentially valuable diagnostic tests CT or MRI of brain: Maybe normal except of complication，When the cases are difficult to diagnosis, the examinations are necessary. Blood cultures Bacteria on the smear of cuta
18、neous petechiae Peripheral blood: WBC, NC,实验室检查(1),脑脊液检查 是确诊本病的主要依据,脑脊液(CSF)正常值,外观 清 亮 压力 新生儿 0.29-0.78（30-80） 儿童 0.69-1.96（70-200） 白细胞数 婴儿 0-20 儿童 0-10 蛋白质 新生儿 20-120mg/dl 儿童 40mg/dl 糖 婴儿 3.9-4.9(70-90) 儿童 2.8-4.4(50-80) 氯化物 婴儿 111-123 儿童 118-128(650-750),化脓性脑膜炎的脑脊液改变： 压力升高，外观浑浊似米汤，白细胞显著增多，以中性粒细胞为主
19、，糖含量降低，蛋白增高。,实验室检查(2),脑脊液涂片 脑脊液细菌培养 血培养 皮肤瘀点、瘀斑涂片 外周血象：白细胞增多，中性粒细胞为主 降钙素原,诊断与鉴别诊断(1),早期诊断是治疗成功与否的关键 临床症状、体征及脑脊液检查 不规则抗生素治疗后,脑脊液检查结果可不典型 起病24小时内脑脊液检查结果可不典型,诊断与鉴别诊断(2),病毒性脑膜炎 结核性脑膜炎 真菌性脑膜炎,几种常见脑膜炎的脑脊液比较,项目 压力 外观 白细胞数 蛋白质 糖 氯化物 化脓性 混浊 1000以中 脑膜炎 脓样 性粒为主 结核性 毛玻 200-500 脑膜炎 璃样 淋巴为主 病毒性 轻度 清亮 0-数百 轻度 正常 正
20、常 脑膜炎 淋巴为主 ,TREATMENT,Antibiotics In order to raise curing rate, reduce the complications, improve the prognosis, the earlier diagnosis and the earlier treatment are very important. A child with rapidly progressing disease of less than 24 hr duration, in the absence of increased ICP, should receive
21、antibiotics at once after an LP is performed.,If there are signs of increased ICP or focal neurologic findings, antibiotics should be given without performing an LP. Increased ICP should be treated simultaneously.,治疗原则(1),选择抗生素原则 早期足量 有效杀菌剂 易通过血脑屏障 疗程足,治疗原则(2),抗生素治疗 肺炎球菌 青霉素、氯霉素、三代头孢菌素 脑膜炎球菌 青霉素、三代头
22、孢菌素 流感杆菌 氨苄西林、三代头孢菌素、氯霉素 疗程10-14天 金黄色葡萄球菌 耐酶青霉素、万古霉素、利福平 大肠杆菌脑膜炎 三代头孢、哌拉西林、氨基甙类 疗程21天,Supportive care Repeated medical assessments of patients with PM are essential to identify early signs of cardiovascular, CNS, and metabolic complications, such as pulse rate, blood pressure, respiratory rate, pupi
23、llary reflexes, level of consciousness, motor strength, cranial nerve signs, and evaluation for seizures. Maintain the balances of fluids, electrolytes, and plasma osomotic pressure.,Corticosteroids Rapid killing of bacteria releases toxic cell products after cell lysis that precipitates the cytokin
24、e-mediated inflammatory response result in edema formation and neurologic injury. Protein and fibrous effusion may result in fibrosis and Hydrocephalus due to interfering absorption of CSF. The corticosteroids can limit production of inflammatory mediators and fibrosis.,治疗原则(3),肾上腺皮质激素 对症治疗、支持治疗 降温 降颅压 20甘露醇、速尿 止惊 鲁米那、安定,治疗原则(4),并发症治疗 硬膜下积液 穿刺放液、外科 脑室炎 引流、脑室内局部抗生素应用,小结 1、小儿化脑常见致病菌。 2、小儿化脑临床特点。 3、化脑脑脊液变化特点。 4、选用敏感抗生素，掌握好剂量及给 药方式。,
