化脓性脑膜炎(英文)课件.pptx

1、Purulent Meningitis in ChildrenJiang LiDepartment of NeurologyChildrens Hospital Chongqing University of Medical Sciences 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 practic

2、es include:fever,increased intracranial pressure,meningeal irritation.One of the most potentially serious infections,associated with high mortality(about 10%)and morbidity.Purulent Meningitis1.Etiology2.1.1 Pathogens:Main pathogens:Neissria meningitidis,streptoccus pneumoniae,Haemophilus influenzae.

3、(2/3 of purulent meningitis are caused by these pathogens)Pathogens in special populations(neonate&3mo infants,malnutrition,immunodeficiency):gramnegative enteric bacilli,group B streptococci,staphlococcus aureus 1.2 Major risk factors for meningitis Immature immunologic function and attenuated immu

4、nologic response to pathogens Low level of immunoglobulin,defects of complement and 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 1.3 Access of bacteria invasion Typi

5、cal access-hematogenous dissemination Bacteria colonizing the mucous membranes 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 Bacteria spread to the

6、 meninges directly:through anatomic defects in the skull or head trauma Invasion from parameningeal organs:such as paranasal sinuses or middle earAccess of bacteria invasion2.Pathology Structure of meninges Characterized by leptomeningeal and perivascular infiltration with polymorphonuclear leukocyt

7、es and an inflammatory exudate.Exudate which may be distributed from convexity of brain to basal region of cranium.Exudate is more thickness due to streptococcus pneumoniae than other pathogens.Pathology3.Clinical manifestations The younger the child is,the higher incidence of meningitis will be.-2/

8、3 of cases occur less than 1yr 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).Subacute onset:Precede by several days of upper respirato

9、ry tract or gastrointestinal 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 Common features of meningitis:signs of systemic infection:fever(90-95%),ano

10、rexia,shock,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 manifestationsbrudzinski sign Seizure(20-30%)Focal or generalized Due to cereb

11、ritis,infarction,electrolyte disturbances Frequently noted with H influenzae&S pneumococcal meningitis Persist after 4th day and difficult to treat with poor prognosisClinical manifestations Clinical manifestations Alteration of mental status and consciousness Including:irritability,lethargy,stupor

12、obtundation,coma Due to increased intracranial pressure,cerebritis,hypotension Often with pneumococcal or meningococcal meningitis Comatose patients with a poor prognosis The symptoms and signs are not evident in neonates and infants younger than 3mo of age;and patients already received irregular an

13、tibiotic therapy.Clinical manifestationsSigns of systemic infectionIncreased intracranial pressuremeningeal irritationTypical(older children)Fever,altered consciousness,seizureHeadache,vomiting,herniationnuchal rigidity,back pain,kernig sign,brudzinski signAtypical(neonate&3mo infant)Fever,normal te

14、mperature 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 manifestations4.Diagnosis Earlier diagnosis and prompt initiation of

15、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 symptoms and signs in neonate,infant and patient already r

16、eceived irregular antibiotic therapy 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,de

17、creased glucose concentration(80%)Diagnosis 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:positiv

18、e in about 80%of cases.definitive diagnosis,determination of antibiotic sensitivity.PCR:amplifies bacterial DNA(H influenzae,N.meningitidis)Diagnosis5.Differential diagnosis Purulent meningitis caused by different pathogens Neissria meningitidis:Occur in epidemics(type A,C),which is more common in s

19、pring,or sporadic all the year (type B,C,Y)Sudden onset with various cutaneous signs (petechiae,purpura,or an erythematous macular rash)Streptococcus pneumoniae:Young infants(1yr)are most susceptible population Peak season:spring and winter Easier to have subdural effusion and hydrocephalus Easily h

20、ave a protracted course and relapseDifferential diagnosis Haemophilus influenzae Occurs predominantly in infants 2mo to 2yr of age Many cases are in winter Higher incidence of subdural effusion Others pathogens:staphylococcus aureus,gramnegative enteric bacilli Special susceptible population:neonate

21、,3mo infants,malnutrition,immunodeficiency Severe infection,difficult to treatDifferential diagnosis Meningitis caused by other microorganisms Differential diagnosisDifferential diagnosisDiseasePressure(Kpa)aspectTotal WBC(x106/L)Protein(g/L)Glucose(mmol/L)smearsculturesnormal0.69-1.96(0.29-0.78)cle

22、ar0-5(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/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;esp

23、ecially common in infants 4-6 month of age(rare in children over 1yr);Causative organisms:45%of cases of meningitis caused by H influenzae,30%by S pneumoniae,9%by N meningitidissubdural effusion Indications:No response to a sensitive antibiotic therapy Prolonged fever or fever reoccurring after an a

24、febrile interval with effective treatment Bulging fontanel,widening of sutures,enlarging head circumference,emesis,seizure,altered consciousness.Improved CSF profile with more serious clinical manifestationssubdural effusion Diagnosis methods:Cranial translucent test B ultrasonic examination and CT

25、Subdural space puncture subdural effusionnormalsubdural effusion6.2 Ventriculitis6.3 hydrocephalusComplicationsCirculation of cerebrospinal fluid(CSF)6.2 Ventriculitis Usually occurs in neonates and infants(50 x106/L,VentriculitisCirculation of cerebrospinal fluid(CSF)6.3 hydrocephalus:Communicating

26、 hydrocephalus:adhered or destroyed arachnoid granulation around the cistern at the base of the brain Obstructive hydrocephalus:following obstructed of the cerebral aqueduct,or the foramina of Magendie and Luschka6.4 others:Deafness,blindness,paralysis,epilepsy,mental retardationComplications7.Treat

27、ment8.7.1 Antibacterial therapy Therapy principles:early treatment,antibiotics susceptible to pathogens and with high permeability through BBB,given intraveninously,enough dose,enough course of antibiotic therapy Susceptible to pathogens First choice:Cefotaxime,Ceftriaxone (3dr generation of cephalo

28、sporins,high permeability through BBB,products of metabolism also has effect,CSF sterilization within 24h)Other choice:Penicillin,Chloromycin,Cefuroxime,Ceftazidime(delayed effect to make CSF sterile,high incidence of relapse and deafness)Antibacterial therapyEtiologyStandard antibiotics of choiceDu

29、ration of therapyH.influenzaeCefotaxime/Ceftriaxone7-10daysN.meningitidisCefotaxime/Ceftriaxone7daysS.pneumoniaeCefotaxime/Ceftriaxone2-3weeksStaphlococcus aureusSemisynthetic penicillins(Oxacillin sodium,Cloxacillin sodium),Norvancomycin3weeksE.coliCefotaxime/Ceftriaxone(or+ampicillin)3weeksUnknown

30、Cefotaxime/Ceftriaxone+ampicillin2-3weeksAntibiotic therapy of bacterial meningitis Maintenance fluid and thermal energy supplement:Fluid administration:60-80ml/kg/day Fluid infusion with dehydration therapy7.2 Supportive care Treatment increased intracranial pressure Osmotic therapy:intravenous man

31、nitol 0.5-1g/kg/every time,q4-6h Combination with intravenous dexamethasone:0.3-0.5mg/kg/day Endotracheal intubation and hyperventilation Treatment Subdural effusion Few volume could be absorbed with treatment spontaneously Subdural puncture:take out 15ml/each time (unilateral puncture),less than 30

32、ml/each time (bilateral puncture),everyday or every other day Stripping operation:for the cases not cure after 3-4weeks Treatmentp 经常不断地学习,你就什么都知道。你知道得越多,你就越有力量p Study Constantly,And You Will Know Everything.The More You Know,The More Powerful You Will Be写在最后感谢聆听不足之处请大家批评指导Please Criticize And Guide The Shortcomings结束语讲师：XXXXXX XX年XX月XX日