化膿性腦膜炎中英文版培訓(xùn)課件

1、AbbreviationsPM purulent meningitis CSF cerebrospinal fluidCNS central nervous systemICP intracranial pressureBBB blood-brain barrierWBC white blood cellNC neutrocyteAbbreviations INTRODUCTION Purulent Meningitis (PM) is one of serious bacterial infection. PM is associated with a high rate of acute

2、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. INTRODUCTION概念 由化膿性細菌引起的 中樞神經(jīng)系統(tǒng)急性感 染性疾病概念 由化膿性細菌引起的病原學(xué)(1)常見病原 腦膜炎球菌 (meningococcus)肺炎鏈球菌 (pneumococcus)流感嗜血桿菌 (haemophilus infl

3、uenzae)金黃色葡萄球菌（staphylococcus aureus）大腸桿菌（escherichia coli）病原學(xué)(1)常見病原 腦膜炎球菌 腦膜炎球菌肺 炎 球 菌肺 炎 球 菌 Common bacteriaThe first 2 month: escherichia coli ; staphylococcus aureus;2 month12 yr: Pneumococcus; Meningococcus; Hemophilus influenzae type b. Common bacteri病原學(xué)(2) 病原菌與年齡的關(guān)系 新生兒 大腸桿菌、綠膿桿菌、金黃色葡萄球菌 兒童

4、腦膜炎球菌、肺炎球菌、流感嗜血桿菌病原學(xué)(2) 病原菌與年齡的關(guān)系 發(fā)病機制(1)發(fā)病機制(1) The risk factors1. Lack of immunity: young age, defects of T-lymphocyte, defects of immunoglobulin, defects of the complement system or properdin system 2. EnvironmentCongenital or acquired CSF leak: such as cranial defect or middle ear fistulas, basa

5、l skull fracture, lumbosacral dermal sinus, penetrating cranial trauma The risk factMeningocele SinusMeningocele 回顧 中樞神經(jīng)系統(tǒng)腦膜的解剖及腦脊液的循環(huán) 回顧 PATHOGENESIS Bacteria attack to the mucosal epithelial cell receptors by pili, enter the circulation, penetrate the BBB (blood-brain barrier) to the CSF, colonize

6、 and multiply, then incite inflammatory response and polymorphonuclear cell infiltration, which produce TNF, IL-1, PG-2 and other cytokines. PATHOGENE致病菌入侵途徑致病菌軟腦膜蛛網(wǎng)膜表層腦血流途徑直接通道臨近感染致病菌入侵途徑致病菌軟腦膜蛛網(wǎng)膜表層腦血流途徑直接通道臨近感發(fā)病機制(2)決定入侵中樞神經(jīng)系統(tǒng)的因素 細菌數(shù)量 毒力 機體免疫狀態(tài)多種細胞因子參與發(fā)病 TNF，IL1等 發(fā)病機制(2)決定入侵中樞神經(jīng)系統(tǒng)的因素 PATHOLOGY Men

7、ingeal exudation and varying thickness Vascular changes: vasculitis , thrombosis, necrosis or occlusion of small vascules Cerebral infarction Increased ICP Ventriculitis Hydrocephalus, communicating Damage of the cerebral cortex P 輕癥化腦的病理變化 軟腦膜及蛛網(wǎng)膜炎、表層腦組織為主的炎癥反應(yīng)，炎癥滲出物主要在大腦頂部表面。 重癥化腦的病理變化 除輕癥的改變外，還出現(xiàn)

8、血管病變、腦實質(zhì)損害，腦室管膜炎、顱神經(jīng)受累。 輕癥化腦的病理變化化膿性腦膜炎中英文版培訓(xùn)課件 CLINICAL MANIFESTATIONS CLINICAL MANI(1) Nonspecific finding: fever; anorexia or poor feeding; symptoms of URI, myalgias, arthralgias, tachycardia, hypotension, various cutaneous signs(1) Nonspecific finding: (2) cerebral dysfunction:Seizures: focal or

9、 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 level of consciounes: irritality, lethargy, stupor, obtundation, coma. Comatose ones have a poor prognosis(2) cere

10、bral dysfunction:(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 auditory nerve paralysis), signs of herniation (tachycardia or bradycardia, apnea or hypervent

11、ilation) (3) Increased ICP: (4) Meningeal irritation: Nuchal rigidity Back pain Kernig sign Brudrinski sign(4) Meningeal irritation:臨床表現(xiàn)(1)年長兒及成人典型表現(xiàn)（）感染中毒及急性腦功能障礙癥狀興奮：煩躁、驚厥抑制：嗜睡、昏睡、淺昏迷、深昏迷 （2）顱高壓表現(xiàn) 頭痛、嘔吐、視乳頭水腫顱高壓三聯(lián)征臨床表現(xiàn)(1)年長兒及成人典型表現(xiàn)（）感染中毒及急性腦功能 頸項強直 （3）體征 ：腦膜刺激征 克氏征陽性 布氏征陽性 頸項強直4歲女孩患腦膜炎 表現(xiàn)為神志淡漠4歲女孩

12、患腦膜炎 表現(xiàn)為神志淡漠4歲女孩患腦膜炎 頸項強直、布氏征陽性4歲女孩患腦膜炎 頸項強直、布氏征陽性44歲女孩患腦膜炎 克氏征陽性44歲女孩患腦膜炎 克氏征陽性臨床表現(xiàn)()年齡小于3個月的幼嬰和新生兒化腦的特點：1、體溫可高可低2、顱壓增高不明顯3、驚厥可不典型4、腦膜刺激征不明顯臨床表現(xiàn)()年齡小于3個月的幼COMPLICATIONSCOMPLICATIONS1. Subdural effusion It is the most common complication of PM in childhood. Its incidence is around 3060%, and adding

13、asymptomatic ones, the incidence is 8590%. Most of 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:1. Subdural effusion fever, seizures, alternation of mental status, bulging fontanel, diast

14、asis of sutures, enlarging head circumference, emesis, positive cranial transillumination, etc. CT or MRI of brain can make the definite diagnosis.fever, seizures, alternation o并發(fā)癥及后遺癥(1)硬膜下積液2ml，蛋白定量 400 mg/L并發(fā)癥及后遺癥(1)硬膜下積液化膿性腦膜炎中英文版培訓(xùn)課件化膿性腦膜炎中英文版培訓(xùn)課件2. Ventriculitis It is occurred in the patients

15、who are not treated in time. The symptoms and signs of PM are not improved and even progressed using effective antibiotics2. Ventriculitis并發(fā)癥及后遺癥(2)腦室管膜炎(見于新生兒、小嬰兒)治療被延誤強力治療后仍持續(xù)發(fā)熱、反復(fù)抽搐、呼吸衰竭且進行性加重腦脊液始終不正常頭顱B超、CT可助診，確診依靠側(cè)腦室穿刺腦室液并發(fā)癥及后遺癥(2)腦室管膜炎(見于新生兒、小嬰兒)化膿性腦膜炎中英文版培訓(xùn)課件3. SIADH (syndrome of inappropriat

16、ion 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 exacerbate cerebral edema or directly produce hyponatremic seizures.3. SIADH (syndrome of inapprop并發(fā)癥及后遺癥(3)抗利尿激素異常分泌

17、綜合征病因 炎癥累及下丘腦及垂體后葉，引起抗利尿激素過量分泌。表現(xiàn) 低鈉及血漿滲透壓降低并發(fā)癥及后遺癥(3)抗利尿激素異常分泌綜合征 othersCranial nerve palsies: such as deafness, blindnessCerebral or cerebellar herniationhydrocephalus other其他并發(fā)癥及后遺癥腦積水各種顱神經(jīng)功能障礙 癲癇其他并發(fā)癥及后遺癥化膿性腦膜炎中英文版培訓(xùn)課件EXAMINATION OF EXPERIMENTEXAMINATION (1) CSF: When PM is suspected, lumbar pun

18、cture (LP) should be performed to get CSF. It should be found in CSF:Turbid or purulent High ICP (1) CSF: Elevated leukocyte count: greater than 1000/mm3 (3002000/mm3) and neutrophilic predominance (7595%) elevated protein (100500mg/dl) reduced glucose and chloride concentrationsGram stain may be po

19、sitive with bacteriaBacteria culture may be positiveElevated leukocyte count: grea(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

20、 cutaneous petechiae Peripheral blood: WBC, NC(2) Other potentially valuable實驗室檢查(1)腦脊液檢查 是確診本病的主要依據(jù)實驗室檢查(1)腦脊液檢查 腦脊液(CSF)正常值外觀清亮壓力 新生兒 0.29-0.78（30-80） 兒童 0.69-1.96（70-200）白細胞數(shù) 嬰兒 0-20 兒童 0-10蛋白質(zhì) 新生兒 20-120mg/dl 兒童 1000以中 腦膜炎 膿樣 性粒為主結(jié)核性 毛玻 200-500 腦膜炎 璃樣 淋巴為主病毒性 輕度 清亮 0-數(shù)百 輕度 正常 正常 腦膜炎 淋巴為主 幾種常見腦膜炎

21、的腦脊液比較項目壓力外觀白細胞數(shù) 蛋TREATMENTTREATMENT 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,

22、should receive antibiotics at once after an LP is performed. Antibi 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. If there are signs of 治療原則(1)選擇抗生素原則早期足量有效殺菌劑易通過血腦屏障療程足 治療原則(1)選

23、擇抗生素原則治療原則(2)抗生素治療肺炎球菌 青霉素、氯霉素、三代頭孢菌素腦膜炎球菌 青霉素、三代頭孢菌素 流感桿菌 氨芐西林、三代頭孢菌素、氯霉素 療程10-14天金黃色葡萄球菌 耐酶青霉素、萬古霉素、利福平大腸桿菌腦膜炎 三代頭孢、哌拉西林、氨基甙類 療程21天治療原則(2)抗生素治療 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, pupillary