儿科英文化脓性脑膜炎Bacterialmeningitis课件

Introduction?Bacterial meningitis is an inflammation of the leptomenings,usually causing by bacterial infection.?Bacterial meningitis may present acutely(symptoms evolving rapidly over 1-24 hours),subacutely(symptoms evolving over 1-7days),or chronically(symptoms evolving over more than 1 week).Introduction?Bacterial meningiIntroduction?Annual incidence in the developed countries is approximately 5-10 per 100000.?30000 infants and children develop bacterial meningitis in United States each year.?Approximately 90 per cent of cases occur in children during the first 5 years of life.Introduction?Annual incidence Introduction?Cases under age 2 years account for almost 75%of all cases and incidence is the highest in early childhood at age 6-12 months than in any other period of life.?There are significant difference in the incidence of bacterial meningitis by season.Introduction?Cases under age 2Etiology?Causative organisms vary with patient age,with three bacteria accounting for over three-quarters of all cases:?Neisseria meningitidis(meningococcus)?Haemophilus influenzae(if very young and unvaccinated)?Streptococcus pneumoniae(pneumococcus)Etiology?Causative organisms vEtiology?Other organisms?Neonates and infants at age 2-3 months?Escherichia coli?B-haemolytic streptococci?Staphylococcusaureus?Staphylococcusepidermidis?Listeria monocytogenesEtiology?Other organisms?NeonEtiology?Elderly and immunocompromised?Listeria monocytogenes?Gram negative bacteria?Hospital-acquired infections?Klebsiella?Escherichia coli?Pseudomonas?Staphylococcus aureusEtiology?Elderly and immunocomEtiology?Themostcommon organisms?Neonates and infants under the age of 2months?Escherichia coli?Pseudomonas?Group B Streptococcus?Staphylococcus aureusEtiology?ThemostcommonorganismEtiology?Children over 2 months?Haemophilus influenzae type b?Neisseria meningitidis?Streptococcus pneumoniae?Children over 12 years?Neisseria meningitidis?Streptococcus pneumoniaeEtiology?Children over 2 monthEtiology?Major routes of leptomening infection?Bacteria are mainly from blood.?Uncommonly,meningitis occurs by direct extension from nearly focus(mastoiditis,sinusitis)or by direct invasion(dermoid sinus tract,head trauma,meningo-myelocele).Etiology?Major routes of leptoPathogenesis?Susceptibility of bacterial infection on CNSin the children?Immaturity of immune systems?Nonspecific immune?Insufficient barrier(Blood-brain barrier)?Insufficient complement activity?Insufficient chemotaxis of neutrophils?Insufficient function of monocyte-macrophage system?Blood levels of diminished interferon(INF)-and interleukin-8(IL-8)Pathogenesis?Susceptibility ofPathogenesis?Susceptibility of bacterial infection on CNS in the children?Specific immune?Immaturity of both the cellular and humoral immune systems?Insufficient antibody-mediated protection?Diminished immunologic response?Bacterial virulence Pathogenesis?Susceptibility ofPathogenesis?A offending bacterium from blood invades the leptomeninges.?Bacterial toxics and Inflammatory mediators are released.?Bacterial toxics?Lipopolysaccharide,LPS?Teichoic acid?Peptidoglycan?Inflammatory mediators?Tumor necrosis factor,TNF?Interleukin-1,IL-1?Prostaglandin E2,PGE2Pathogenesis?A offending bactePathogenesis?Bacterial toxics and inflammatory mediators cause suppurative inflammation.?Inflammatory infiltration?Vascular permeability alter?Tissue edema?Blood-brain barrier detroy?Thrombosis Pathogenesis?Bacterial toxics Pathology?Diffuse bacterial infections involve the leptomeninges,arachnoid membrane and superficial cortical structures,and brain parenchyma is also inflamed.?Meningeal exudate of varying thickness is found.?There is purulent material around veins and venous sinuses,over the convexity of the brain,in the depths of the sulci,within the basal cisterns,and around the cerebellum,and spinal cord may be encased in pus.?Ventriculitis(purulent material within the ventricles)has been observed repeatedly in children who have died of their disease.Pathology?Diffuse bacterial inPathology?Invasion of the ventricular wall with perivascular collections of purulent material,loss of ependymal lining,and subependymal gliosis maybe noted.?Subdural empyema may occur.?Hydrocephalus is an common complication of meningitis.?Obstructive hydrocephalus?Communicating hydrocephalusPathology?Invasion of the ventPathology?Blood vessel walls may infiltrated by inflammatory cells.?Endothelial cell injury?Vessel stenosis?Secondary ischemia and infarction?Ventricle dilatation which ensues may be associated with necrosis of cerebral tissue due to the inflammatory process itself or to occlusion of cerebral veins or arteries.Pathology?Blood vessel walls mPathology?Inflammatory process may result in cerebral edema and damage of the cerebral cortex.?Conscious disturbance?Convulsion?Motor disturbance?Sensory disturbance?Meningeal irritation sign is found because the spinal nerve root is irritated.?Cranial nerve may be damagedPathology?Inflammatory processClinical manifestation?Bacterial meningitis may present acutely(symptoms evolving rapidly over 1-24 hours)in most cases.?Symptoms and signs of upper respiratory or gastrointestinal infection are found before several days when the clnical manifestations of bacterial meningitis happen.?Some patients may access suddenly with shock and DIC.Clinical manifestation?BacteriClinical manifestation?Toxic symptom all over the body?Hyperpyrexia?Headache?Photophobia?Painful eye movement?Fatigued and weak?Malaise,myalgia,anorexia,?Vomiting,diarrhea and abdominal pain?Cutaneous rash?Petechiae,purpuraClinical manifestation?Toxic sClinical manifestation?Clinical manifestation of CNS?Increased intracranial pressure?Headache?Projectile vomiting?Hypertension?Bradycardia?Bulging fontanel?Cranial sutures diastasis?Coma?Decerebrate rigidity?Cerebral herniaClinical manifestation?ClinicaClinical manifestation?Clinical manifestation of CNS?Seizures?Seizures occur in about 20%-30%of children with bacterial meningitis.?Seizures is often found in haemophilus influenzae and pneumococal infection.?Seizuresis correlative with the inflammation of brain parenchyma,cerbral infarction and electrolyte disturbances.第一课件网站Clinical manifestation?ClinicaClinical manifestation?Clinical manifestation of CNS?Conscious disturbance?Drowsiness?Clouding of consciousness?Coma?Psychiatric symptom?Irritation?Dysphoria?dullnessClinical manifestation?ClinicaClinical manifestation?Clinical manifestation of CNS?Meningeal irritation sign?Neck stiffness?Positive Kernigs sign?Positive Brudzinskis signClinical manifestation?ClinicaClinical manifestation?Clinical manifestation of CNS?Transient or permanent paralysis of cranial nerves and limbs may be noted.?Deafness or disturbances in vestibular function are relatively common.?Involvement of the optic nerve,with blindness,is rare.?Paralysis of the 6thcranial nerve,usually transient,is noted frequently early in the course.Clinical manifestation?ClinicaClinical manifestation?Symptom and signs of the infant under the age of 3 months?In some children,particularly young infants under the age of 3 months,symptom and signs of meningeal inflammation may be minimal.?Fever is generally present,but its absence or hypothermiain a infant with meningeal inflammation is common.?Only irritability,restlessness,dullness,vomiting,poor feeding,cyanosis,dyspnea,jaundice,seizures,shock and coma may be noted.?Bulging fontanel may be found,but there is not meningeal irritation sign.Clinical manifestation?SymptomComplication?Subdural effusion?Subdural effusions occur in about 10%-30%of children with bacterial meningitis.?Subdural effusions appear to be more frequent in the children under the age of 1 year and in haemophilus influenzae and pneumococal infection.?Clinical manifestations are enlargement in head circumference,bulging fontanel,cranial sutures diastasis and abnormal transillumination of the skull.?Subdural effusions may be diagnosed by the examination of CT or MRI and subdural pricking.Complication?Subdural effusionComplication?Ependymitis?Neonate or infant with meningitis?Gram-negative bacterial infection?Clinical manifestation?Persistent hyperpyrexia,?Frequent convulsion?Acute respiratory failure?Bulging fontanel?Ventriculomegaly(CT)?Cerebrospinal fluidby ventricular puncture?WBC50109/L?Glucoseo.4g/LComplication?Ependymitis?NeonComplication?Cerebullar hyponatremia?Syndrem of inappropriate secretion of antidiuretic hormone(SIADH)?Hyponatremia?Degrade of blood osmotic pressure?Aggravated cerebral edema?Frequent convulsion?Aggravated conscious disturbanceComplication?Cerebullar hyponaComplication?Hydrocephalus?Increased intracranial pressure?Bulging fontanel?Augmentation of head circumference?Brain function disorder?Other complication?Deafness or blindness?Epilepsy?Paralysis?Mental retardation?Behavior disorderComplication?Hydrocephalus?InLaboratory Findings?Peripheral hemogram?Total WBC count?20109/L 40109/L WBC?Decreased WBC count at severe infection?Leukocyte differential count?80%90%NeutrophilsLaboratory Findings?PeripheralLaboratory Findings?Rout examination of cerebrospinal fluid(CSF)?Increased pressure of cerebrospinal fluid?Cloudiness?Evident Increased total WBC count(1000 109/L)?Evident Increased neutrophils in leukocyte differential count?Evident Decreased glucose(1.1mmol/l)?Evident Increased protein level?Decreased or normal chloridate?CSF film preparation or cultivation:positive result Laboratory Findings?Rout examiLaboratory Findings?Especial examination of CSF?Specific bacterial antigen test?Countercurrent immuno-electrophoresis?Latex agglutination?Immunofluorescent test?Neisseria meningitidis(meningococcus)?Haemophilus influenzae?Streptococcus pneumoniae(pneumococcus)?Group B streptococcusLaboratory Findings?Especial eLaboratory Findings?Especial examination of CSF?Other test of CSF?LDH?Lactic acid?CRP?TNF and Ig?Neuron specific enolase(NSE)Laboratory Findings?Especial eLaboratory Findings?Other bacterial test?Blood cultivation?Film preparation of skin petechiae and purpura?Secretion culture of local lesion?Imageology examinationLaboratory Findings?Other bactDiagnosis?Diagnostic methods?A careful evaluation of history?A careful evaluation of infants signs and symptoms?A careful evaluation of information on longitudinal changes in vital signs and laboratory indicators?Rout examination of cerebrospinal fluid(CSF)Diagnosis?Diagnostic methods?ADifferential diagnosis?Clinical manifestation of bacterial meningitis is similar to clinical manifestation of viral,tuberculous,fungal and aseptic meningitis.?Differentiation of these disorders depends upon careful examination of cerebrospinal fluid obtained by lumbar puncture and additional immunologic,roentgenographic,and isotope studies.Differential diagnosis?ClinicaCharacteristics of CSF on common diseasein CNSPM TM VW FM TE Pressure or Cloudiness or Pandy T or or ororWBC N L orL M Protein or or Glucos Chloridate or Cultivation Bacterium TB Viral Fungus Characteristicsof CSF on commoTreatmentAntibiotic Therapy?Therapeutic principle?Good permeability for Blood-brain barrier?Drug combination?Intravenous drip?Full dosage?Full course of treatmentTreatmentAntibiotic Therapy?ThAntibiotic Therapy?Selection of antibiotic?No Certainly Bacterium?Community-acquired bacterial infection?Nosocomial infection acquired in a hospital?Broad-spectrum antibiotic coverage as noted below?Children under age 3 months?Cefotaxime and ampicillin?Ceftriaxone and ampicillin(children over age 1months)?Children over 3 months?Cefotaxime or Ceftriaxone or ampicillin and chloramphenicolAntibiotic Therapy?Selection oAntibiotic Therapy?Certainly Bacterium?Once the pathogen has been identified and the antibiotic sensitivities determined,the most appropriate drugs should selected.?N meningitidis:penicillin,tert-cephalosporin?S pneumoniae:penicillin,tert-cephalosporin,vancomycin?H influenzae:ampicillin,tert-cephalosporin?S aureus:penicillin,nefcillin,vancomycin?E coli:ampicillin,chloramphenicol,tert-cephalosporinAntibiotic Therapy?Certainly BAntibiotic Therapy?Course of treatment?7 days for meningococcal infection?1014 days for H influenzae or S pneumoniae infection?More than 21 days for S aureus or E coli infection?1421 days for other organismsAntibiotic Therapy?Course of tTreatmentGeneral and Supportive Measures?Monitor of vital sign?Correcting metabolic imbalances?Supplying sufficient heat quantity?Correcting hypoglycemia?Correcting metabolic acidemia?Correcting fluids and electrolytes disorder?Application of cortical hormone?Lessening inflammatory reaction?Lessening toxic symptom?lessening cerebral edemaTreatmentGeneral and SupportivGeneral and Supportive Measures?Treatment of hyperpyrexia and seizures?Pyretolysis by physiotherapy and/or drug?Convulsive management?Diazepam?Phenobarbital?Subhibernation therapy?Treatment of increased intracranial pressure?Dehydration therapy?20%Mannitol 5ml/kg vi q6h?Lasix 1-2mg/kg viGeneral and Supportive MeasureGeneral and Supportive Measures?Treatment of septic shock and DIC?Volume expansion?Dopamine?Corticosteroids?Heparin?Fresh frozen plasma?Platelet transfusionsGeneral and Supportive MeasureTreatmentComplication Measures?Subdural effusions?Subduaral pricking?Draw-off effusions on one side is 20-30ml/time.?Once daily or every other day is requested.?Time cell of pricking may be prolonged after 2 weeks.?Ependymitis?Ventricular puncture drainage?Pressure in ventricle be depressed.?Ventricular puncture may give ventricle an injection ofantibiotic.TreatmentComplication Measures