化脓性脑膜炎专题教育培训ppt课件

化化脓脓性性脑脑膜炎膜炎专题专题教育教育化脓性脑膜炎专题教育1Purpose and demand:To familiarize the pathogeny of purulent meningitis.To understand the mechanism and pathology change.To grasp the clinical manifestation,diagnosis,differential diagnosis and treatment.To self-study the accessory examination of neural system.化脓性脑膜炎专题教育2Purpose and demand:To familiarContentsInductionEtiology&pathogenesisManifestationsComplicationsLaboratory findingsDiagnosis&differential diagnosisTreatment&prevention化脓性脑膜炎专题教育3ContentsInduction化脓性脑膜炎专题教育3Introduction Acute infection of central nervous system(CNS).75%of cases occur in the age of 2yr.The inflammation of meninges caused by various bacteria.Common features in clinical practices include:fever,headache,vomit,convulsions,disturbance of consciousness,increased intracranial pressure,meningeal irritation.One of the most potentially serious infections,associated with high mortality(about 10%)and morbidity.化脓性脑膜炎专题教育4Introduction Acute infection oEtiology1.Pathogens:Main pathogens:Neissria meningitidis,streptoccus pneumoniae,Haemophilus influenzae.2/3 of purulent meningitis are caused by these pathogens 化脓性脑膜炎专题教育5Etiology1.Pathogens:化脓性脑膜炎专题教1.Pathogens(Pathogens in special populations)neonate&3mo infants:Escherichia coli Streptococcus haemolyticus group B Staphlococcus aureus3mo infants:Haemophilus influenzae group B Streptococcus pneumoniae Neisseria meningitidis5yr children:Neisseria meningitidis Streptococcus pneumoniaeEtiology化脓性脑膜炎专题教育61.Pathogens(Pathogens in specEtiology2.Major risk factors for meningitisImmature immunologic function and attenuated immunologic response to pathogens Low level of immunoglobulin,defects of complement Immature or impaired blood-brain-barrier(BBB)Immature BBB function:maturation at about 1yr Impaired BBB:Congenial or acquired defects across mucocutaneous barrier化脓性脑膜炎专题教育7Etiology2.Major risk factorsAccess of bacteria invasionTypical access-hematogenous dissemination Bacteria colonizing the mucous membranes of the nasopharynx invasion into local tissue bacteremia through BBS mainly effect on arachnoid and leptomeninges Mode of transmission:Person to person contact through respiratory tract secretions or droplets化脓性脑膜炎专题教育8Access of bacteria invasionTypAccess of bacteria invasionInvasion from parameningeal organs:such as paranasal sinuses or middle earBacteria spread to the meninges directly:through anatomic defects in the skull or head trauma化脓性脑膜炎专题教育9Access of bacteria invasionInv Structure of meninges 化脓性脑膜炎专题教育10 Structure of meninges 化脓性脑膜炎专PathologyCharacterized by leptomeningeal and perivascular infiltration with polymorphonuclear leukocytes 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.化脓性脑膜炎专题教育11PathologyCharacterized by leptClinical manifestationsProdrome:acute onset,precede by several days of upper respiratory infections or gastrointestinal symptoms fulminant onset:epidemic cerebrospinal meningitis manifestations:progressing shock bleeding spots in the skin or ecchymosis disseminated intravascular coagulation disturbance of central nervous system.化脓性脑膜炎专题教育12Clinical manifestationsProdromClinical manifestationsCommon features of meningitis:signs of systemic infection:fever,headache,fatigue,weakness,anorexia,bleeding spots in the skin,ecchymosis,alteration of mental status and consciousness化脓性脑膜炎专题教育13Clinical manifestationsCommon Clinical manifestationsCommon features of meningitis:neurological signs:meningeal irritation:nuchal rigidity,kernig sign,brudzinski sign increased intracranial pressure:headache,vomiting,herniation Seizure(20-30%)Focal or generalized Due to cerebritis,infarction,electrolyte disturbances Frequently noted with H influenzae&S pneumococcal meningitis化脓性脑膜炎专题教育14Clinical manifestationsCommon When flexing the hip 90 degrees and then extending the leg,the patient feels subsequent pain化脓性脑膜炎专题教育15When flexing the hip 90 degreeWhen passively flexing the neck while supine,patient involuntarily flexes his knees and hips.化脓性脑膜炎专题教育16When passively flexing the necClinical manifestationsCommon features of meningitis:neurological signs:alteration of mental status and consciousnessincluding:irritability,lethargy,somnolence,confusion,stuppor,comadue to increased intracranial pressure,cerebritis focal signs、cranial nerves in trouble,paralysis,sensory disturbance,mainly caused by vascular occlusion化脓性脑膜炎专题教育17Clinical manifestationsCommon Clinical manifestations The symptoms and signs are not evident in neonates and infants younger than 3mo of age;and patients already received irregular antibiotic therapy.化脓性脑膜炎专题教育18Clinical manifestations Comparison of the manifestations of meningitis between different age groupsSigns of systemic infectionIncreased intracranial pressuremeningeal irritationTypical(older children)Fever,altered consciousness,seizureHeadache,vomiting,herniationnuchal rigidity,back pain,kernig sign,brudzinski signAtypical(neonate&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);Causative organisms:H influenzae,S pneumoniae化脓性脑膜炎专题教育20Complications and sequelaeSubdComplications and sequelaeIndications:No response to a sensitive antibiotic therapy Prolonged fever or fever reoccurring after an afebrile interval with effective treatment Bulging fontanel,widening of sutures,enlarging head circumference,vomit,seizure,altered consciousness.Improved CSF profile with more serious clinical manifestations化脓性脑膜炎专题教育21Complications and sequelaeIndiComplications and sequelae Diagnosis methods:Cranial translucent test B ultrasonic examination and CT Subdural space puncture normalsubdural effusion化脓性脑膜炎专题教育22Complications and sequelae DiaComplications and sequelae2.VentriculitisUsually occurs in neonates and infants(50 x106/L,Glucose1.6mmol/L,or Glucose400mg/L.protein400mg/L.化脓性脑膜炎专题教育23Complications and sequelae2.VComplications and sequelae3.hydrocephalus:Communicating hydrocephalus&Obstructive hydrocephalus:Severe hydrocephalus:enlarging head circumference;bulging fontanel;suture separation;sunset eyes;increasing neuropsychiatric symptoms4.Cerebral hyponatremia:The syndrome of inappropriate secretion of antidiuretic hormone5.others:Deafness,blindness,paralysis,epilepsy,mental retardation化脓性脑膜炎专题教育24Complications and sequelae3.h化脓性脑膜炎专题教育培训ppt课件25Examinations2.Cerebrospinal fluid examinations:(2)special examination:Specific bacterial antigen-detection test Countercurrent immuno-electrophoresis,CIE Latex agglutination Immunofluorescent testLDH,lactic acid,CRP,TNF,Ig,NSE determinations化脓性脑膜炎专题教育26Examinations2.Cerebrospinal flExaminations3.Other examinations(1)blood culture:before antibiotic therapy(2)petechia smear:epidemic cerebrospinal meningitis(3)other secretion cultures:(4)imaging:CT&MRI化脓性脑膜炎专题教育27Examinations3.Other examinatioDiagnosisEarlier diagnosis and prompt initiation of effective antibiotic treatment is critical for minimizing sequelae of purulent meningitis.Suspected cases:febrile infants with seizure,meningeal irritation,increased intracranial pressure,altered mental status Pay attention to the atypical symptoms and signs in neonate,infant and patient already received irregular antibiotic therapy化脓性脑膜炎专题教育28DiagnosisEarlier diagnosis andDiagnosisDiagnosis 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,Decreased glucose concentration(80%)化脓性脑膜炎专题教育29DiagnosisDiagnosis is confirmeDiagnosis 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:positive in about 80%of cases.definitive diagnosis,determination of antibiotic sensitivity.PCR:amplifies bacterial DNA(H influenzae,N.meningitidis)化脓性脑膜炎专题教育30Diagnosis Confirmation of tDifferential diagnosisViral meningitis/encephalitis:Less severe systemic infectious symptoms Usually not develop after 2-3weeks CSF:normal glucoseTuberculous meningitis:Subacute onset and progress A history of close contact with known cases of tuberculosis Evidence of acute or healed tubercular infection on chest x-ray Tuberculin skin test:OT,PPD CSF化脓性脑膜炎专题教育31Differential diagnosisViral meDifferential diagnosisCryptococcal meningitis:slow onset,a long course of disease,increased intracranial pressuresevere headacheCSF changes:similar with tuberculous meningitisconfirmed by Indiainkstaining or culture of CSFMollarets meningitis:etiology:unknowclinical manifestations and CSF:recurrent,similar to purulent meningitisCSF:Mollarets cellsadrenocortical hormone therapy:effective化脓性脑膜炎专题教育32Differential diagnosisCryptocoDifferential diagnosisBrain abscess:slow onsetCSF:pressure,cellnormal or,protein further diagnosis:CT or MRIAcute toxic encephalopathy:manifestations:delirium,convulsions,coma,meningeal irritation,cerebral palsyCSF:only pressure 化脓性脑膜炎专题教育33Differential diagnosisBrain ab压力力kpa外外观潘氏潘氏试验白白细胞数胞数（106/L）蛋白蛋白质（g/L)糖糖（mmol/L）氯化物化物（mmol/L）其他其他正常正常0.69-1.96新生儿新生儿0.29-0.78清清010小小婴儿儿0200.20.4新生儿新生儿0.21.22.84.5婴儿儿3.95.0117127婴儿儿110122化化脑升高升高混混浊+数百数百数万，数万，多核多核为主主明明显增增加加减低减低正常或减低正常或减低涂片，涂片，培养可培养可发现致致病菌病菌结脑升高升高阻塞阻塞时低低不太清不太清毛玻璃毛玻璃样+数十数十数百，数百，淋巴淋巴为主主增高，增高，阻塞阻塞时明明显增增高高降低降低降低降低涂片或涂片或培养可培养可见抗酸抗酸杆菌杆菌病病脑正常或升高正常或升高多数清多数清+正常正常数百。数百。淋巴淋巴为主主正常或正常或稍增高稍增高正常正常正常正常病毒培病毒培养有养有时阳性阳性真菌性真菌性脑膜炎膜炎高高不太清不太清+数十数十数百，数百，单核核为主主增高增高降低降低降低降低墨汁染墨汁染色色脑脓肿常升高常升高清或者清或者不太清不太清+正常正常数百数百正常或正常或稍高稍高正常正常正常正常中毒性中毒性脑病病升高升高清清+正常正常正常或正常或稍高稍高正常正常正常正常化脓性脑膜炎专题教育34压力kpa外观潘氏试验白细胞数（106/L）蛋白质糖（mmTreatment1.Antibacterial therapyTherapy principles:early treatment,antibiotics susceptible to pathogens and with high permeability through BBB,given intraveninously,enough dose,enough course of antibiotic therapy 化脓性脑膜炎专题教育35Treatment1.Antibacterial theraTreatmentat the time of unknown pathogenic bacteria:First choice:Cefotaxime,Ceftriaxone (3dr generation of cephalosporins,high permeability through BBB,products of metabolism also has effect,CSF sterilization within 24h)Other choice:Penicillin,Chloramphenicol,(side effects:gray baby syndrome and bone marrow suppression)at the time of known pathogenic bacteria:refer to drug sensitivity test 化脓性脑膜炎专题教育36Treatmentat the time of unknowAntibiotic therapy of bacterial meningitisEtiologyStandard antibiotics of choiceDuration of therapyH.influenzaeCeftriaxone/ampicillin 2-3weeksS.pneumoniaeCefotaxime/Ceftriaxone 2-3weeksN.meningitidisPenicillin G/Ceftriaxone7-10daysStaphlococcus aureusCloxacillin/Ceftriaxone/Norvancomycin3-4weeksE.coliCefotaxime/Ceftriaxone(or+ampicillin)3-4weeksUnknownCefotaxime/Ceftriaxone+ampicillin2-3weeks化脓性脑膜炎专题教育37Antibiotic therapy of bacteriaTreatment2.Adrenal cortical hormone:dexamethasone:0.3-0.5mg/kg/day3.Symptomatic treatment&supportive care Increased intracranial pressure:Intravenous mannitol 0.5-1g/kg/every time,q4-6hConvulsions:diazepam&chloral hydrate&phenobarbitalFever:Acetaminophen&ibuprofen Maintenance fluid and thermal energy supplement:fluid administration:60-80ml/kg/day fluid infusion with dehydration therapy 化脓性脑膜炎专题教育38Treatment2.Adrenal cortical hoTreatment4.Treatment of complicationsSubdural effusion Few volume could be absorbed with treatment spontaneously Subdural puncture:take out 20-30ml/each time (unilateral puncture),less than 50-60ml/each time (bilateral puncture),everyday or every other dayVentriculitis:lateral ventricle puncture and injection of antibiotics locally Cerebral hyponatremia:supplement of sodium化脓性脑膜炎专题教育39Treatment4.Treatment of compli