病例报告细菌性脑膜炎（case report bacterial meningitis）课件

Case report Boy, 6 yrs, admitted in 23, Apr. 2005. CC: Fever, headache and vomiting for 2 days. HPI: Fever (T 39), headache, malaise, anorexia, vomiting (2), no convulsion Intracranial hypertension Vomiting, severe headache-in children A bulging fontanel (前囟隆起)-in babies Increased head circumference /papilledema-prolonged IH Cerebral hernia-severer IH Meningeal irritation Nuchal rigidity and Brudzinskis and Kernigs signs (+) Skin petechiae in epidemic cerebrospinal meningitis When flexing the hip 90 degrees and then extending the leg, the patient feels subsequent pain. When passively flexing the neck while supine, patient involuntarily flexes his knees and hips. Meningitis in neonates and younger babies Clinical findings are nonspecific fever is often absent / hypothermia Sepsis-like manifestations (refusal of feedings, pale/grey skin) Not have obvious seizure and IH Hyperactivities, fixed eyes Vomiting, high pitched cry A full, tense, or bulging fontanel Cerebrospinal fluid (CSF) findings a high pressure hydrocephalus; tuberculomas, vasculitis (infraction/malacia） cryptococcal: basal meningitis /granulomas Bacterial meningitis (enhanced MRI) enhanced density of meninges /enlarged ventricles Bacterial meningitis (enhanced CT) subdural effusion accompanied with high density of meninges HSV encephalitis (left: MRI T1; right: MRI T2) focal lesion on right temporal and insula lobes Cryptococcal meningitis (enhanced MRI) disseminated high-density on meninges, and enhanced focuses (granulomas) of left basal nuclei, temporal and occipital lobes TB meningitis (enhanced CT): high-density on cerebral basal pool and basal meninges, many tuberculomas in cerebellar hemisphere. Basal pool filled with cheesy necrotic substances TB meningitis (boy aged 8 months, enhanced CT scan) High-density basal meninges and very enlarged ventricle system TB meningitis infarction in basal nuclei and internal capsula Differential diagnosis for Tuberculous meningitis CSF culture positive for tubercle bacilli CSF TB gene fragment detected by PCR Detection of TB Ags or Abs in CSF or serum CSF /:10-14d; 3w; :3-4w; If patient having complications, duration should be prolonged. Steroid therapy Action: inhibiting the production of inflammatory factors inflammation; alleviating brain edema and ICP Regimen of dexamethasone: 0.6mg/kg.d, iv. divided 4 times (q6h), for 2- 4d Administer steroid 10-20min prior to (or time of) starting antibiotics Supportive Care Repeated medical and neurological assessments (monitoring HR, RR, pupils, consciousness) Keep air tract opening & oxygenation for the patient with coma Fluid, electrolytes, acid-base metabolism must be managed very carefully, especially until SIADH and increased ICP are ruled out Symptomatic treatment Increased ICP: mannitol is the first choice, may need to be treated emergently with intubation and hyperventilation Seizures: alternately use following drugs luminal /valium /6% chloral hydrate水合氯 醛 Fever: defervescents or physical methods (ice pillow or alcohol bath) Management for complications Subdural effusion: if presenting increased ICP, treated by aspiration Ventriculitis: drainage from ventricles and antibiotic injection through drainage tube Hydrocephalus: surgical therapy SIADH (hyponatremia): 130mmol/L: fluid restriction 120mmol/L: fluid restriction + 3%NaCl supplement Prognosis Mortality: 5-15% 1/3 survivors remain neurological sequelae Younger infants aged below 6 months usually had a worsen outcome. Back to case report CSF findings: WBC 210/mm3, N 61%, Glu 2.04 mmol/L, Pro 882.5mg/L Treatment & outcome: He got ceftriaxone and symptomatic treatments. After 4 days, his fever and headache were relieved. 10 days later, his meningeal irritation disappeared. Bacterial meningitis was confirmed Q2: Why does he have recurrent onset of bacterial meningitis? We suspected that he had focal infection nearby meningeal membrane. He was found to have cerebrospinal rhinorrhea and left mastoiditis by CT scan, and finally he was transferred to the word of ENT department. After one month, he was taken