儿科英文化脓性脑膜炎.ppt

Introduction Bacterialmeningitisisaninflammationoftheleptomenings usuallycausingbybacterialinfection Bacterialmeningitismaypresentacutely symptomsevolvingrapidlyover1 24hours subacutely symptomsevolvingover1 7days orchronically symptomsevolvingovermorethan1week Introduction Annualincidenceinthedevelopedcountriesisapproximately5 10per100000 30000infantsandchildrendevelopbacterialmeningitisinUnitedStateseachyear Approximately90percentofcasesoccurinchildrenduringthefirst5yearsoflife Introduction Casesunderage2yearsaccountforalmost75 ofallcasesandincidenceisthehighestinearlychildhoodatage6 12monthsthaninanyotherperiodoflife Therearesignificantdifferenceintheincidenceofbacterialmeningitisbyseason Etiology Causativeorganismsvarywithpatientage withthreebacteriaaccountingforoverthree quartersofallcases Neisseriameningitidis meningococcus Haemophilusinfluenzae ifveryyoungandunvaccinated Streptococcuspneumoniae pneumococcus Etiology OtherorganismsNeonatesandinfantsatage2 3monthsEscherichiacoliB haemolyticstreptococciStaphylococcusaureusStaphylococcusepidermidisListeriamonocytogenes Etiology ElderlyandimmunocompromisedListeriamonocytogenesGramnegativebacteriaHospital acquiredinfectionsKlebsiellaEscherichiacoliPseudomonasStaphylococcusaureus Etiology ThemostcommonorganismsNeonatesandinfantsundertheageof2monthsEscherichiacoliPseudomonasGroupBStreptococcusStaphylococcusaureus Etiology Childrenover2monthsHaemophilusinfluenzaetypebNeisseriameningitidisStreptococcuspneumoniaeChildrenover12yearsNeisseriameningitidisStreptococcuspneumoniae Etiology MajorroutesofleptomeninginfectionBacteriaaremainlyfromblood Uncommonly meningitisoccursbydirectextensionfromnearlyfocus mastoiditis sinusitis orbydirectinvasion dermoidsinustract headtrauma meningo myelocele Pathogenesis SusceptibilityofbacterialinfectiononCNSinthechildrenImmaturityofimmunesystemsNonspecificimmuneInsufficientbarrier Blood brainbarrier InsufficientcomplementactivityInsufficientchemotaxisofneutrophilsInsufficientfunctionofmonocyte macrophagesystemBloodlevelsofdiminishedinterferon INF andinterleukin 8 IL 8 Pathogenesis SusceptibilityofbacterialinfectiononCNSinthechildrenSpecificimmuneImmaturityofboththecellularandhumoralimmunesystemsInsufficientantibody mediatedprotectionDiminishedimmunologicresponseBacterialvirulence Pathogenesis Aoffendingbacteriumfrombloodinvadestheleptomeninges BacterialtoxicsandInflammatorymediatorsarereleased BacterialtoxicsLipopolysaccharide LPSTeichoicacidPeptidoglycanInflammatorymediatorsTumornecrosisfactor TNFInterleukin 1 IL 1ProstaglandinE2 PGE2 Pathogenesis Bacterialtoxicsandinflammatorymediatorscausesuppurativeinflammation InflammatoryinfiltrationVascularpermeabilityalterTissueedemaBlood brainbarrierdetroyThrombosis Pathology Diffusebacterialinfectionsinvolvetheleptomeninges arachnoidmembraneandsuperficialcorticalstructures andbrainparenchymaisalsoinflamed Meningealexudateofvaryingthicknessisfound Thereispurulentmaterialaroundveinsandvenoussinuses overtheconvexityofthebrain inthedepthsofthesulci withinthebasalcisterns andaroundthecerebellum andspinalcordmaybeencasedinpus Ventriculitis purulentmaterialwithintheventricles hasbeenobservedrepeatedlyinchildrenwhohavediedoftheirdisease Pathology Invasionoftheventricularwallwithperivascularcollectionsofpurulentmaterial lossofependymallining andsubependymalgliosismaybenoted Subduralempyemamayoccur Hydrocephalusisancommoncomplicationofmeningitis ObstructivehydrocephalusCommunicatinghydrocephalus Pathology Bloodvesselwallsmayinfiltratedbyinflammatorycells EndothelialcellinjuryVesselstenosisSecondaryischemiaandinfarctionVentricledilatationwhichensuesmaybeassociatedwithnecrosisofcerebraltissueduetotheinflammatoryprocessitselfortoocclusionofcerebralveinsorarteries Pathology Inflammatoryprocessmayresultincerebraledemaanddamageofthecerebralcortex ConsciousdisturbanceConvulsionMotordisturbanceSensorydisturbanceMeningealirritationsignisfoundbecausethespinalnerverootisirritated Cranialnervemaybedamaged Clinicalmanifestation Bacterialmeningitismaypresentacutely symptomsevolvingrapidlyover1 24hours inmostcases Symptomsandsignsofupperrespiratoryorgastrointestinalinfectionarefoundbeforeseveraldayswhentheclnicalmanifestationsofbacterialmeningitishappen SomepatientsmayaccesssuddenlywithshockandDIC Clinicalmanifestation ToxicsymptomalloverthebodyHyperpyrexiaHeadachePhotophobiaPainfuleyemovementFatiguedandweakMalaise myalgia anorexia Vomiting diarrheaandabdominalpainCutaneousrashPetechiae purpura Clinicalmanifestation ClinicalmanifestationofCNSIncreasedintracranialpressureHeadacheProjectilevomitingHypertensionBradycardiaBulgingfontanelCranialsuturesdiastasisComaDecerebraterigidityCerebralhernia Clinicalmanifestation ClinicalmanifestationofCNSSeizuresSeizuresoccurinabout20 30 ofchildrenwithbacterialmeningitis Seizuresisoftenfoundinhaemophilusinfluenzaeandpneumococalinfection Seizuresiscorrelativewiththeinflammationofbrainparenchyma cerbralinfarctionandelectrolytedisturbances 第一课件网站 Clinicalmanifestation ClinicalmanifestationofCNSConsciousdisturbanceDrowsinessCloudingofconsciousnessComaPsychiatricsymptomIrritationDysphoriadullness Clinicalmanifestation ClinicalmanifestationofCNSMeningealirritationsignNeckstiffnessPositiveKernig ssignPositiveBrudzinski ssign Clinicalmanifestation ClinicalmanifestationofCNSTransientorpermanentparalysisofcranialnervesandlimbsmaybenoted Deafnessordisturbancesinvestibularfunctionarerelativelycommon Involvementoftheopticnerve withblindness israre Paralysisofthe6thcranialnerve usuallytransient isnotedfrequentlyearlyinthecourse Clinicalmanifestation Symptomandsignsoftheinfantundertheageof3monthsInsomechildren particularlyyounginfantsundertheageof3months symptomandsignsofmeningealinflammationmaybeminimal Feverisgenerallypresent butitsabsenceorhypothermiainainfantwithmeningealinflammationiscommon Onlyirritability restlessness dullness vomiting poorfeeding cyanosis dyspnea jaundice seizures shockandcomamaybenoted Bulgingfontanelmaybefound butthereisnotmeningealirritationsign Complication SubduraleffusionSubduraleffusionsoccurinabout10 30 ofchildrenwithbacterialmeningitis Subduraleffusionsappeartobemorefrequentinthechildrenundertheageof1yearandinhaemophilusinfluenzaeandpneumococalinfection Clinicalmanifestationsareenlargementinheadcircumference bulgingfontanel cranialsuturesdiastasisandabnormaltransilluminationoftheskull SubduraleffusionsmaybediagnosedbytheexaminationofCTorMRIandsubduralpricking Complication EpendymitisNeonateorinfantwithmeningitisGram negativebacterialinfectionClinicalmanifestationPersistenthyperpyrexia FrequentconvulsionAcuterespiratoryfailureBulgingfontanelVentriculomegaly CT CerebrospinalfluidbyventricularpunctureWBC 50 109 LGlucoseo 4g L Complication CerebullarhyponatremiaSyndremofinappropriatesecretionofantidiuretichormone SIADH HyponatremiaDegradeofbloodosmoticpressureAggravatedcerebraledemaFrequentconvulsionAggravatedconsciousdisturbance Complication HydrocephalusIncreasedintracranialpressureBulgingfontanelAugmentationofheadcircumferenceBrainfunctiondisorderOthercomplicationDeafnessorblindnessEpilepsyParalysisMentalretardationBehaviordisorder LaboratoryFindings PeripheralhemogramTotalWBCcount20 109 L 40 109 LWBCDecreasedWBCcountatsevereinfectionLeukocytedifferentialcount80 90 Neutrophils LaboratoryFindings Routexaminationofcerebrospinalfluid CSF IncreasedpressureofcerebrospinalfluidCloudinessEvidentIncreasedtotalWBCcount 1000 109 L EvidentIncreasedneutrophilsinleukocytedifferentialcountEvidentDecreasedglucose 1 1mmol l EvidentIncreasedproteinlevelDecreasedornormalchloridateCSFfilmpreparationorcultivation positiveresult LaboratoryFindings EspecialexaminationofCSFSpecificbacterialantigentestCountercurrentimmuno electrophoresisLatexagglutinationImmunofluorescenttestNeisseriameningitidis meningococcus HaemophilusinfluenzaeStreptococcuspneumoniae pneumococcus GroupBstreptococcus LaboratoryFindings EspecialexaminationofCSFOthertestofCSFLDHLacticacidCRPTNFandIgNeuronspecificenolase NSE LaboratoryFindings OtherbacterialtestBloodcultivationFilmpreparationofskinpetechiaeandpurpuraSecretioncultureoflocallesionImageologyexamination Diagnosis DiagnosticmethodsAcarefulevaluationofhistoryAcarefulevaluationofinfant ssignsandsymptomsAcarefulevaluationofinformationonlongitudinalchangesinvitalsignsandlaboratoryindicatorsRoutexaminationofcerebrospinalfluid CSF Differentialdiagnosis Clinicalmanifestationofbacterialmeningitisissimilartoclinicalmanifestationofviral tuberculous fungalandasepticmeningitis Differentiationofthesedisordersdependsuponcarefulexaminationofcerebrospinalfluidobtainedbylumbarpunctureandadditionalimmunologic roentgenographic andisotopestudies CharacteristicsofCSFoncommondiseaseinCNS TreatmentAntibioticTherapy TherapeuticprincipleGoodpermeabilityforBlood brainbarrierDrugcombinationIntravenousdripFulldosageFullcourseoftreatment AntibioticTherapy SelectionofantibioticNoCertainlyBacteriumCommunity acquiredbacterialinfectionNosocomialinfectionacquiredinahospitalBroad spectrumantibioticcoverageasnotedbelowChildrenunderage3monthsCefotaximeandampicillinCeftriaxoneandampicillin childrenoverage1months Childrenover3monthsCefotaximeorCeftriaxoneorampicillinandchloramphenicol AntibioticTherapy CertainlyBacteriumOncethepathogenhasbeenidentifiedandtheantibioticsensitivitiesdetermined themostappropriatedrugsshouldselected Nmeningitidis penicillin tert cephalosporinSpneumoniae penicillin tert cephalosporin vancomycinHinfluenzae ampicillin tert cephalosporinSaureus penicillin nefcillin vancomycinEcoli ampicillin chloramphenicol tert cephalosporin AntibioticTherapy Courseoftreatment7daysformeningococcalinfection10 14daysforHinfluenzaeorSpneumoniaeinfectionMorethan