《化脑双语袁宝莉》PPT课件

化脓性脑膜炎purulentmeningitis,AbbreviationsPMpurulentmeningitisCSFcerebrospinalfluidCNScentralnervoussystemICPintracranialpressureBBBblood-brainbarrierWBCwhitebloodcellNCneutrocyte,INTRODUCTIONPurulentMeningitis(PM)isoneofseriousbacterialinfection.PMisassociatedwithahighrateofacutecomplicationsandriskofchronicsequelae.PMisquitecommonCNSdisordersinchildhood,anditshouldbeincludedinthedifferentialdiagnosisofalteredmentalstatus.,概念,由化脓性细菌引起的中枢神经系统急性感染性疾病,病原学(1),常见病原脑膜炎球菌(meningococcus)肺炎球菌(pneumococcus)流感杆菌(haemophilusinfluenzae)金黄色葡萄球菌（staphylococcusaureus）大肠杆菌（escherichiacoli）,脑膜炎球菌,肺炎球菌,CommonbacteriaThefirst2month:escherichiacoli;staphylococcusaureus;2month12yr:Pneumococcus;Meningococcus;Hemophilusinfluenzaetypeb.,病原学(2),病原菌与年龄的关系新生儿大肠杆菌、绿脓杆菌、金黄色葡萄球菌儿童脑膜炎球菌、肺炎球菌、流感嗜血杆菌,发病机制(1),Theriskfactors1.Lackofimmunity:youngage,defectsofT-lymphocyte,defectsofimmunoglobulin,defectsofthecomplementsystemorproperdinsystem2.EnvironmentCongenitaloracquiredCSFleak:suchascranialdefectormiddleearfistulas,basalskullfracture,lumbosacraldermalsinus,penetratingcranialtrauma,MeningoceleSinus,回顾中枢神经系统脑膜的解剖及脑脊液的循环,PATHOGENESISBacteriaattacktothemucosalepithelialcellreceptorsbypili,enterthecirculation,penetratetheBBB(blood-brainbarrier)totheCSF,colonizeandmultiply,theninciteinflammatoryresponseandpolymorphonuclearcellinfiltration,whichproduceTNF,IL-1,PG-2andothercytokines.,致病菌入侵途径,致病菌,软脑膜,蛛网膜,表层脑,血流途径,直接通道,临近感染,发病机制(2),决定入侵中枢神经系统的因素细菌数量毒力机体免疫状态多种细胞因子参与发病TNF，IL1等,PATHOLOGYMeningealexudationandvaryingthicknessVascularchanges:vasculitis,thrombosis,necrosisorocclusionofsmallvasculesCerebralinfarctionIncreasedICPVentriculitisHydrocephalus,communicatingDamageofthecerebralcortex,轻症化脑的病理变化软脑膜及蛛网膜炎、表层脑组织为主的炎症反应，炎症渗出物主要在大脑顶部表面。重症化脑的病理变化除轻症的改变外，还出现血管病变、脑实质损害，脑室管膜炎、颅神经受累。,CLINICALMANIFESTATIONS,(1)Nonspecificfinding:fever;anorexiaorpoorfeeding;symptomsofURI,myalgias,arthralgias,tachycardia,hypotension,variouscutaneoussigns,(2)cerebraldysfunction:Seizures:focalorgeneralizedduetocerebritis,infarction,orelectrolytedisturbances.After4days,persistingseizuresareassociatedwithapoorprognosis.Alternationsofmentalstatusandreducedlevelofconsciounes:irritality,lethargy,stupor,obtundation,coma.Comatoseoneshaveapoorprognosis,(3)IncreasedICP:headache,emesis,papilledema(morechronicprocess).bulgingfontanelandwideningofthesutures,cranialneurologicparalysis(suchasfacial,oculomotor,abducensorauditorynerveparalysis),signsofherniation(tachycardiaorbradycardia,apneaorhyperventilation),(4)Meningealirritation:NuchalrigidityBackpainKernigsignBrudrinskisign,临床表现(1),年长儿及成人典型表现,（）感染中毒及急性脑功能障碍症状,兴奋：烦躁、惊厥抑制：嗜睡、昏睡、浅昏迷、深昏迷,（2）颅高压表现头痛、呕吐、视乳头水肿,颅高压三联征,颈项强直（3）体征：脑膜刺激征克氏征阳性布氏征阳性,4岁女孩患脑膜炎表现为神志淡漠,4岁女孩患脑膜炎颈项强直、布氏征阳性,4,4岁女孩患脑膜炎克氏征阳性,临床表现(),年龄小于3个月的幼婴和新生儿化脑的特点：1、体温可高可低2、颅压增高不明显3、惊厥可不典型4、脑膜刺激征不明显,COMPLICATIONS,1.SubduraleffusionItisthemostcommoncomplicationofPMinchildhood.Itsincidenceisaround3060%,andaddingasymptomaticones,theincidenceis8590%.Mostofcasesoccurininfants.Manifestations:Aftertreatingandgettingagoodeffectbyantibiotic,thenthepatientsmanifestthesymptomsandsignsofPMagain:,fever,seizures,alternationofmentalstatus,bulgingfontanel,diastasisofsutures,enlargingheadcircumference,emesis,positivecranialtransillumination,etc.CTorMRIofbraincanmakethedefinitediagnosis.,并发症及后遗症(1),硬膜下积液2ml，蛋白定量400mg/L,2.VentriculitisItisoccurredinthepatientswhoarenottreatedintime.ThesymptomsandsignsofPMarenotimprovedandevenprogressedusingeffectiveantibiotics,并发症及后遗症(2),脑室管膜炎(见于新生儿、小婴儿)强力治疗后仍持续发热、反复抽搐、呼吸衰竭且进行性加重脑脊液始终不正常头颅B超、CT可助诊，确诊依靠侧脑室穿刺脑室液细胞数50106/L,中性粒细胞为主，糖400mg/L,3.SIADH(syndromeofinappropriationADH-secretion)OccurringinthemajorityofpatientswithPM.Itisaresultofhypothalamicorpituitarydysfunction.Resultinginhyponatremiaandreducedserumosmolarity,andexacerbatecerebraledemaordirectlyproducehyponatremicseizures.,并发症及后遗症(3),抗利尿激素异常分泌综合征病因炎症累及下丘脑及垂体后叶，引起抗利尿激素过量分泌。表现低钠及血浆渗透压降低,othersCranialnervepalsies:suchasdeafness,blindnessCerebralorcerebellarherniationhydrocephalus,其他并发症及后遗症颅神经受损脑积水癫痫,EXAMINATIONOFEXPERIMENT,(1)CSF:WhenPMissuspected,lumbarpuncture(LP)shouldbeperformedtogetCSF.ItshouldbefoundinCSF:TurbidorpurulentHighICP,Elevatedleukocytecount:greaterthan1000/mm3(3002000/mm3)andneutrophilicpredominance(7595%)elevatedprotein(100500mg/dl)reducedglucoseandchlorideconcentrationsGramstainmaybepositivewithbacteriaBacteriaculturemaybepositive,(2)OtherpotentiallyvaluablediagnostictestsCTorMRIofbrain:Maybenormalexceptofcomplication，Whenthecasesaredifficulttodiagnosis,theexaminationsarenecessary.BloodculturesBacteriaonthesmearofcutaneouspetechiaePeripheralblood:WBC,NC,实验室检查(1),脑脊液检查是确诊本病的主要依据,脑脊液(CSF)正常值,外观清亮压力新生儿0.29-0.78（30-80）儿童0.69-1.96（70-200）白细胞数婴儿0-20儿童0-10蛋白质新生儿20-120mg/dl儿童0.5ng/L影像学检查,诊断与鉴别诊断(1),早期诊断是治疗成功与否的关键临床症状、体征及脑脊液检查不规则抗生素治疗后,脑脊液检查结果可不典型起病24小时内脑脊液检查结果可不典型,诊断与鉴别诊断(2),病毒性脑膜炎结核性脑膜炎真菌性脑膜炎,几种常见脑膜炎的脑脊液比较,项目压力外观白细胞数蛋白质糖氯化物化脓性混浊1000以中脑膜炎脓样性粒为主结核性毛玻200-500脑膜炎璃样淋巴为主病毒性轻度清亮0-数百轻度正常正常脑膜炎淋巴为主,TREATMENT,AntibioticsInordertoraisecuringrate,reducethecomplications,improvetheprognosis,theearlierdiagnosisandtheearliertreatmentareveryimportant.Achildwithrapidlyprogressingdiseaseoflessthan24hrduration,intheabsenceofincreasedICP,shouldreceiveantibioticsatonceafteranLPisperformed.,IftherearesignsofincreasedICPorfocalneurologicfindings,antibioticsshouldbegivenwithoutperforminganLP.IncreasedICPshouldbetreatedsimultaneously.,治疗原则(1),选择抗生素原则早期足量有效杀菌剂易通过血脑屏障疗程足,治疗原则(2),抗生素治疗肺炎球菌青霉素、氯霉素、三代头孢菌素流感杆菌氨苄西林、三代头孢菌素、氯霉素疗程10-14天脑膜炎球菌青霉素、三代头孢菌素疗程7天金黄色葡萄球菌耐酶青霉素、万古霉素、利福平大肠杆菌脑膜炎三代头孢、哌拉西林、氨基甙类疗程21天,SupportivecareRepeatedmedicalassessmentsofpatientswithPMareessentialtoidentifyearlysignsofcardiovascular,CNS,andmetaboliccomplications,suchaspulserate,bloodpressure,respiratoryrate,pupillaryreflexes,lev