化脓性脑膜炎11152.ppt

PurulentMeningitis,Purposeanddemand:,Tofamiliarizethepathogenyofpurulentmeningitis.Tounderstandthemechanismandpathologychange.Tograsptheclinicalmanifestation,diagnosis,differentialdiagnosisandtreatment.Toself-studytheaccessoryexaminationofneuralsystem.,Contents,InductionEtiologyandpatientsalreadyreceivedirregularantibiotictherapy.,Comparisonofthemanifestationsofmeningitisbetweendifferentagegroups,Complicationsandsequelae,SubduraleffusionDefinitivediagnosis:volumeoffluidinsubduralspace2ml,protein0.4g/L,Incidence:developin10-30%ofpatients,asymptomaticin85-90%ofpatients;especiallycommonininfants4-6monthofage(rareinchildrenover1yr);Causativeorganisms:Hinfluenzae,Spneumoniae,Complicationsandsequelae,Indications:NoresponsetoasensitiveantibiotictherapyProlongedfeverorfeverreoccurringafteranafebrileintervalwitheffectivetreatmentBulgingfontanel,wideningofsutures,enlargingheadcircumference,vomit,seizure,alteredconsciousness.ImprovedCSFprofilewithmoreseriousclinicalmanifestations,Complicationsandsequelae,Diagnosismethods:CranialtranslucenttestBultrasonicexaminationandCTSubduralspacepuncture,normal,subduraleffusion,Complicationsandsequelae,2.VentriculitisUsuallyoccursinneonatesandinfants(50 x106/L,Glucose400mg/L.,Complicationsandsequelae,3.hydrocephalus:Communicatinghydrocephalusincreasingneuropsychiatricsymptoms4.Cerebralhyponatremia:Thesyndromeofinappropriatesecretionofantidiuretichormone5.others:Deafness,blindness,paralysis,epilepsy,mentalretardation,Examinations,1.Bloodroutineexamination:WBCraisedproteinconcentration,1g/LFindingbacteriainCSF,Examinations,2.Cerebrospinalfluidexaminations:(2)specialexamination:Specificbacterialantigen-detectiontestCountercurrentimmuno-electrophoresis,CIELatexagglutinationImmunofluorescenttestLDH,lacticacid,CRP,TNF,Ig,NSEdeterminations,Examinations,3.Otherexaminations(1)bloodculture:beforeantibiotictherapy(2)petechiasmear:epidemiccerebrospinalmeningitis(3)othersecretioncultures:(4)imaging:CT&MRI,Diagnosis,Earlierdiagnosisandpromptinitiationofeffectiveantibiotictreatmentiscriticalforminimizingsequelaeofpurulentmeningitis.Suspectedcases:febrileinfantswithseizure,meningealirritation,increasedintracranialpressure,alteredmentalstatusPayattentiontotheatypicalsymptomsandsignsinneonate,infantandpatientalreadyreceivedirregularantibiotictherapy,Diagnosis,Diagnosisisconfirmedbyanalysisofcerebrospinalfluid(CSF)SuggestionbacterialmeningitisIncreasedpressure(90%)Appearance:slightlycloudytopurulentRaisedwhitebloodcells,consistingchieflyofpolymorphonuclearleukocytesRaisedproteinconcentration,Decreasedglucoseconcentration(80%),Diagnosis,Confirmationofthediagnosis:isolationfromtheCSFofaspecificbacterialpathogenbymicroscopyorapositivecultureorrapidantigen-detectiontestofCSFGram-stainedsmearofCSF:identifythecausativeorganismin70-90%ofcasesCSFculture:positiveinabout80%ofcases.definitivediagnosis,determinationofantibioticsensitivity.PCR:amplifiesbacterialDNA(Hinfluenzae,N.meningitidis),Differentialdiagnosis,Viralmeningitis/encephalitis:LessseveresystemicinfectioussymptomsUsuallynotdevelopafter2-3weeksCSF:normalglucoseTuberculousmeningitis:SubacuteonsetandprogressAhistoryofclosecontactwithknowncasesoftuberculosisEvidenceofacuteorhealedtubercularinfectiononchestx-rayTuberculinskintest:OT,PPDCSF,Differentialdiagnosis,Cryptococcalmeningitis:slowonset,alongcourseofdisease,increasedintracranialpressuresevereheadacheCSFchanges:similarwithtuberculousmeningitisconfirmedbyIndiainkstainingorcultureofCSFMollaretsmeningitis:etiology:unknowclinicalmanifestationsandCSF:recurrent,similartopurulentmeningitisCSF:Mollaretscellsadrenocorticalhormonetherapy:effective,Differentialdiagnosis,Brainabscess:slowonsetCSF:pressure,cellnormalor,proteinfurtherdiagnosis:CTorMRIAcutetoxicencephalopathy:manifestations:delirium,convulsions,coma,meningealirritation,cerebralpalsyCSF:onlypressure,Treatment,1.AntibacterialtherapyTherapyprinciples:earlytreatment,antibioticssusceptibletopathogensandwithhighpermeabilitythroughBBB,givenintraveninously,enoughdose,enoughcourseofantibiotictherapy,Treatment,atthetimeofunknownpathogenicbacteria:Firstchoice:Cefotaxime,Ceftriaxone(3drgenerationofcephalosporins,highpermeabilitythroughBBB,productsofmetabolismalsohaseffect,CSFsterilizationwithin24h)Otherchoice:Penicillin,Chloramphenicol,(sideeffects:graybabysyndromeandbonemarrowsuppression)atthetimeofknownpathogenicbacteria:refertodrugsensitivitytest,Antibiotictherapyofbacterialmeningitis,Treatment,2.Adrenalcorticalhormone:dexamethasone:0.3-0.5mg/kg/day3.Symptomatictreatment&supportivecareIncreasedintracranialpressure:Intravenousmannitol0.5-1g/kg/everytime,q4-6hConvulsions:diazepam&chloralhydrate&phenobarbitalFever:Acetaminophen&ibuprofenMaintenancefluidandthermalenergysupplement:fluidadministration:60-80ml/kg/dayfluidinfusionwithdehydrationtherapy,Treatment,4.TreatmentofcomplicationsSubduraleffusionFewvolumecouldbeabsorbedwithtrea