湘雅儿科精品课件-Tuberculous Meningitis.ppt

结核性脑膜炎,TuberculousMeningitis,化脓性脑膜炎/急性细菌性脑膜炎,PurulentMeningitis（AcuteBacterialMeningitis）,第十六章第三节,Tuberculousmeningitisisaninfectionofthemembranescoveringthebrainandspinalcordwhichiscausedbythetuberculosisbacteria.,Definition-TuberculousMeningitis,TuberculousmeningitisisatypeofsevereTB,itoccursmostfrequentlywithin6monthsaftertheonsetofinitialinfectionTuberculousmeningitisismostcommonlyfoundinyoungchildren(age6to24months)butmayoccurinallagegroups,Definition-TuberculousMeningitis,Purulentmeningitisisaninfectionofthemembranescoveringthebrainandspinalcordwhichiscausedbybacteria.,Definition-PurulentMeningitis,Purulentmeningitisoccursmostfrequentlyinwinter&spring.Purulentmeningitisismostcommonlyfoundinyoungchildren(age6to12months).Manifestedbyfever,headache,vomiting,convulsion,changesinconsciousness,meningesirritationsigns,purulentchangesofspinalfluid.,Definition-PurulentMeningitis,MeningitisDiplococcus/脑膜炎双球菌StreptococcusPneumoniae/肺炎链球菌HaemophilusInfluenza/流感嗜血杆菌E.coli/大肠杆菌GroupBHaemolyticStreptococcus/B组溶血性链球菌StaphylococcusAureus/金黄色葡萄球菌,Etiology,MycobacteriaTubercolusis结核杆菌,tubercolous,purulent,Blood-borneinfection(majorform)BacteriaBloodMeninges,Routesofinfectiontothemeninges,passthroughB.B.B.,Respiratorytractinfections(U.R.I)/pneumoniaSkinlesion:furuncle,impetigo,cellulitis,inflammationofumbilicusEnteritis:salmonellaeinfection,etc.,InfectionofAdjacenttissue,Routesofinfectiontothemeninges,Noseinfection:Rhinitis,SinusitisEarinfection:Otitismedia,MastoiditisInjuryoftheskullorruptureofbrainabscess,神经系统不成熟，血脑屏障不完善，免疫功能低下。结脑常常是全身性粟粒性结核病的一部分；化脑为致病菌通过血行即菌血症传播而引起。结核或化脓邻近病灶蔓延侵犯脑膜，如脊椎、颅骨或中耳、乳突病变等。,PathogenesisandPathology,全部脑组织表面、脑底、脑沟、脑裂、基底池和脊髓表面均可有不同程度的炎性渗出物覆盖软脑膜、蛛网膜均可受累血管病变脑实质炎症、脑水肿、颅内压增加,PathogenesisandPathology,Infectionexudateusuallyassembleatthebaseofthebrain炎症渗出物易在脑底部积聚,Infectionexudateusuallyassembleatthetopofthebrain炎症渗出物易在脑顶部积聚,TuberculousMeningitis,PurulentMeningitis,ClinicalManifestation临床表现,Commonmanifestations/一般症候群CNSmanifestations/CNS症候群“两颅、两脑、一脊髓”,ClinicalManifestationofCNSInfection,TB:toxicsymptomsoftuberculousinfectionPurulent：acuteinfectioustoxicsymptoms,两颅：increasedintracraniaipressure颅内压增高Cranialnerveinjury颅神经受累两脑：MeningesIrritationSigns脑膜刺激征Cetebro-ParenchymaDamage脑实质受累一脊髓：SpinalCordDamage脊髓受累,ClinicalManifestationofTuberculousMeningitis,Stage1:nonspecificsymptom结脑早期（前驱期）：约12周主要症状：性格行为改变,ClinicalManifestation,Clinicalmanifestationoftuberculousmeningitismaybeconvenientlygroupedinto3stages:,Stage2:appearanceofdefiniteneurologicsigns结脑中期（脑膜刺激期）：约12周主要症状：两颅、两脑、一脊髓,Nuchalrigidity/颈项强直Kernig&Brudzinskisigns颅神经受累:面神经（其次是动眼神经、外展神经）Confusion/disorientation/slurredSpeech/Grimacing/changesinconsciousness/Athoidmovement/hemiparesis,etc.,ClinicalManifestation,Stage3:Coma结脑晚期（昏迷期）：约13周,Unresponsiveness/无反应Opisthotonos/角弓反张Decerebraterigidity/（去大脑强直Papilledema/视神经乳头水肿etc.,ClinicalManifestation,ClinicalManifestationofPurulentMeningitis,不同年龄化脑临床表现不同尤其是囟门未闭儿缺乏典型的症状和体征,Febrileorlowtemperature（发热或体温不升）Lethargy（嗜睡）Irritable（易激惹）Idlystaringintospace（目光呆滞）Vomiting（呕吐）Jaundice（黄疸）Cyanosis（发绀）Shock（休克）Irregularbreath（呼吸不规则）Convulsion（惊厥）Coma（昏迷）etc.,Symptoms,囟门未闭儿,囟门未闭儿,Signs,Frontalfontanelleprojection(前囟隆起)Meningesirritationsignsrarelyoccur(脑膜刺激征少见),CommonComplicationofpurulentmeningitis,SubduralEffusion(硬膜下积液)Pyocephalus(脑室管膜炎)Syndromeofinappropriatesecretionofantidiuretichormone,SIADH（抗利尿激素异常分泌综合症)Hydrocephalus(脑积水)Other,SubduralEffusion,age1yearsoldinfantoftenoccuredmoreofteninpatientsinfectedwithStreptococcuspneumoniae&influenzaHaemophilus,ClinicalPictureofSubduralEffusion,治疗过程中，体温不退或退而复升前囟持续性隆起或正常后有复隆起症状好转后复出现惊厥和意识障碍颅骨透光试验和颅脑CT等检查穿刺,OtherComplication,Deafness（耳聋）Blindness（失明）Epilepsy（癫痫）Paralysis（瘫痪）Dysnoesia（智力障碍）etc.,Diagnosis,DiagnosticProgram,StepOne,Meningitis,YesorNot？,StepTwo,DiagnosticProgram,Meningitis,Whichtype?PurulentorTuberculous?,AttentionMakingDiagnosisAsEarlyAsPossibleNoticingAtypicalCase,ChangesofCerebrospinalFluid(C.S.F.)inMeningitis,DifferentialDiagnosis,几种常见脑膜炎的脑脊液改变,Diagnosis,Diagnosisshouldbeestablishedasearlyaspossible.,Historyofexposuretotuberculosisisuseful.Tuberculinskintestisnearlyalwayspositive.ChestX-raymayshowapulmonarylesion.Abnormalspinalfluid:WBCusually500106/L&primarilymononuclearcells.PelliclemayformasC.S.F.standforseveralhrs.,Treatment,Treatment,GeneralTherapyRestNursingcareNutrition,对因治疗：两个环节控制炎症控制颅高压,Treatment,结脑：控制炎症抗结核治疗,化脑：控制炎症抗生素治疗,结脑：抗结核治疗,抗结核治疗的原则：早期、联合、适量、规律、全程结脑的抗结核治疗分两个阶段：强化治疗阶段：巩固治疗阶段：,结脑：抗结核治疗,强化治疗阶段：3HRZS（E）or4HRZS（E）开始12周内，INH半量静脉使用，半量口服，病情好转全量口服。,结脑：抗结核治疗,巩固治疗阶段：继用INH和RFP（EMB）INH总疗程：12年RFP总疗程：912个月,结脑：抗结核治疗,抗结核治疗的疗程抗结核治疗不少于12个月脑脊液正常后继续治疗6个月DOTS方案3HRZS/6HR,化脑：抗生素治疗,选择抗生素的原则选用对病原体敏感的杀菌剂；选用易透过血脑屏障的抗生素；应尽早静脉使用抗生素；早期联合用药，再根据药敏改药；大剂量、足疗程。,化脑：抗生素治疗,抗生素治疗的疗程流感嗜血杆菌脑膜炎和肺炎链球菌脑膜炎治疗不少于23周。大肠杆菌和金黄色葡萄球菌脑膜炎疗程应达34周以上。如出现并发症或耐药，要酌情更换抗生素和延长疗程。,控制颅高压,肾上腺皮质激素（使用抗炎药的基础上）能够控制炎症，减少渗出，降低颅内压，减少粘连，利于脑脊液循环。结脑：泼尼松，每日12mg/kg（小于3045mg/d）1个月后减量，疗程812周。化脑：静注地塞米松，每日0.20.6mg/kg，共35天。,控制颅高压,脱水剂：20%甘露醇，每次0.51g/kg，30min内静推，每46小时一次，23日后减少次数，710日停用。利尿剂：,控制颅高压,侧脑室引流：腰穿减压和鞘内注射：脑外科手术：脑脊液分流术,控制颅高压,腰穿减压和鞘内注射适应症（结脑）颅内压较高，激素和脱水剂治疗无效脑膜炎症控制不佳，颅内压难于控制脑脊液蛋白大于3g/L,控制颅高压,腰穿减压和鞘内注射：方法（结脑）：24周为1疗程适量放脑脊液后，鞘内注射N.S23mlINH2050mg（3岁，剂量减半）DXM2mg,治疗,对症治疗,降温止惊维持水、电解质、酸碱平衡并发症的处理高压氧治疗其他,Prognosis,Twomajorfactorsdetermineprognosisoftuberculousmeningitis,Theageofthepa