病例报告-细菌性脑膜炎（Case report Bacterial Meningitis）.ppt

Casereport,Boy,6yrs,admittedin23,Apr.2005.CC:Fever,headacheandvomitingfor2days.HPI:Fever(T39),headache,malaise,anorexia,vomiting(2),noconvulsioncellwall(G+:peptidoglycan/teichoicacid)andcellularmembrane(G-:LPS/LOS)-activatingendotheliumcellsandmacrophagestoreleasecytokinesInflammatoryfactors:TNF-,IL-1,PAF,PGE2-causinginflammation,thrombosis,increasingpermeabilityofBBBPolynuclearleucocytes-releasingcytokinesanddestroyingcellsandconnectivetissues,bacteriaenterbloodstream,penetratevulnerablesitesofBBB(e.g.choroidplexusandcerebralcapillaries),DirectextensionDermalsinusHeadtrauma,bacteriareplicateinsubarachnoidspace,antibiotictreatment,bacterialcomponents:peptidoglycan/teichoicacidIntracranialhypertensionVomiting,severeheadache-inchildrenAbulgingfontanel(前囟隆起)-inbabiesIncreasedheadcircumference/papilledema-prolongedIHCerebralhernia-severerIHMeningealirritationNuchalrigidityandBrudzinskisandKernigssigns(+),Skinpetechiaeinepidemiccerebrospinalmeningitis,Whenflexingthehip90degreesandthenextendingtheleg,thepatientfeelssubsequentpain.,Whenpassivelyflexingtheneckwhilesupine,patientinvoluntarilyflexeshiskneesandhips.,Meningitisinneonatesandyoungerbabies,Clinicalfindingsarenonspecificfeverisoftenabsent/hypothermiaSepsis-likemanifestations(refusaloffeedings,pale/greyskin)NothaveobviousseizureandIHHyperactivities,fixedeyesVomiting,highpitchedcryAfull,tense,orbulgingfontanel,Cerebrospinalfluid(CSF)findings,ahighpressurehydrocephalus;tuberculomas,vasculitis(infraction/malacia）cryptococcal:basalmeningitis/granulomas,Bacterialmeningitis(enhancedMRI)enhanceddensityofmeninges/enlargedventricles,Bacterialmeningitis(enhancedCT)subduraleffusionaccompaniedwithhighdensityofmeninges,HSVencephalitis(left:MRIT1;right:MRIT2)focallesiononrighttemporalandinsulalobes,Cryptococcalmeningitis(enhancedMRI)disseminatedhigh-densityonmeninges,andenhancedfocuses(granulomas)ofleftbasalnuclei,temporalandoccipitallobes,TBmeningitis(enhancedCT):high-densityoncerebralbasalpoolandbasalmeninges,manytuberculomasincerebellarhemisphere.,Basalpoolfilledwithcheesynecroticsubstances,TBmeningitis(boyaged8months,enhancedCTscan)High-densitybasalmeningesandveryenlargedventriclesystem,TBmeningitisinfarctioninbasalnucleiandinternalcapsula,DifferentialdiagnosisforTuberculousmeningitis,CSFculturepositivefortuberclebacilliCSFTBgenefragmentdetectedbyPCRDetectionofTBAgsorAbsinCSForserumCSFalleviatingbrainedemaandICPRegimenofdexamethasone:0.6mg/kg.d,iv.divided4times(q6h),for2-4dAdministersteroid10-20minpriorto(ortimeof)startingantibiotics,SupportiveCare,Repeatedmedicalandneurologicalassessments(monitoringHR,RR,pupils,consciousness)Keepairtractopening&oxygenationforthepatientwithcomaFluid,electrolytes,acid-basemetabolismmustbemanagedverycarefully,especiallyuntilSIADHandincreasedICPareruledout,Symptomatictreatment,IncreasedICP:mannitolisthefirstchoice,mayneedtobetreatedemergentlywithintubationandhyperventilationSeizures:alternatelyusefollowingdrugsluminal/valium/6%chloralhydrate水合氯醛Fever:defervescentsorphysicalmethods(icepilloworalcoholbath),Managementforcomplications,Subduraleffusion:ifpresentingincreasedICP,treatedbyaspirationVentriculitis:drainagefromventriclesandantibioticinjectionthroughdrainagetubeHydrocephalus:surgicaltherapySIADH(hyponatremia):130mmol/L:fluidrestriction120mmol/L:fluidrestriction+3%NaClsupplement,Prognosis,Mortality:5-15%1/3survivorsremainneurologicalsequelaeYoungerinfantsagedbelow6monthsusuallyhadaworsenoutcome.,Backtocasereport,CSFfindings:WBC210/mm3,N61%,Glu2.04mmol/L,Pro882.5mg/LTreatment&outcome:Hegotceftriaxoneandsymptomatictreatments.After4days,hisfeverandheadachewererelieved.10dayslater,hismeningealirritationdisappeared.BacterialmeningitiswasconfirmedQ2:Whydoeshehaverecurrentonsetofbacterialmeningitis?,Wesuspectedthathehadfocalinfectionnearbymeningealmembrane.HewasfoundtohavecerebrospinalrhinorrheaandleftmastoiditisbyCTscan,andfinallyhewastransferredtothewordofENTdepartment.Aft