兒科英文化膿性腦膜炎

1、Bacterial meningitis,,Introduction,Bacterial meningitis is an inflammation of the leptomenings, usually causing by bacterial infection.Bacterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours)

2、, subacutely (symptoms evolving over 1-7days), or chronically (symptoms evolving over more than 1 week).,Introduction,Annual incidence in the developed countries is approximately 5-10 per 100000. 30000 infants and child

3、ren develop bacterial meningitis in United States each year. Approximately 90 per cent of cases occur in children during the first 5 years of life.,Introduction,Cases under age 2 years account for almost 75% of all case

4、s and incidence is the highest in early childhood at age 6-12 months than in any other period of life.There are significant difference in the incidence of bacterial meningitis by season.,Etiology,Causative organisms va

5、ry with patient age, with three bacteria accounting for over three-quarters of all cases:Neisseria meningitidis (meningococcus)Haemophilus influenzae (if very young and unvaccinated)Streptococcus pneumoniae ( pneumoco

6、ccus),Etiology,Other organisms Neonates and infants at age 2-3 months Escherichia coliB-haemolytic streptococciStaphylococcus aureusStaphylococcus epidermidisListeria monocytogenes,Etiology,Elderly and immunocompr

7、omisedListeria monocytogenesGram negative bacteriaHospital-acquired infectionsKlebsiellaEscherichia coliPseudomonasStaphylococcus aureus,Etiology,The most common organisms Neonates and infants under the age of 2m

8、onthsEscherichia coli Pseudomonas Group B StreptococcusStaphylococcus aureus,Etiology,Children over 2 monthsHaemophilus influenzae type bNeisseria meningitidisStreptococcus pneumoniaeChildren over 12 yearsNeisse

9、ria meningitidisStreptococcus pneumoniae,Etiology,Major routes of leptomening infectionBacteria are mainly from blood.Uncommonly, meningitis occurs by direct extension from nearly focus (mastoiditis, sinusitis) or by

10、direct invasion (dermoid sinus tract, head trauma, meningo-myelocele).,Pathogenesis,Susceptibility of bacterial infection on CNS in the children Immaturity of immune systemsNonspecific immuneInsufficient barrier (B

11、lood-brain barrier)Insufficient complement activityInsufficient chemotaxis of neutrophilsInsufficient function of monocyte-macrophage systemBlood levels of diminished interferon (INF) -γand interleukin -8 ( IL-8 ),Pa

12、thogenesis,Susceptibility of bacterial infection on CNS in the childrenSpecific immuneImmaturity of both the cellular and humoral immune systemsInsufficient antibody-mediated protectionDiminished immunologic response

13、Bacterial virulence,Pathogenesis,A offending bacterium from blood invades the leptomeninges. Bacterial toxics and Inflammatory mediators are released.Bacterial toxicsLipopolysaccharide, LPSTeichoic acidPeptidoglyc

14、an Inflammatory mediatorsTumor necrosis factor, TNFInterleukin-1, IL-1Prostaglandin E2, PGE2,Pathogenesis,Bacterial toxics and inflammatory mediators cause suppurative inflammation.Inflammatory infiltrationVascular

15、 permeability alterTissue edema Blood-brain barrier detroyThrombosis,Pathology,Diffuse bacterial infections involve the leptomeninges, arachnoid membrane and superficial cortical structures, and brain parenchyma is al

16、so inflamed.Meningeal exudate of varying thickness is found.There is purulent material around veins and venous sinuses, over the convexity of the brain, in the depths of the sulci, within the basal cisterns, and aroun

17、d the cerebellum, and spinal cord may be encased in pus. Ventriculitis (purulent material within the ventricles) has been observed repeatedly in children who have died of their disease.,Pathology,Invasion of the ventric

18、ular wall with perivascular collections of purulent material, loss of ependymal lining, and subependymal gliosis may be noted. Subdural empyema may occur.Hydrocephalus is an common complication of meningitis.Obstructi

19、ve hydrocephalus Communicating hydrocephalus,Pathology,Blood vessel walls may infiltrated by inflammatory cells.Endothelial cell injuryVessel stenosisSecondary ischemia and infarctionVentricle dilatation which ensue

20、s may be associated with necrosis of cerebral tissue due to the inflammatory process itself or to occlusion of cerebral veins or arteries.,Pathology,Inflammatory process may result in cerebral edema and damage of the cer

21、ebral cortex.Conscious disturbanceConvulsionMotor disturbance Sensory disturbance Meningeal irritation sign is found because the spinal nerve root is irritated.Cranial nerve may be damaged,Clinical manifestation,Ba

22、cterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours) in most cases.Symptoms and signs of upper respiratory or gastrointestinal infection are found before several days when the clnical mani

23、festations of bacterial meningitis happen.Some patients may access suddenly with shock and DIC.,Clinical manifestation,Toxic symptom all over the body HyperpyrexiaHeadachePhotophobiaPainful eye movementFatigued and

24、 weak Malaise, myalgia, anorexia, Vomiting, diarrhea and abdominal painCutaneous rashPetechiae, purpura,Clinical manifestation,Clinical manifestation of CNSIncreased intracranial pressureHeadacheProjectile vomitin

25、g Hypertension Bradycardia Bulging fontanel Cranial sutures diastasisComa Decerebrate rigidity Cerebral hernia,Clinical manifestation,Clinical manifestation of CNSSeizuresSeizures occur in about 20%-30% of child

26、ren with bacterial meningitis.Seizures is often found in haemophilus influenzae and pneumococal infection.Seizures is correlative with the inflammation of brain parenchyma, cerbral infarction and electrolyte disturbanc

27、es.,第一課件網(wǎng)站 www.1kejian.com,Clinical manifestation,Clinical manifestation of CNSConscious disturbanceDrowsiness Clouding of consciousness ComaPsychiatric symptom Irritation Dysphoria dullness,Clinical manifestatio

28、n,Clinical manifestation of CNSMeningeal irritation signNeck stiffnessPositive Kernig’s signPositive Brudzinski’s sign,Clinical manifestation,Clinical manifestation of CNSTransient or permanent paralysis of cranial

29、nerves and limbs may be noted. Deafness or disturbances in vestibular function are relatively common.Involvement of the optic nerve, with blindness, is rare. Paralysis of the 6th cranial nerve, usually transient, is n

30、oted frequently early in the course.,Clinical manifestation,Symptom and signs of the infant under the age of 3 monthsIn some children, particularly young infants under the age of 3 months, symptom and signs of meningeal

31、 inflammation may be minimal.Fever is generally present, but its absence or hypothermia in a infant with meningeal inflammation is common. Only irritability, restlessness, dullness, vomiting, poor feeding, cyanosis,

32、dyspnea, jaundice, seizures, shock and coma may be noted. Bulging fontanel may be found, but there is not meningeal irritation sign.,Complication,Subdural effusionSubdural effusions occur in about 10%-30% of children w

33、ith bacterial meningitis.Subdural effusions appear to be more frequent in the children under the age of 1 year and in haemophilus influenzae and pneumococal infection.Clinical manifestations are enlargement in head ci

34、rcumference, bulging fontanel, cranial sutures diastasis and abnormal transillumination of the skull.Subdural effusions may be diagnosed by the examination of CT or MRI and subdural pricking.,Complication,Ependymitis

35、Neonate or infant with meningitis Gram-negative bacterial infection Clinical manifestation Persistent hyperpyrexia, Frequent convulsion Acute respiratory failure Bulging fontanel Ventriculomegaly (CT) Cerebrospi

36、nal fluid by ventricular punctureWBC>50×109/LGlucoseo.4g/L,Complication,Cerebullar hyponatremiaSyndrem of inappropriate secretion of antidiuretic hormone (SIADH)Hyponatremia Degrade of blood osmotic pressure

37、Aggravated cerebral edemaFrequent convulsion Aggravated conscious disturbance,Complication,Hydrocephalus Increased intracranial pressureBulging fontanelAugmentation of head circumferenceBrain function disorder O

38、ther complicationDeafness or blindnessEpilepsyParalysis Mental retardationBehavior disorder,Laboratory Findings,Peripheral hemogramTotal WBC count 20×109/L ～40×109/L WBCDecreased WBC count at severe

39、 infectionLeukocyte differential count80%～90% Neutrophils,Laboratory Findings,Rout examination of cerebrospinal fluid (CSF) Increased pressure of cerebrospinal fluid Cloudiness Evident Increased total WBC count (&g

40、t;1000×109/L)Evident Increased neutrophils in leukocyte differential countEvident Decreased glucose (<1.1mmol/l) Evident Increased protein level Decreased or normal chloridateCSF film preparation or cultivat

41、ion : positive result,Laboratory Findings,Especial examination of CSFSpecific bacterial antigen testCountercurrent immuno-electrophoresisLatex agglutinationImmunofluorescent test Neisseria meningitidis (meningococc

42、us)Haemophilus influenzae Streptococcus pneumoniae ( pneumococcus)Group B streptococcus,Laboratory Findings,Especial examination of CSFOther test of CSFLDHLactic acidCRPTNF and IgNeuron specific enolase (NSE),La

43、boratory Findings,Other bacterial testBlood cultivationFilm preparation of skin petechiae and purpuraSecretion culture of local lesion Imageology examination,Diagnosis,Diagnostic methodsA careful evaluation of histo

44、ry A careful evaluation of infant’s signs and symptomsA careful evaluation of information on longitudinal changes in vital signs and laboratory indicatorsRout examination of cerebrospinal fluid (CSF),Differential diag

45、nosis,Clinical manifestation of bacterial meningitis is similar to clinical manifestation of viral, tuberculous , fungal and aseptic meningitis. Differentiation of these disorders depends upon careful examination of ce

46、rebrospinal fluid obtained by lumbar puncture and additional immunologic, roentgenographic, and isotope studies.,Characteristics of CSF on common disease in CNS,Treatment Antibiotic Therapy,Therapeutic principleGood pe

47、rmeability for Blood-brain barrier Drug combination Intravenous drip Full dosage Full course of treatment,Antibiotic Therapy,Selection of antibioticNo Certainly BacteriumCommunity-acquired bacterial infectionNosoc

48、omial infection acquired in a hospitalBroad-spectrum antibiotic coverage as noted belowChildren under age 3 monthsCefotaxime and ampicillinCeftriaxone and ampicillin (children over age 1months)Children over 3 months

49、Cefotaxime or Ceftriaxone or ampicillin and chloramphenicol,Antibiotic Therapy,Certainly BacteriumOnce the pathogen has been identified and the antibiotic sensitivities determined, the most appropriate drugs should sel

50、ected.N meningitidis : penicillin, tert- cephalosporin S pneumoniae: penicillin, tert- cephalosporin, vancomycin H influenzae: ampicillin, tert- cephalosporin S aureus: penicillin, nefcillin, vancomycin E coli: am

51、picillin, chloramphenicol, tert- cephalosporin,Antibiotic Therapy,Course of treatment7 days for meningococcal infection10～14 days for H influenzae or S pneumoniae infectionMore than 21 days for S aureus or E coli infe

52、ction14～21 days for other organisms,Treatment General and Supportive Measures,Monitor of vital sign Correcting metabolic imbalancesSupplying sufficient heat quantity Correcting hypoglycemia Correcting metabolic ac

53、idemiaCorrecting fluids and electrolytes disorderApplication of cortical hormoneLessening inflammatory reaction Lessening toxic symptom lessening cerebral edema,General and Supportive Measures,Treatment of hyperpyr

54、exia and seizures Pyretolysis by physiotherapy and/or drugConvulsive management Diazepam Phenobarbital Subhibernation therapy Treatment of increased intracranial pressureDehydration therapy 20%Mann

55、itol 5ml/kg vi q6hLasix 1-2mg/kg vi,General and Supportive Measures,Treatment of septic shock and DICVolume expansionDopamine Corticosteroids Heparin Fresh frozen plasmaPlatelet transfusions,Treatment Complicati

56、on Measures,Subdural effusions Subduaral prickingDraw-off effusions on one side is 20-30ml/time.Once daily or every other day is requested. Time cell of pricking may be prolonged after 2 weeks. Ependymitis Ventr

57、icular puncture — drainage Pressure in ventricle be depressed. Ventricular puncture may give ventricle an injection of antibiotic.,Complication Measures,HydrocephalusOperative treatmentAdhesiolysis By-pass operatio

58、n of cerebrospinal fluid Dilatation of aqueductSIADH (Cerebral hyponatremia)Restriction of fluidsupplement of serum sodium diuretic,Prognosis,Appropriate antibiotic therapy reduces the mortality rate for bacterial m

59、eningitis in children, but mortality remain high.Overall mortality in the developed countries ranges between 5% and 30%.50 percent of the survivors have some sequelae of the disease.,Prognosis,Prognosis depends upon ma

60、ny factors:AgeCausative organismNumber of organisms and bacterial virulence Duration of illness prior to effective antibiotic therapyPresence of disorders that may compromise host response to infection,第一課件網(wǎng)站 www.1k