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1、AbbreviationsPM purulent meningitis CSF cerebrospinal fluidCNS central nervous systemICP intracranial pressureBBB blood-brain barrierWBC white blood cellNC neutrocyte,Abbreviations,INTRODUCTION Purulent Meningitis (PM) is one of serious bacterial infection. PM is associated with a high rate of acute
2、 complications and risk of chronic sequelae. PM is quite common CNS disorders in childhood, and it should be included in the differential diagnosis of altered mental status.,INTRODUCTION,概念,由化脓性细菌引起的 中枢神经系统急性感 染性疾病,概念 由化脓性细菌引起的,病原学(1),常见病原 脑膜炎球菌 (meningococcus)肺炎链球菌 (pneumococcus)流感嗜血杆菌 (haemophilus
3、 influenzae)金黄色葡萄球菌（staphylococcus aureus）大肠杆菌（escherichia coli）,病原学(1)常见病原,脑膜炎球菌,脑膜炎球菌,肺 炎 球 菌,肺 炎 球 菌,Common bacteriaThe first 2 month: escherichia coli ; staphylococcus aureus;2 month12 yr: Pneumococcus; Meningococcus; Hemophilus influenzae type b.,Common bacteri,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
4、色葡萄球菌 儿童 脑膜炎球菌、肺炎球菌、流感嗜血杆菌,病原学(2) 病原菌与年龄的关系,发病机制(1),发病机制(1),The risk factors1. Lack of immunity: young age, defects of T-lymphocyte, defects of immunoglobulin, defects of the complement system or properdin system 2. EnvironmentCongenital or acquired CSF leak: such as cranial defect or middle ear fis
5、tulas, basal skull fracture, lumbosacral dermal sinus, penetrating cranial trauma,The risk fact,Meningocele Sinus,Meningocele, 回顾 中枢神经系统脑膜的解剖及脑脊液的循环, 回顾 ,PATHOGENESIS Bacteria attack to the mucosal epithelial cell receptors by pili, enter the circulation, penetrate the BBB (blood-brain barrier) to t
6、he CSF, colonize and multiply, then incite inflammatory response and polymorphonuclear cell infiltration, which produce TNF, IL-1, PG-2 and other cytokines.,PATHOGENE,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,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,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,发病机制(2)
7、决定入侵中枢神经系统的因素,PATHOLOGY Meningeal exudation and varying thickness Vascular changes: vasculitis , thrombosis, necrosis or occlusion of small vascules Cerebral infarction Increased ICP Ventriculitis Hydrocephalus, communicating Damage of the cerebral cortex,P,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
8、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。,轻症化脑的病理变化,化脓性脑膜炎中英文版培训课件,CLINICAL MANIFESTATIONS,CLINICAL MANI,(1) Nonspecific finding: fever; anorexia or poor feeding; symptoms of URI, myalgias, arthralgias, tachycardia, hypotension, various cutaneous signs,(1) Nonspecific finding:,(2) cerebral
9、dysfunction:Seizures: focal or generalized due to cerebritis, infarction, or electrolyte disturbances. After 4 days, persisting seizures are associated with a poor prognosis.Alternations of mental status and reduced level of consciounes: irritality, lethargy, stupor, obtundation, coma. Comatose ones
10、 have a poor prognosis,(2) cerebral dysfunction:,(3) Increased ICP: headache, emesis, papilledema (more chronic process). bulging fontanel and widening of the sutures, cranial neurologic paralysis (such as facial, oculomotor, abducens or auditory nerve paralysis), signs of herniation (tachycardia or
11、 bradycardia, apnea or hyperventilation),(3) Increased ICP:,(4) Meningeal irritation: Nuchal rigidity Back pain Kernig sign Brudrinski sign,(4) Meningeal irritation:,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,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,颈项强直 （3）体征 ：脑膜刺
12、激征 克氏征阳性 布氏征阳性,颈项强直,4岁女孩患脑膜炎 表现为神志淡漠,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,44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,临床表现()年龄小于3个月的幼,COMPLICATIONS,COMPLICATIONS,1. Subdural effusion It is the most common complication of PM in c
13、hildhood. Its incidence is around 3060%, and adding asymptomatic ones, the incidence is 8590%. Most of cases occur in infants. Manifestations: After treating and getting a good effect by antibiotic, then the patients manifest the symptoms and signs of PM again:,1. Subdural effusion,fever, seizures,
14、alternation of mental status, bulging fontanel, diastasis of sutures, enlarging head circumference, emesis, positive cranial transillumination, etc. CT or MRI of brain can make the definite diagnosis.,fever, seizures, alternation o,并发症及后遗症(1),硬膜下积液2ml，蛋白定量 400 mg/L,并发症及后遗症(1)硬膜下积液,化脓性脑膜炎中英文版培训课件,化脓性
15、脑膜炎中英文版培训课件,2. Ventriculitis It is occurred in the patients who are not treated in time. The symptoms and signs of PM are not improved and even progressed using effective antibiotics,2. Ventriculitis,并发症及后遗症(2),脑室管膜炎(见于新生儿、小婴儿)治疗被延误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,并发症及后遗症(2)
16、脑室管膜炎(见于新生儿、小婴儿),化脓性脑膜炎中英文版培训课件,3. SIADH (syndrome of inappropriation ADH-secretion) Occurring in the majority of patients with PM. It is a result of hypothalamic or pituitary dysfunction. Resulting in hyponatremia and reduced serum osmolarity, and exacerbate cerebral edema or directly produce hypon
17、atremic seizures.,3. SIADH (syndrome of inapprop,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,并发症及后遗症(3)抗利尿激素异常分泌综合征,othersCranial nerve palsies: such as deafness, blindnessCerebral or cerebellar herniationhydrocephalus,other,其他并发症及后遗症脑积水各种颅神经功能障碍 癫痫,其他并发症及后遗症,化脓性脑膜炎中英文版培训课件,EXAM
18、INATION OF EXPERIMENT,EXAMINATION,(1) CSF: When PM is suspected, lumbar puncture (LP) should be performed to get CSF. It should be found in CSF:Turbid or purulent High ICP,(1) CSF:,Elevated leukocyte count: greater than 1000/mm3 (3002000/mm3) and neutrophilic predominance (7595%) elevated protein (1
19、00500mg/dl) reduced glucose and chloride concentrationsGram stain may be positive with bacteriaBacteria culture may be positive,Elevated leukocyte count: grea,(2) Other potentially valuable diagnostic tests CT or MRI of brain: Maybe normal except of complication，When the cases are difficult to diagn
20、osis, the examinations are necessary. Blood cultures Bacteria on the smear of cutaneous petechiae Peripheral blood: WBC, NC,(2) Other potentially valuable,实验室检查(1),脑脊液检查 是确诊本病的主要依据,实验室检查(1)脑脊液检查,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 40
21、mg/dl糖 婴儿 3.9-4.9(70-90) 儿童 2.8-4.4(50-80)氯化物 婴儿 111-123 儿童 118-128(650-750),脑脊液(CSF)正常值外观清亮,化脓性脑膜炎的脑脊液改变： 压力升高，外观浑浊似米汤，白细胞显著增多，以中性粒细胞为主，糖含量降低，蛋白增高。,化脓性脑膜炎的脑脊液改变：,实验室检查(2),脑脊液涂片 脑脊液细菌培养 血培养 皮肤瘀点、瘀斑涂片 外周血象：白细胞增多，中性粒细胞为主 降钙素原,实验室检查(2),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
22、时内脑脊液检查结果可不典型,诊断与鉴别诊断(1)早期诊断是治疗成功与否的关键,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,诊断与鉴别诊断(2)病毒性脑膜炎,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 ,几种常见脑膜炎的脑脊液比较项目压力外观白细胞数 蛋,TREATMENT,TREATMENT,Antibiotics In order to raise curing rate, reduce t
23、he complications, improve the prognosis, the earlier diagnosis and the earlier treatment are very important. A child with rapidly progressing disease of less than 24 hr duration, in the absence of increased ICP, should receive antibiotics at once after an LP is performed.,Antibi,If there are signs o
24、f increased ICP or focal neurologic findings, antibiotics should be given without performing an LP. Increased ICP should be treated simultaneously.,If there are signs of,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(1)选择抗生素原则,治疗原则(2),抗生素治疗肺炎球菌 青霉素、氯霉素、三代头孢菌素脑膜炎球菌 青霉素、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天金黄
25、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,治疗原则(2)抗生素治疗,Supportive care Repeated medical assessments of patients with PM are essential to identify early signs of cardiovascular, CNS, and metabolic complications, such as pulse rate, blood pressure, respiratory rate, pupillary reflexes, level of
26、 consciousness, motor strength, cranial nerve signs, and evaluation for seizures. Maintain the balances of fluids, electrolytes, and plasma osomotic pressure.,Supportive,Corticosteroids Rapid killing of bacteria releases toxic cell products after cell lysis that precipitates the cytokine-mediated in
27、flammatory response result in edema formation and neurologic injury. Protein and fibrous effusion may result in fibrosis and Hydrocephalus due to interfering absorption of CSF. The corticosteroids can limit production of inflammatory mediators and fibrosis.,Corticosteroi,治疗原则(3),肾上腺皮质激素对症治疗、支持治疗 降温 降颅压 20甘露醇、速尿 止惊 鲁米那、安定,治疗原则(3)肾上腺皮质激素,治疗原则(4),并发症治疗硬膜下积液 穿刺放液、外科脑室炎 引流、脑室内局部抗生素应用,治疗原则(4)并发症治疗,小结 1、小儿化脑常见致病菌。 2、小儿化脑临床特点。 3、化脑脑脊液变化特点。 4、选用敏感抗生素，掌握好剂量及给 药方式。,小结,
