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1、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),subacutely(symptoms evolving over 1-7days),or chronically(symptoms evolving over more,than 1 week)
2、.,Introduction,?,Annual incidence in the developed countries is,approximately 5-10 per 100000,.,?,30000 infants and children 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 ag
3、e 2 years account for almost,75%of all cases 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 vary with patient age,with,three bac
4、teria accounting for over three-,quarters of all cases:,?,Neisseria meningitidis(meningococcus),?,Haemophilus influenzae(if very young and,unvaccinated),?,Streptococcus pneumoniae(pneumococcus),Etiology,?,Other organisms,?,Neonates and infants at age 2-3 months,?,Escherichia coli,?,B-haemolytic stre
5、ptococci,?,Staphylococcus,aureus,?,Staphylococcus,epidermidis,?,Listeria monocytogenes,Etiology,?,Elderly and immunocompromised,?,Listeria monocytogenes,?,Gram negative bacteria,?,Hospital-acquired infections,?,Klebsiella,?,Escherichia coli,?,Pseudomonas,?,Staphylococcus aureus,Etiology,?,The,most,c
6、ommon,organisms,?,Neonates and infants under the age of 2months,?,Escherichia coli,?,Pseudomonas,?,Group B Streptococcus,?,Staphylococcus aureus,Etiology,?,Children over 2 months,?,Haemophilus influenzae type b,?,Neisseria meningitidis,?,Streptococcus pneumoniae,?,Children over 12 years,?,Neisseria
7、meningitidis,?,Streptococcus pneumoniae,Etiology,?,Major routes of leptomening infection,?,Bacteria are mainly from blood.,?,Uncommonly,meningitis occurs by direct,extension from nearly focus(mastoiditis,sinusitis)or by direct invasion(dermoid sinus,tract,head trauma,meningo-myelocele).,Pathogenesis
8、,?,Susceptibility of,bacterial infection on CNS,in,the children,?,Immaturity of immune systems,?,Nonspecific immune,?,Insufficient barrier,(,Blood-brain barrier,),?,Insufficient complement activity,?,Insufficient chemotaxis of neutrophils,?,Insufficient function of monocyte-macrophage system,?,Blood
9、 levels of diminished interferon(INF)-,and,interleukin-8(IL-8),Pathogenesis,?,Susceptibility of bacterial infection on CNS in,the children,?,Specific immune,?,Immaturity of both the cellular and humoral immune,systems,?,Insufficient antibody-mediated protection,?,Diminished immunologic response,?,Ba
10、cterial virulence,Pathogenesis,?,A offending bacterium from blood invades the,leptomeninges.,?,Bacterial toxics and Inflammatory mediators are,released.,?,Bacterial toxics,?,Lipopolysaccharide,LPS,?,Teichoic acid,?,Peptidoglycan,?,Inflammatory mediators,?,Tumor necrosis factor,TNF,?,Interleukin-1,IL
11、-1,?,Prostaglandin E2,PGE2,Pathogenesis,?,Bacterial toxics and inflammatory mediators,cause suppurative inflammation.,?,Inflammatory infiltration,?,Vascular permeability alter,?,Tissue edema,?,Blood-brain barrier,detroy,?,Thrombosis,Pathology,?,Diffuse bacterial infections involve the leptomeninges,
12、arachnoid membrane and superficial cortical,structures,and brain parenchyma is also 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
13、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 ventricular wall with perivascular,collections of purulent material,loss of ependymal,
14、lining,and subependymal gliosis may,be noted.,?,Subdural empyema may occur.,?,Hydrocephalus is an common complication of,meningitis.,?,Obstructive hydrocephalus,?,Communicating hydrocephalus,Pathology,?,Blood vessel walls may infiltrated by inflammatory cells.,?,Endothelial cell injury,?,Vessel sten
15、osis,?,Secondary ischemia and infarction,?,Ventricle dilatation,which ensues 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 cerebr
16、al cortex.,?,Conscious disturbance,?,Convulsion,?,Motor disturbance,?,Sensory disturbance,?,Meningeal irritation sign is found,because the,spinal nerve root is irritated.,?,Cranial nerve may be damaged,Clinical manifestation,?,Bacterial meningitis may present acutely(symptoms,evolving rapidly over 1
17、-24 hours)in most cases.,?,Symptoms and signs of upper respiratory or,gastrointestinal infection are found before several days,when the clnical manifestations of bacterial meningitis,happen.,?,Some patients may access suddenly with shock and DIC.,Clinical manifestation,?,Toxic symptom all over the b
18、ody,?,Hyperpyrexia,?,Headache,?,Photophobia,?,Painful eye movement,?,Fatigued and weak,?,Malaise,myalgia,anorexia,?,Vomiting,diarrhea and abdominal pain,?,Cutaneous rash,?,Petechiae,purpura,Clinical manifestation,?,Clinical manifestation of CNS,?,Increased intracranial pressure,?,Headache,?,Projecti
19、le vomiting,?,Hypertension,?,Bradycardia,?,Bulging fontanel,?,Cranial sutures diastasis,?,Coma,?,Decerebrate rigidity,?,Cerebral hernia,Clinical manifestation,?,Clinical manifestation of CNS,?,Seizures,?,Seizures occur in about 20%-30%of children,with bacterial meningitis.,?,Seizures is often found
20、in haemophilus influenzae,and pneumococal infection.,?,Seizures,is correlative with the inflammation of,brain parenchyma,cerbral infarction and,electrolyte disturbances.,第一课件网站,Clinical manifestation,?,Clinical manifestation of CNS,?,Conscious disturbance,?,Drowsiness,?,Clouding of consciousness,?,C
21、oma,?,Psychiatric,symptom,?,Irritation,?,Dysphoria,?,dullness,Clinical manifestation,?,Clinical manifestation of CNS,?,Meningeal irritation sign,?,Neck stiffness,?,Positive Kernig,s sign,?,Positive Brudzinski,s sign,Clinical manifestation,?,Clinical manifestation of CNS,?,Transient or permanent para
22、lysis of cranial 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 6,th,cranial nerve,usually transient,is noted frequently early in the course.,Clinical manifestation,?,
23、Symptom and signs of the infant under the age of 3,months,?,In some children,particularly young infants under the age,of 3 months,symptom and signs of meningeal inflammation,may be minimal.,?,Fever is generally present,but its absence or,hypothermia,in,a infant with meningeal inflammation is common.
24、,?,Only irritability,restlessness,dullness,vomiting,poor,feeding,cyanosis,dyspnea,jaundice,seizures,shock and,coma may be noted.,?,Bulging fontanel may be found,but there is not meningeal,irritation sign.,Complication,?,Subdural effusion,?,Subdural effusions occur in about 10%-30%of children,with ba
25、cterial 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,circumference,bulging fontanel,cranial sutures,diastasis,and abnormal transilluminati
26、on of the skull.,?,Subdural effusions may be diagnosed by the examination,of CT or MRI and subdural pricking.,Complication,?,Ependymitis,?,Neonate or infant with meningitis,?,Gram-negative bacterial infection,?,Clinical manifestation,?,Persistent hyperpyrexia,?,Frequent convulsion,?,Acute respirator
27、y failure,?,Bulging fontanel,?,Ventriculomegaly(CT),?,Cerebrospinal fluid,by ventricular puncture,?,WBC50,10,9,/L,?,Glucose1.6mmol/L,?,Proteino.4g/L,Complication,?,Cerebullar hyponatremia,?,Syndrem of inappropriate secretion of,antidiuretic hormone(SIADH),?,Hyponatremia,?,Degrade of blood osmotic pr
28、essure,?,Aggravated,cerebral edema,?,Frequent convulsion,?,Aggravated,c,onscious disturbance,Complication,?,Hydrocephalus,?,Increased intracranial pressure,?,Bulging fontanel,?,Augmentation of head circumference,?,Brain function disorder,?,Other complication,?,Deafness or blindness,?,Epilepsy,?,Para
29、lysis,?,Mental retardation,?,Behavior disorder,Laboratory Findings,?,Peripheral hemogram,?,Total WBC count,?,20,10,9,/L,40,10,9,/L WBC,?,Decreased WBC count at severe infection,?,Leukocyte differential count,?,80%,90%Neutrophils,Laboratory Findings,?,Rout,e,xamination of cerebrospinal fluid(CSF),?,I
30、ncreased pressure of cerebrospinal fluid,?,Cloudiness,?,Evident Increased total WBC count(1000,10,9,/L),?,Evident Increased neutrophils in leukocyte differential,count,?,Evident Decreased glucose(1.1mmol/l),?,Evident Increased protein level,?,Decreased or normal chloridate,?,CSF film preparation or
31、cultivation:positive result,Laboratory Findings,?,Especial examination of CSF,?,Specific bacterial antigen test,?,Countercurrent immuno-electrophoresis,?,Latex agglutination,?,Immunofluorescent test,?,Neisseria meningitidis(meningococcus),?,Haemophilus influenzae,?,Streptococcus pneumoniae(pneumococ
32、cus),?,Group B streptococcus,Laboratory Findings,?,Especial examination of CSF,?,Other test of CSF,?,LDH,?,Lactic acid,?,CRP,?,TNF and Ig,?,Neuron specific enolase(NSE),Laboratory Findings,?,Other bacterial test,?,Blood cultivation,?,Film preparation of skin petechiae and purpura,?,Secretion culture
33、 of local lesion,?,Imageology examination,Diagnosis,?,Diagnostic methods,?,A careful evaluation of history,?,A careful evaluation of infants signs and,symptoms,?,A careful evaluation of information on,longitudinal changes in vital signs and,laboratory indicators,?,Rout,e,xamination of cerebrospinal
34、fluid(CSF),Differential diagnosis,?,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 cerebrospinal fluid obtained by lumbar,puncture and add
35、itional immunologic,roentgenographic,and isotope studies.,Characteristics,of CSF on common disease,in CNS,PM TM VW FM TE,Pressure,or,Cloudiness,or,Pandy T,or,or,or,or,WBC N L,orL M,Protein,or,or,Glucos,Chloridate,or,Cultivation Bacterium TB Viral Fungus,Treatment,Antibiotic Therapy,?,Therapeutic pri
36、nciple,?,Good permeability for Blood-brain barrier,?,Drug combination,?,Intravenous drip,?,Full dosage,?,Full course of treatment,Antibiotic Therapy,?,Selection of antibiotic,?,No Certainly Bacterium,?,Community-acquired bacterial infection,?,Nosocomial infection acquired in a hospital,?,Broad-spect
37、rum antibiotic coverage as noted below,?,Children under age 3 months,?,Cefotaxime and ampicillin,?,Ceftriaxone and ampicillin(children over age 1months),?,Children over 3 months,?,Cefotaxime or Ceftriaxone or ampicillin and chloramphenicol,Antibiotic Therapy,?,Certainly Bacterium,?,Once the pathogen
38、 has been identified and the,antibiotic sensitivities determined,the most,appropriate drugs,should selected.,?,N meningitidis:,penicillin,tert-,cephalosporin,?,S pneumoniae:,penicillin,tert-,cephalosporin,vancomycin,?,H influenzae:,ampicillin,tert-,cephalosporin,?,S aureus:,penicillin,nefcillin,vanc
39、omycin,?,E coli:,ampicillin,chloramphenicol,tert-,cephalosporin,Antibiotic Therapy,?,Course of treatment,?,7 days for meningococcal infection,?,10,14 days for H influenzae or S pneumoniae,infection,?,More than 21 days for S aureus or E coli infection,?,14,21 days for other organisms,Treatment,Genera
40、l and Supportive Measures,?,Monitor of vital sign,?,Correcting metabolic imbalances,?,Supplying,sufficient,heat quantity,?,Correcting hypoglycemia,?,Correcting metabolic acidemia,?,Correcting fluids and electrolytes disorder,?,Application of cortical hormone,?,Lessening inflammatory reaction,?,Lesse
41、ning toxic symptom,?,lessening cerebral edema,General and Supportive Measures,?,Treatment of hyperpyrexia and seizures,?,Pyretolysis by physiotherapy and/or drug,?,Convulsive management,?,Diazepam,?,Phenobarbital,?,Subhibernation therapy,?,Treatment of increased intracranial pressure,?,Dehydration t
42、herapy,?,20%Mannitol 5ml/kg vi q6h,?,Lasix 1-2mg/kg vi,General and Supportive Measures,?,Treatment of septic shock and DIC,?,Volume expansion,?,Dopamine,?,Corticosteroids,?,Heparin,?,Fresh frozen plasma,?,Platelet transfusions,Treatment,Complication Measures,?,Subdural effusions,?,Subduaral pricking
43、,?,Draw-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,?,Ventricular puncture,drainage,?,Pressure in ventricle be depressed.,?,Ventricular puncture may give ventricle an injection of,antibiotic.,
