化脓性脑膜炎英文版.pptx

Purulent Meningitis in ChildrenJiang LiDepartment of NeurologyChildrens Hospital Chongqing University of Medical Sciences第1页 Acute infection of central nervous system(CNS).90%of cases occur in the age of 1mo-5yr.The inflammation of meninges caused by various bacteria.Common features in clinical practices include:fever,increased intracranial pressure,meningeal irritation.One of the most potentially serious infections,associated with high mortality(about 10%)and morbidity.Purulent Meningitis第2页1.Etiology2.1.1 Pathogens:Main pathogens:Neissria meningitidis,streptoccus pneumoniae,Haemophilus influenzae.(2/3 of purulent meningitis are caused by these pathogens)Pathogens in special populations(neonate&3mo infants,malnutrition,immunodeficiency):gramnegative enteric bacilli,group B streptococci,staphlococcus aureus 第3页1.2 Major risk factors for meningitis Immature immunologic function and attenuated immunologic response to pathogens Low level of immunoglobulin,defects of complement and properdin system Immature or impaired blood-brain-barrier(BBB)Immature BBB function:maturation at about 1yr Impaired BBB:Congenial or acquired defects across mucocutaneous barrier 第4页 1.3 Access of bacteria invasion Typical access-hematogenous dissemination Bacteria colonizing the mucous membranes of the nasopharynx invasion into local tissue bacteremia hematogenous seeding to the subarachnoid space Mode of transmission:Person to person contact through respiratory tract secretions or droplets第5页 Bacteria spread to the meninges directly:through anatomic defects in the skull or head trauma Invasion from parameningeal organs:such as paranasal sinuses or middle earAccess of bacteria invasion第6页2.Pathology Structure of meninges 第7页 Characterized by leptomeningeal and perivascular infiltration with polymorphonuclear leukocytes and an inflammatory exudate.Exudate which may be distributed from convexity of brain to basal region of cranium.Exudate is more thickness due to streptococcus pneumoniae than other pathogens.Pathology第8页3.Clinical manifestations The younger the child is,the higher incidence of meningitis will be.-2/3 of cases occur less than 1yr of age.Mode of presentation:Acute or fulminant onset:symptoms and signs of sepsis;meningitis evolve rapidly over a few hours and death within 24 hours;usually infected with Neissria meningitides (N.meningitides).第9页 Subacute onset:Precede by several days of upper respiratory tract or gastrointestinal symptoms;difficult to pinpoint the exact onset of meningitis;usually with meningitis due to Haemophilus influenzae (H influenzae)and streptoccus pneumococcus (S pneumococcus).Mode of presentation第10页 Common features of meningitis:signs of systemic infection:fever(90-95%),anorexia,shock,alteration of mental status and consciousness neurological signs:increased intracranial pressure:headache,vomiting(82%),herniation meningeal irritation:nuchal rigidity(77%),kernig sign,brudzinski sign Clinical manifestations第11页brudzinski sign第12页 Seizure(20-30%)Focal or generalized Due to cerebritis,infarction,electrolyte disturbances Frequently noted with H influenzae&S pneumococcal meningitis Persist after 4th day and difficult to treat with poor prognosisClinical manifestations第13页 Clinical manifestations Alteration of mental status and consciousness Including:irritability,lethargy,stupor obtundation,coma Due to increased intracranial pressure,cerebritis,hypotension Often with pneumococcal or meningococcal meningitis Comatose patients with a poor prognosis第14页 The symptoms and signs are not evident in neonates and infants younger than 3mo of age;and patients already received irregular antibiotic therapy.Clinical manifestations第15页Signs of systemic infectionIncreased intracranial pressuremeningeal irritationTypical(older children)Fever,altered consciousness,seizureHeadache,vomiting,herniationnuchal rigidity,back pain,kernig sign,brudzinski signAtypical(neonate&3mo infant)Fever,normal temperature or hypothermia;minim or subtle seizure;poor feeding;less activityScream,frown;bulging or full fontanel;widening of the suturesNot evidentComparison of the manifestations of meningitis between different age groupsClinical manifestations第16页4.Diagnosis Earlier diagnosis and prompt initiation of effective antibiotic treatment is critical for minimizing sequelae of purulent meningitis.Suspected cases:febrile infants with seizure,meningeal irritability,increased intracranial pressure,altered mental status Pay attention to the atypical symptoms and signs in neonate,infant and patient already received irregular antibiotic therapy 第17页 Diagnosis is confirmed by analysis of cerebrospinal fluid(CSF)Suggestion bacterial meningitis Increased pressure(90%)Appearance:slightly cloudy to purulent Raised white blood cells,consisting chiefly of polymorphonuclear leukocytes Raised protein concentration,decreased glucose concentration(80%)Diagnosis第18页 Confirmation of the diagnosis:isolation from the CSF of a specific bacterial pathogen by microscopy or a positive culture or rapid antigen-detection test of CSF Gram-stained smear of CSF:identify the causative organism in 70-90%of cases CSF culture:positive in about 80%of cases.definitive diagnosis,determination of antibiotic sensitivity.PCR:amplifies bacterial DNA(H influenzae,N.meningitidis)Diagnosis第19页5.Differential diagnosis Purulent meningitis caused by different pathogens Neissria meningitidis:Occur in epidemics(type A,C),which is more common in spring,or sporadic all the year (type B,C,Y)Sudden onset with various cutaneous signs (petechiae,purpura,or an erythematous macular rash)第20页 Streptococcus pneumoniae:Young infants(1yr)are most susceptible population Peak season:spring and winter Easier to have subdural effusion and hydrocephalus Easily have a protracted course and relapseDifferential diagnosis第21页 Haemophilus influenzae Occurs predominantly in infants 2mo to 2yr of age Many cases are in winter Higher incidence of subdural effusion Others pathogens:staphylococcus aureus,gramnegative enteric bacilli Special susceptible population:neonate,3mo infants,malnutrition,immunodeficiency Severe infection,difficult to treatDifferential diagnosis第22页 Meningitis caused by other microorganisms Viral meningitis/encephalitisViral meningitis/encephalitis:Less severe Less severe systemic infectious symptoms systemic infectious symptoms Usually not develop after 2-3weeks Usually not develop after 2-3weeks CSF:normal glucoseCSF:normal glucose Differential diagnosis第23页 Tuberculous meningitisTuberculous meningitis Subacute onset and progress Subacute onset and progress A history of close contact with known A history of close contact with known cases of tuberculosis cases of tuberculosis Evidence of acute or healed tubercular Evidence of acute or healed tubercular infection on chest x-ray infection on chest x-ray Tuberculin skin test:OT,PPD Tuberculin skin test:OT,PPD CSF CSFDifferential diagnosis第24页DiseasePressure(Kpa)aspectTotal WBC(x106/L)Protein(g/L)Glucose(mmol/L)smearsculturesnormal0.69-1.96(0.29-0.78)clear0-5(0-20)0.2-0.4(0.2-1.2)2.2-4.4-Purulentmeningitiscloudy(PMN)(1-5)(2.2)Grams stain+TuberculousmeningitisNormal or cloudy(MN)AFB stain+Viral meningitis/encephalitisNormal or Normal Normal or(MN)Normal or(2ml,protein0.4g/L,Incidence:develop in 10-30%of patients,asymptomatic in 85-90%of patients;especially common in infants 4-6 month of age(rare in children over 1yr);第26页 Causative organisms:45%of cases of meningitis caused by H influenzae,30%by S pneumoniae,9%by N meningitidissubdural effusion第27页 Indications:No response to a sensitive antibiotic therapy Prolonged fever or fever reoccurring after an afebrile interval with effective treatment Bulging fontanel,widening of sutures,enlarging head circumference,emesis,seizure,altered consciousness.Improved CSF profile with more serious clinical manifestationssubdural effusion第28页 Diagnosis methods:Cranial translucent test B ultrasonic examination and CT Subdural space puncture subdural effusionnormalsubdural effusion第29页6.2 Ventriculitis6.3 hydrocephalusComplications第30页Circulation of cerebrospinal fluid(CSF)第31页6.2 Ventriculitis Usually occurs in neonates and infants(50 x106/L,Glucose1.6mmol/L,Glucose400mg/L.or protein400mg/L.Ventriculitis第33页Circulation of cerebrospinal fluid(CSF)第34页6.3 hydrocephalus:Communicating hydrocephalus:adhered or destroyed arachnoid granulation around the cistern at the base of the brain Obstructive hydrocephalus:following obstructed of the cerebral aqueduct,or the foramina of Magendie and Luschka6.4 others:Deafness,blindness,paralysis,epilepsy,mental retardationComplications第35页7.Treatment8.7.1 Antibacterial therapyTherapy principles:early treatment,antibiotics susceptible to pathogens and with high permeability through BBB,given intraveninously,enough dose,enough course of antibiotic therapy 第36页 Susceptible to pathogens First choice:Cefotaxime,Ceftriaxone (3dr generation of cephalosporins,high permeability through BBB,products of metabolism also has effect,CSF sterilization within 24h)Other choice:Penicillin,Chloromycin,Cefuroxime,Ceftazidime(delayed effect to make CSF sterile,high incidence of relapse and deafness)Antibacterial therapy第37页EtiologyStandard antibiotics of choiceDuration of therapyH.influenzaeCefotaxime/Ceftriaxone7-10daysN.meningitidisCefotaxime/Ceftriaxone7daysS.pneumoniaeCefotaxime/Ceftriaxone2-3weeksStaphlococcus aureusSemisynthetic penicillins(Oxacillin sodium,Cloxacillin sodium),Norvancomycin3weeksE.coliCefotaxime/Ceftriaxone(or+ampicillin)3weeksUnknownCefotaxime/Ceftriaxone+ampicillin2-3weeksAntibiotic therapy of bacterial meningitis第38页 Maintenance fluid and thermal energy supplement:Fluid administration:60-80ml/kg/day Fluid infusion with dehydration therapy7.2 Supportive care Treatment第39页 increased intracranial pressure Osmotic therapy:intravenous mannitol 0.5-1g/kg/every time,q4-6h Combination with intravenous dexamethasone:0.3-0.5mg/kg/day Endotracheal intubation and hyperventilation Treatment第40页 Subdural effusion Few volume could be absorbed with treatment spontaneously Subdural puncture:take out 15ml/each time (unilateral puncture),less than 30ml/each time (bilateral puncture),everyday or every other day Stripping operation:for the cases not cure after 3-4weeks Treatment第41页 Others:Ventriculitis:lateral ventricle puncture and injection of antibiotics locally Epilepsy:AEDsTreatment第42页