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1、Introductionn nBacterial meningitis is an inflammation of the leptomenings, usually causing by bacterial infection.n nBacterial 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
2、week).Introductionn nAnnual incidence in the developed countries is approximately 5-10 per 100000. n n30000 infants and children develop bacterial meningitis in United States each year. n nApproximately 90 per cent of cases occur in children during the first 5 years of life.Introductionn nCases unde
3、r age 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.n nThere are significant difference in the incidence of bacterial meningitis by season. Etiologyn nCausative organisms vary with patient age, with thr
4、ee bacteria accounting for over three-quarters of all cases:n nNeisseria meningitidis (meningococcus)Neisseria meningitidis (meningococcus)n nHaemophilus influenzae (if very young and Haemophilus influenzae (if very young and unvaccinated)unvaccinated)n nStreptococcus pneumoniae ( pneumococcus)Strep
5、tococcus pneumoniae ( pneumococcus)Etiologyn nOther organisms n nNeonates and infants at age 2-3 months n nEscherichia coliEscherichia colin nB-haemolytic streptococciB-haemolytic streptococcin nStaphylococcus aureusStaphylococcus aureusn nStaphylococcusStaphylococcus epidermidisn nListeria monocyto
6、genesListeria monocytogenesEtiologyn nElderly and immunocompromisedElderly and immunocompromisedn nListeria monocytogenesListeria monocytogenesn nGram negative bacteriaGram negative bacterian nHospital-acquired infectionsHospital-acquired infectionsn nKlebsiellaKlebsiellan nEscherichia coliEscherich
7、ia colin nPseudomonasPseudomonasn nStaphylococcus aureusStaphylococcus aureusEtiologyn nThe most common organisms n nNeonates and infants under the age of 2monthsNeonates and infants under the age of 2monthsn nEscherichia coli Escherichia coli n nPseudomonas Pseudomonas n nGroup B StreptococcusGroup
8、 B Streptococcusn nStaphylococcus aureusStaphylococcus aureus Etiologyn nChildren over 2 monthsn nHaemophilus influenzae type bHaemophilus influenzae type bn nNeisseria meningitidisNeisseria meningitidisn nStreptococcus pneumoniaeStreptococcus pneumoniaen nChildren over 12 yearsn nNeisseria meningit
9、idisNeisseria meningitidisn nStreptococcus pneumoniaeStreptococcus pneumoniaeEtiologyn nMajor routes of leptomening infectionn nBacteria are mainly from blood.Bacteria are mainly from blood.n nUncommonly, meningitis occurs by direct Uncommonly, meningitis occurs by direct extension from nearly focus
10、 (mastoiditis, extension from nearly focus (mastoiditis, sinusitis) or by direct invasion (dermoid sinus sinusitis) or by direct invasion (dermoid sinus tract, head trauma, meningo-myelocele).tract, head trauma, meningo-myelocele).Pathogenesisn nSusceptibility of bacterial infection on CNS in the ch
11、ildren n nImmaturity of immune systemsn nNonspecific immuneNonspecific immunen nInsufficient barrierInsufficient barrier ( (Blood-brain barrierBlood-brain barrier) )n nInsufficient complement activityInsufficient complement activityn nInsufficient chemotaxis of neutrophilsInsufficient chemotaxis of
12、neutrophilsn nInsufficient function of monocyte-macrophage systemInsufficient function of monocyte-macrophage systemn nBlood levels of diminished interferon (INF) -and Blood levels of diminished interferon (INF) -and interleukin -8 ( IL-8 ) interleukin -8 ( IL-8 ) Pathogenesisn nSusceptibility of ba
13、cterial infection on CNS in the childrenn nSpecific immuneSpecific immunen nImmaturity of both the cellular and humoral immune Immaturity of both the cellular and humoral immune systemssystemsn nInsufficient antibody-mediated protectionInsufficient antibody-mediated protectionn nDiminished immunolog
14、ic responseDiminished immunologic responsen nBacterial virulence Bacterial virulence Pathogenesisn nA offending bacterium from blood invades the A offending bacterium from blood invades the leptomeninges. leptomeninges. n nBacterial toxics and Inflammatory mediators are Bacterial toxics and Inflamma
15、tory mediators are released.released.n nBacterial toxicsBacterial toxicsn nLipopolysaccharide, LPSLipopolysaccharide, LPSn nTeichoic acidTeichoic acidn nPeptidoglycan Peptidoglycan n nInflammatory mediatorsInflammatory mediatorsn nTumor necrosis factor, TNFTumor necrosis factor, TNFn nInterleukin-1,
16、 IL-1Interleukin-1, IL-1n nProstaglandin E2, PGE2Prostaglandin E2, PGE2Pathogenesisn nBacterial toxics and inflammatory mediators cause suppurative inflammation.n nInflammatory infiltrationInflammatory infiltrationn nVascular permeability alterVascular permeability altern nTissue edema Tissue edema
17、n nBlood-brain barrierBlood-brain barrier detroydetroyn nThrombosis Thrombosis Pathologyn nDiffuse bacterial infections involve the leptomeninges, Diffuse bacterial infections involve the leptomeninges, arachnoid membrane and superficial cortical arachnoid membrane and superficial cortical structure
18、s, and brain parenchyma is also inflamed.structures, and brain parenchyma is also inflamed.n nMeningeal exudate of varying thickness is found.Meningeal exudate of varying thickness is found.n nThere is purulent material around veins and venous There is purulent material around veins and venous sinus
19、es, over the convexity of the brain, in the depths of sinuses, over the convexity of the brain, in the depths of the sulci, within the basal cisterns, and around the the sulci, within the basal cisterns, and around the cerebellum, and spinal cord may be encased in pus.cerebellum, and spinal cord may
20、 be encased in pus. n nVentriculitis (purulent material within the ventricles) Ventriculitis (purulent material within the ventricles) has been observed repeatedly in children who have has been observed repeatedly in children who have died of their disease.died of their disease.Pathologyn nInvasion
21、of the ventricular wall with perivascular Invasion of the ventricular wall with perivascular collections of purulent material, loss of ependymal collections of purulent material, loss of ependymal lining, and subependymal gliosis maylining, and subependymal gliosis may be noted. be noted. n nSubdura
22、l empyema may occur.Subdural empyema may occur.n nHydrocephalus is an common complication of Hydrocephalus is an common complication of meningitis.meningitis.n nObstructive hydrocephalus Obstructive hydrocephalus n nCommunicating hydrocephalusCommunicating hydrocephalus Pathologyn nBlood vessel wall
23、s may infiltrated by inflammatory cells.Blood vessel walls may infiltrated by inflammatory cells.n nEndothelial cell injuryEndothelial cell injuryn nVessel stenosisVessel stenosisn nSecondary ischemia and infarctionSecondary ischemia and infarctionn nVentricle dilatationVentricle dilatation which en
24、sues may be associated with which ensues may be associated with necrosis of cerebral tissue due to the inflammatory necrosis of cerebral tissue due to the inflammatory process itself or to occlusion of cerebral veins or arteries.process itself or to occlusion of cerebral veins or arteries.Pathologyn
25、 nInflammatory process may result in cerebral Inflammatory process may result in cerebral edema and damage of the cerebral cortex.edema and damage of the cerebral cortex.n nConscious disturbanceConscious disturbancen nConvulsionConvulsionn nMotor disturbance Motor disturbance n nSensory disturbanceS
26、ensory disturbance n nMeningeal irritation sign is foundMeningeal irritation sign is found because the because the spinal nerve root is irritated.spinal nerve root is irritated.n nCranial nerve may be damagedCranial nerve may be damagedClinical manifestationn nBacterial meningitis may present acutel
27、y (symptoms Bacterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours) in most cases.evolving rapidly over 1-24 hours) in most cases.n nSymptoms and signs of upper respiratory or Symptoms and signs of upper respiratory or gastrointestinal infection are found before several
28、days gastrointestinal infection are found before several days when the clnical manifestations of bacterial meningitis when the clnical manifestations of bacterial meningitis happen.happen.n nSome patients may access suddenly with shock and DIC.Some patients may access suddenly with shock and DIC.Cli
29、nical manifestationn nToxic symptom all over the body n nHyperpyrexiaHyperpyrexian nHeadacheHeadachen nPhotophobiaPhotophobian nPainful eye movementPainful eye movementn nFatigued and weak Fatigued and weak n nMalaise, myalgia, anorexia, Malaise, myalgia, anorexia, n nVomiting, diarrhea and abdomina
30、l painVomiting, diarrhea and abdominal painn nCutaneous rashCutaneous rashn nPetechiae, purpuraPetechiae, purpura Clinical manifestationn nClinical manifestation of CNSn nIncreased intracranial pressureIncreased intracranial pressuren nHeadacheHeadachen nProjectile vomiting Projectile vomiting n nHy
31、pertension Hypertension n nBradycardia Bradycardia n nBulging fontanel Bulging fontanel n nCranial sutures diastasisCranial sutures diastasisn nComa Coma n nDecerebrate rigidity Decerebrate rigidity n nCerebral herniaCerebral hernia Clinical manifestationn nClinical manifestation of CNSn nSeizuresn
32、nSeizures occur in about 20%-30% of children Seizures occur in about 20%-30% of children with bacterial meningitis.with bacterial meningitis.n nSeizures is often found in haemophilus influenzae Seizures is often found in haemophilus influenzae and pneumococal infection.and pneumococal infection.n nS
33、eizuresSeizures is correlative with the inflammation of is correlative with the inflammation of brain parenchyma, cerbral infarction and brain parenchyma, cerbral infarction and electrolyte disturbances.electrolyte disturbances. 第一课件网站 Clinical manifestationn nClinical manifestation of CNSn nConsci
34、ous disturbancen nDrowsinessDrowsiness n nClouding of consciousness Clouding of consciousness n nComaComan nPsychiatricPsychiatric symptomsymptom n nIrritation Irritation n nDysphoria Dysphoria n ndullnessdullness Clinical manifestationn nClinical manifestation of CNSn nMeningeal irritation signn nN
35、eck stiffnessNeck stiffnessn nPositive KernigPositive Kernig s signs signn nPositive BrudzinskiPositive Brudzinski s signs signClinical manifestationn nClinical manifestation of CNSn nTransient or permanent paralysis of cranial nerves Transient or permanent paralysis of cranial nerves and limbs may
36、be noted. and limbs may be noted. n nDeafness or disturbances in vestibular function Deafness or disturbances in vestibular function are relatively common.are relatively common.n nInvolvement of the optic nerve, with blindness, is Involvement of the optic nerve, with blindness, is rare. rare. n nPar
37、alysis of the 6Paralysis of the 6thth cranial nerve, usually transient, cranial nerve, usually transient, is noted frequently early in the course.is noted frequently early in the course.Clinical manifestationn nSymptom and signs of the infant under the age of 3 Symptom and signs of the infant under
38、the age of 3 monthsmonthsn nIn some children, particularly young infants under the age In some children, particularly young infants under the age of 3 months, symptom and signs of meningeal inflammation of 3 months, symptom and signs of meningeal inflammation may be minimal.may be minimal.n nFever i
39、s generally present, but its absence or Fever is generally present, but its absence or hypothermiahypothermia in in a infant with meningeal inflammation is common. a infant with meningeal inflammation is common. n nOnly irritability, restlessness, dullnessOnly irritability, restlessness, dullness, ,
40、 vomiting, poor vomiting, poor feeding, cyanosis, dyspnea, jaundice, seizures, shock and feeding, cyanosis, dyspnea, jaundice, seizures, shock and coma may be noted. coma may be noted. n nBulging fontanel may be found, but there is not meningeal Bulging fontanel may be found, but there is not mening
41、eal irritation sign.irritation sign.Complication n nSubdural effusionSubdural effusionn nSubdural effusions occur in about 10%-30% of children Subdural effusions occur in about 10%-30% of children with bacterial meningitis.with bacterial meningitis.n nSubdural effusions appear to be more frequent in
42、 the Subdural effusions appear to be more frequent in the children under the age of 1 year and inchildren under the age of 1 year and in haemophilus haemophilus influenzae and pneumococal infection.influenzae and pneumococal infection.n nClinical manifestations are enlargement in head Clinical manif
43、estations are enlargement in head circumference, bulging fontanel, circumference, bulging fontanel, cranial sutures cranial sutures diastasis diastasis and abnormal transillumination of the skull.and abnormal transillumination of the skull.n nSubdural effusions may be diagnosed by the examination Su
44、bdural effusions may be diagnosed by the examination of CT or MRI and subdural pricking.of CT or MRI and subdural pricking. Complicationn nEpendymitis n nNeonate or infant with meningitis Neonate or infant with meningitis n nGram-negative bacterial infection Gram-negative bacterial infection n nClin
45、ical manifestationClinical manifestation n nPersistent hyperpyrexia, Persistent hyperpyrexia, n nFrequent convulsion Frequent convulsion n nAcute respiratory failure Acute respiratory failure n nBulging fontanel Bulging fontanel n nVentriculomegaly (CT) Ventriculomegaly (CT) n nCerebrospinal fluidCe
46、rebrospinal fluid by ventricular punctureby ventricular puncturen nWBC5010WBC50109 9/L/Ln nGlucose1.6mmol/LGlucoseo.4g/LProteino.4g/LComplicationn nCerebullar hyponatremian nSyndrem of inappropriate secretion of antidiuretic hormone (SIADH)n nHyponatremia Hyponatremia n nDegrade of blood osmotic pre
47、ssureDegrade of blood osmotic pressuren nAggravatedAggravated cerebral edema cerebral edeman nFrequent convulsion Frequent convulsion n nAggravatedAggravated c conscious disturbanceonscious disturbance Complicationn nHydrocephalus Hydrocephalus n nIncreased intracranial pressureIncreased intracrania
48、l pressuren nBulging fontanelBulging fontaneln nAugmentation of head circumferenceAugmentation of head circumferencen nBrain function disorder Brain function disorder n nOther complicationOther complicationn nDeafness or blindnessDeafness or blindnessn nEpilepsyEpilepsyn nParalysis Paralysis n nMent
49、al retardationMental retardationn nBehavior disorderBehavior disorder Laboratory Findingsn nPeripheral hemogramn nTotal WBC count n n20109/L 40109/L WBCn nDecreased WBC count at severe infectionn nLeukocyte differential countn n80%90% NeutrophilsLaboratory Findingsn nRout Rout e examination of cereb
50、rospinal fluid (CSF) xamination of cerebrospinal fluid (CSF) n nIncreased pressure of cerebrospinal fluid Increased pressure of cerebrospinal fluid n nCloudinessCloudiness n nEvident Increased total WBC count (100010Evident Increased total WBC count (1000109 9/L)/L)n nEvident Increased neutrophils i
51、n leukocyte differential Evident Increased neutrophils in leukocyte differential countcountn nEvident Decreased glucose (1.1mmol/l)Evident Decreased glucose (1.1mmol/l) n nEvident Increased protein levelEvident Increased protein level n nDecreased or normal chloridateDecreased or normal chloridaten
52、nCSF film preparation or cultivation : positive result CSF film preparation or cultivation : positive result Laboratory Findingsn nEspecial examination of CSFn nSpecific bacterial antigen testn nCountercurrent immuno-electrophoresisCountercurrent immuno-electrophoresisn nLatex agglutinationLatex agg
53、lutinationn nImmunofluorescent testImmunofluorescent test n nNeisseria meningitidis (meningococcus)Neisseria meningitidis (meningococcus)n nHaemophilus influenzae Haemophilus influenzae n nStreptococcus pneumoniae ( pneumococcus)Streptococcus pneumoniae ( pneumococcus)n nGroup B streptococcusGroup B
54、 streptococcusLaboratory Findingsn nEspecial examination of CSFn nOther test of CSFn nLDHLDHn nLactic acidLactic acidn nCRPCRPn nTNF and IgTNF and Ign nNeuron specific enolase (NSE)Neuron specific enolase (NSE)Laboratory Findingsn nOther bacterial testn nBlood cultivationBlood cultivationn nFilm pre
55、paration of skin petechiae and purpuraFilm preparation of skin petechiae and purpuran nSecretion culture of local lesion Secretion culture of local lesion n nImageology examinationDiagnosisn nDiagnostic methodsn nA careful evaluation of history n nA careful evaluation of infants signs and symptomsn
56、nA careful evaluation of information on longitudinal changes in vital signs and laboratory indicatorsn nRout Rout e examination of cerebrospinal fluid (CSF)xamination of cerebrospinal fluid (CSF)Differential diagnosisn nClinical manifestation of bacterial meningitis is similar Clinical manifestation
57、 of bacterial meningitis is similar to clinical manifestation of viral, tuberculous , fungal to clinical manifestation of viral, tuberculous , fungal and aseptic meningitis. and aseptic meningitis. n nDifferentiation of these disorders depends upon careful Differentiation of these disorders depends
58、upon careful examination of cerebrospinal fluid obtained by lumbar examination of cerebrospinal fluid obtained by lumbar puncture and additional immunologic, puncture and additional immunologic, roentgenographic, and isotope studies. roentgenographic, and isotope studies. Characteristics of CSF on c
59、ommon 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 Therapyn nTherapeutic principlen nGood permeability for Blood-brain barrier Good permeability for Blood-brain
60、barrier n nDrug combination Drug combination n nIntravenous drip Intravenous drip n nFull dosage Full dosage n nFull course of treatmentFull course of treatment Antibiotic Therapyn nSelection of antibioticn nNo Certainly BacteriumNo Certainly Bacteriumn nCommunity-acquired bacterial infectionCommuni
61、ty-acquired bacterial infectionn nNosocomial infection acquired in a hospitalNosocomial infection acquired in a hospitaln nBroad-spectrum antibiotic coverage as noted belowBroad-spectrum antibiotic coverage as noted belown nChildren under age 3 monthsChildren under age 3 monthsn nCefotaxime and ampi
62、cillinCefotaxime and ampicillinn nCeftriaxone and ampicillin (children over age 1months)Ceftriaxone and ampicillin (children over age 1months)n nChildren over 3 monthsChildren over 3 monthsn nCefotaxime or Ceftriaxone or ampicillin and chloramphenicolCefotaxime or Ceftriaxone or ampicillin and chlor
63、amphenicolAntibiotic Therapyn nCertainly Bacteriumn nOnce the pathogen has been identified and the Once the pathogen has been identified and the antibiotic sensitivities determined, the most antibiotic sensitivities determined, the most appropriate drugsappropriate drugs should selected.should selec
64、ted.n nN meningitidis : N meningitidis : penicillin,penicillin, tert-tert- cephalosporincephalosporin n nS pneumoniae: S pneumoniae: penicillin,penicillin, tert-tert- cephalosporin, vancomycincephalosporin, vancomycin n nH influenzae: H influenzae: ampicillin,ampicillin, tert-tert- cephalosporinceph
65、alosporin n nS aureus: S aureus: penicillin,penicillin, nefcillinnefcillin, , vancomycinvancomycin n nE coli: E coli: ampicillin,ampicillin, chloramphenicolchloramphenicol, , tert-tert- cephalosporincephalosporin Antibiotic Therapyn nCourse of treatmentn n7 days for meningococcal infection7 days for
66、 meningococcal infectionn n101014 days for H influenzae or S pneumoniae 14 days for H influenzae or S pneumoniae infectioninfectionn nMore than 21 days for S aureus or E coli infectionMore than 21 days for S aureus or E coli infectionn n141421 days for other organisms21 days for other organisms Trea
67、tment General and Supportive Measuresn nMonitor of vital sign n nCorrecting metabolic imbalancesn nSupplying Supplying sufficientsufficient heat quantity heat quantity n nCorrecting hypoglycemiaCorrecting hypoglycemia n nCorrecting metabolic acidemiaCorrecting metabolic acidemian nCorrecting fluids
68、and electrolytes disorderCorrecting fluids and electrolytes disordern nApplication of cortical hormonen nLessening inflammatory reaction Lessening inflammatory reaction n nLessening toxic symptom Lessening toxic symptom n nlessening cerebral edemalessening cerebral edema General and Supportive Measu
69、resn nTreatment of hyperpyrexia and seizuresTreatment of hyperpyrexia and seizures n nPyretolysis by physiotherapy and/or drugPyretolysis by physiotherapy and/or drugn nConvulsive management Convulsive management n nDiazepam Diazepam n nPhenobarbital Phenobarbital n nSubhibernation therapySubhiberna
70、tion therapy n nTreatment of increased intracranial pressureTreatment of increased intracranial pressuren nDehydration therapyDehydration therapy n n20%Mannitol 5ml/kg vi q6h20%Mannitol 5ml/kg vi q6hn nLasix 1-2mg/kg viLasix 1-2mg/kg viGeneral and Supportive Measuresn nTreatment of septic shock and
71、DICn nVolume expansionn nDopamine n nCorticosteroids n nHeparin n nFresh frozen plasman nPlatelet transfusionsTreatment Complication Measuresn nSubdural effusions Subdural effusions n nSubduaral prickingSubduaral prickingn nDraw-off effusions on one side is 20-30ml/time.Draw-off effusions on one sid
72、e is 20-30ml/time.n nOnce daily or every other day is requested. Once daily or every other day is requested. n nTime cell of pricking may be prolonged after 2 weeks.Time cell of pricking may be prolonged after 2 weeks. n nEpendymitisEpendymitis n nVentricular puncture Ventricular puncture drainage drainage n nPressure in ventricle be depressed.Pressure in ventricle be depressed. n nVentricular puncture may give ventricle an injection ofVentricular puncture may give ventricle an injection of antibiotic. antibiotic.
