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), subacutely (symptoms evolving over 1-7days), or chronically (symptoms evolving o
2、ver more than 1 week).,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,Ca
3、ses under 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.There are significant difference in the incidence of bacterial meningitis by season.,Etiology,Causative organisms vary with patient age, with
4、three bacteria 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 coliB-haemolytic streptococ
5、ciStaphylococcus aureusStaphylococcus epidermidisListeria monocytogenes,Etiology,Elderly and immunocompromisedListeria monocytogenesGram negative bacteriaHospital-acquired infectionsKlebsiellaEscherichia coliPseudomonasStaphylococcus aureus,Etiology,The most common organisms Neonates and infants und
6、er the age of 2monthsEscherichia coli Pseudomonas Group B StreptococcusStaphylococcus aureus,Etiology,Children over 2 monthsHaemophilus influenzae type bNeisseria meningitidisStreptococcus pneumoniaeChildren over 12 yearsNeisseria meningitidisStreptococcus pneumoniae,Etiology,Major routes of leptome
7、ning infectionBacteria 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,Susceptibility of bacterial infection on CNS in the children Immaturity
8、of immune systemsNonspecific immuneInsufficient barrier (Blood-brain barrier)Insufficient complement activityInsufficient chemotaxis of neutrophilsInsufficient function of monocyte-macrophage systemBlood levels of diminished interferon (INF) -and interleukin -8 ( IL-8 ),Pathogenesis,Susceptibility o
9、f bacterial infection on CNS in the childrenSpecific immuneImmaturity of both the cellular and humoral immune systemsInsufficient antibody-mediated protectionDiminished immunologic responseBacterial virulence,Pathogenesis,A offending bacterium from blood invades the leptomeninges. Bacterial toxics a
10、nd Inflammatory mediators are released.Bacterial toxicsLipopolysaccharide, LPSTeichoic acidPeptidoglycan Inflammatory mediatorsTumor necrosis factor, TNFInterleukin-1, IL-1Prostaglandin E2, PGE2,Pathogenesis,Bacterial toxics and inflammatory mediators cause suppurative inflammation.Inflammatory infi
11、ltrationVascular permeability alterTissue edema Blood-brain barrier detroyThrombosis,Pathology,Diffuse bacterial infections involve the leptomeninges, arachnoid membrane and superficial cortical structures, and brain parenchyma is also inflamed.Meningeal exudate of varying thickness is found.There i
12、s purulent material around veins and venous sinuses, over the convexity of the brain, in the depths of the sulci, within the basal cisterns, and around the cerebellum, and spinal cord may be encased in pus. Ventriculitis (purulent material within the ventricles) has been observed repeatedly in child
13、ren who have died of their disease.,Pathology,Invasion of the ventricular 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.Obstructive hydrocephal
14、us Communicating hydrocephalus,Pathology,Blood vessel walls may infiltrated by inflammatory cells.Endothelial cell injuryVessel stenosisSecondary ischemia and infarctionVentricle dilatation which ensues may be associated with necrosis of cerebral tissue due to the inflammatory process itself or to o
15、cclusion of cerebral veins or arteries.,Pathology,Inflammatory process may result in cerebral edema and damage of the cerebral cortex.Conscious disturbanceConvulsionMotor disturbance Sensory disturbance Meningeal irritation sign is found because the spinal nerve root is irritated.Cranial nerve may b
16、e damaged,Clinical manifestation,Bacterial 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 manifestations of bacterial meningitis happen.Some
17、patients may access suddenly with shock and DIC.,Clinical manifestation,Toxic symptom all over the body HyperpyrexiaHeadachePhotophobiaPainful eye movementFatigued and weak Malaise, myalgia, anorexia, Vomiting, diarrhea and abdominal painCutaneous rashPetechiae, purpura,Clinical manifestation,Clinic
18、al manifestation of CNSIncreased intracranial pressureHeadacheProjectile vomiting Hypertension Bradycardia Bulging fontanel Cranial sutures diastasisComa Decerebrate rigidity Cerebral hernia,Clinical manifestation,Clinical manifestation of CNSSeizuresSeizures occur in about 20%-30% of children with
19、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 disturbances.,第一课件网站 ,Clinical manifestation,Clinical manifestation of CNSConscious disturbanceDrowsi
20、ness Clouding of consciousness ComaPsychiatric symptom Irritation Dysphoria dullness,Clinical manifestation,Clinical manifestation of CNSMeningeal irritation signNeck stiffnessPositive Kernigs signPositive Brudzinskis sign,Clinical manifestation,Clinical manifestation of CNSTransient or permanent pa
21、ralysis 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 6th cranial nerve, usually transient, is noted frequently early in the course.,Clinical manifestation,Symp
22、tom 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 inflammation may be minimal.Fever is generally present, but its absence or hypothermia in a infant with meningeal inflammation is common. Only i
23、rritability, 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 effusionSubdural effusions occur in about 10%-30% of children with bacteri
24、al 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 transillumination of the
25、 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 respiratory failure Bulging fontane
26、l Ventriculomegaly (CT) Cerebrospinal fluid by ventricular punctureWBC50109/LGlucoseo.4g/L,Complication,Cerebullar hyponatremiaSyndrem of inappropriate secretion of antidiuretic hormone (SIADH)Hyponatremia Degrade of blood osmotic pressureAggravated cerebral edemaFrequent convulsion Aggravated consc
27、ious disturbance,Complication,Hydrocephalus Increased intracranial pressureBulging fontanelAugmentation of head circumferenceBrain function disorder Other complicationDeafness or blindnessEpilepsyParalysis Mental retardationBehavior disorder,Laboratory Findings,Peripheral hemogramTotal WBC count 201
28、09/L 40109/L WBCDecreased WBC count at severe infectionLeukocyte differential count80%90% Neutrophils,Laboratory Findings,Rout examination of cerebrospinal fluid (CSF) Increased pressure of cerebrospinal fluid Cloudiness Evident Increased total WBC count (1000109/L)Evident Increased neutrophils in l
29、eukocyte differential countEvident Decreased glucose (1.1mmol/l) Evident Increased protein level Decreased or normal chloridateCSF film preparation or cultivation : positive result,Laboratory Findings,Especial examination of CSFSpecific bacterial antigen testCountercurrent immuno-electrophoresisLate
30、x agglutinationImmunofluorescent test Neisseria meningitidis (meningococcus)Haemophilus influenzae Streptococcus pneumoniae ( pneumococcus)Group B streptococcus,Laboratory Findings,Especial examination of CSFOther test of CSFLDHLactic acidCRPTNF and IgNeuron specific enolase (NSE),Laboratory Finding
31、s,Other bacterial testBlood cultivationFilm preparation of skin petechiae and purpuraSecretion culture of local lesion Imageology examination,Diagnosis,Diagnostic methodsA careful evaluation of history A careful evaluation of infants signs and symptomsA careful evaluation of information on longitudi
32、nal changes in vital signs and laboratory indicatorsRout examination of cerebrospinal 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 depen
33、ds upon careful examination of cerebrospinal 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 permeability for Blood-brain barrier Drug combinati
34、on Intravenous drip Full dosage Full course of treatment,Antibiotic Therapy,Selection of antibioticNo Certainly BacteriumCommunity-acquired bacterial infectionNosocomial infection acquired in a hospitalBroad-spectrum antibiotic coverage as noted belowChildren under age 3 monthsCefotaxime and ampicil
35、linCeftriaxone and ampicillin (children over age 1months)Children over 3 monthsCefotaxime 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 select
36、ed.N meningitidis : penicillin, tert- cephalosporin S pneumoniae: penicillin, tert- cephalosporin, vancomycin H influenzae: ampicillin, tert- cephalosporin S aureus: penicillin, nefcillin, vancomycin E coli: ampicillin, chloramphenicol, tert- cephalosporin,Antibiotic Therapy,Course of treatment7 day
37、s for meningococcal infection1014 days for H influenzae or S pneumoniae infectionMore than 21 days for S aureus or E coli infection1421 days for other organisms,Treatment General and Supportive Measures,Monitor of vital sign Correcting metabolic imbalancesSupplying sufficient heat quantity Correctin
38、g hypoglycemia Correcting metabolic acidemiaCorrecting fluids and electrolytes disorderApplication of cortical hormoneLessening inflammatory reaction Lessening toxic symptom lessening cerebral edema,General and Supportive Measures,Treatment of hyperpyrexia and seizures Pyretolysis by physiotherapy a
39、nd/or drugConvulsive management Diazepam Phenobarbital Subhibernation therapy Treatment of increased intracranial pressureDehydration therapy 20%Mannitol 5ml/kg vi q6hLasix 1-2mg/kg vi,General and Supportive Measures,Treatment of septic shock and DICVolume expansionDopamine Corticosteroids Heparin F
40、resh frozen plasmaPlatelet transfusions,Treatment Complication 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 Ventricular puncture drainage Pres
41、sure in ventricle be depressed. Ventricular puncture may give ventricle an injection of antibiotic.,Complication Measures,HydrocephalusOperative treatmentAdhesiolysis By-pass operation of cerebrospinal fluid Dilatation of aqueductSIADH (Cerebral hyponatremia)Restriction of fluidsupplement of serum s
42、odium diuretic,Prognosis,Appropriate antibiotic therapy reduces the mortality rate for bacterial meningitis 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 many 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,第一课件网站 ,
