化膿性腦膜炎英文第一頁，共四十二頁，2022年，8月28日Acuteinfectionofcentralnervoussystem(CNS).90%ofcasesoccurintheageof1mo-5yr.Theinflammationofmeningescausedbyvariousbacteria.Commonfeaturesinclinicalpracticesinclude:fever,increasedintracranialpressure,meningealirritation.Oneofthemostpotentiallyseriousinfections,associatedwithhighmortality(about10%)andmorbidity.PurulentMeningitis第二頁，共四十二頁，2022年，8月28日Etiology1.1Pathogens:Mainpathogens:Neissriameningitidis,streptoccuspneumoniae,Haemophilusinfluenzae.(2/3ofpurulentmeningitisarecausedbythesepathogens)Pathogensinspecialpopulations(neonate&<3moinfants,malnutrition,immunodeficiency):gramnegativeentericbacilli,groupBstreptococci,staphlococcusaureus

第三頁，共四十二頁，2022年，8月28日1.2Majorriskfactorsformeningitis

ImmatureimmunologicfunctionandattenuatedimmunologicresponsetopathogensLowlevelofimmunoglobulin,defectsofcomplementandproperdinsystemImmatureorimpairedblood-brain-barrier(BBB)

ImmatureBBBfunction:maturationatabout1yrImpairedBBB:Congenialoracquireddefectsacrossmucocutaneousbarrier

第四頁，共四十二頁，2022年，8月28日

1.3AccessofbacteriainvasionTypicalaccess---hematogenousdissemination

BacteriacolonizingthemucousmembranesofthenasopharynxinvasionintolocaltissuebacteremiahematogenousseedingtothesubarachnoidspaceModeoftransmission:Persontopersoncontactthroughrespiratorytractsecretionsordroplets第五頁，共四十二頁，2022年，8月28日Bacteriaspreadtothemeningesdirectly:throughanatomicdefectsintheskullorheadtraumaInvasionfromparameningealorgans:suchasparanasalsinusesormiddleearAccessofbacteriainvasion第六頁，共四十二頁，2022年，8月28日2.PathologyStructureofmeninges第七頁，共四十二頁，2022年，8月28日Characterizedbyleptomeningealandperivascularinfiltrationwithpolymorphonuclearleukocytesandaninflammatoryexudate.Exudatewhichmaybedistributedfromconvexityofbraintobasalregionofcranium.Exudateismorethicknessduetostreptococcuspneumoniaethanotherpathogens.Pathology第八頁，共四十二頁，2022年，8月28日3.ClinicalmanifestationsTheyoungerthechildis,thehigherincidenceofmeningitiswillbe.?-2/3ofcasesoccurlessthan1yrofage.Modeofpresentation:Acuteorfulminantonset:symptomsandsignsofsepsis;meningitisevolverapidlyoverafewhoursanddeathwithin24hours;usuallyinfectedwithNeissriameningitides(N.meningitides).

第九頁，共四十二頁，2022年，8月28日

Subacuteonset:Precedebyseveraldaysofupperrespiratorytractorgastrointestinalsymptoms;difficulttopinpointtheexactonsetofmeningitis;usuallywithmeningitisduetoHaemophilusinfluenzae(Hinfluenzae)andstreptoccuspneumococcus(Spneumococcus).Modeofpresentation第十頁，共四十二頁，2022年，8月28日Commonfeaturesofmeningitis:

signsofsystemicinfection:fever(90-95%),anorexia,shock,alterationofmentalstatusandconsciousnessneurologicalsigns:increasedintracranialpressure:headache,vomiting(82%),herniationmeningealirritation:nuchalrigidity(77%),kernigsign,brudzinskisign

Clinicalmanifestations第十一頁，共四十二頁，2022年，8月28日brudzinskisign第十二頁，共四十二頁，2022年，8月28日

Seizure(20-30%)

FocalorgeneralizedDuetocerebritis,infarction,electrolytedisturbancesFrequentlynotedwithHinfluenzae&SpneumococcalmeningitisPersistafter4thdayanddifficulttotreatwithpoorprognosisClinicalmanifestations第十三頁，共四十二頁，2022年，8月28日

Clinicalmanifestations

AlterationofmentalstatusandconsciousnessIncluding:irritability,lethargy,stuporobtundation,comaDuetoincreasedintracranialpressure,cerebritis,hypotensionOftenwithpneumococcalormeningococcalmeningitisComatosepatientswithapoorprognosis第十四頁，共四十二頁，2022年，8月28日Thesymptomsandsignsarenotevidentinneonatesandinfantsyoungerthan3moofage;andpatientsalreadyreceivedirregularantibiotictherapy.Clinicalmanifestations第十五頁，共四十二頁，2022年，8月28日SignsofsystemicinfectionIncreasedintracranialpressuremeningealirritationTypical(olderchildren)Fever,alteredconsciousness,seizureHeadache,vomiting,herniationnuchalrigidity,backpain,kernigsign,brudzinskisignAtypical(neonate&<3moinfant)Fever,normaltemperatureorhypothermia;minimorsubtleseizure;poorfeeding;lessactivityScream,frown;bulgingorfullfontanel;wideningofthesuturesNotevidentComparisonofthemanifestationsofmeningitisbetweendifferentagegroupsClinicalmanifestations第十六頁，共四十二頁，2022年，8月28日4.DiagnosisEarlierdiagnosisandpromptinitiationofeffectiveantibiotictreatmentiscriticalforminimizingsequelaeofpurulentmeningitis.Suspectedcases:febrileinfantswithseizure,meningealirritability,increasedintracranialpressure,alteredmentalstatusPayattentiontotheatypicalsymptomsandsignsinneonate,infantandpatientalreadyreceivedirregularantibiotictherapy

第十七頁，共四十二頁，2022年，8月28日Diagnosisisconfirmedbyanalysisofcerebrospinalfluid(CSF)Suggestionbacterialmeningitis

Increasedpressure(90%)Appearance:slightlycloudytopurulentRaisedwhitebloodcells,consistingchieflyofpolymorphonuclearleukocytesRaisedproteinconcentration,decreasedglucoseconcentration(80%)

Diagnosis第十八頁，共四十二頁，2022年，8月28日

Confirmationofthediagnosis:isolationfromtheCSFofaspecificbacterialpathogenbymicroscopyorapositivecultureorrapidantigen-detectiontestofCSFGram-stainedsmearofCSF:identifythecausativeorganismin70-90%ofcasesCSFculture:positiveinabout80%ofcases.definitivediagnosis,determinationofantibioticsensitivity.PCR:amplifiesbacterialDNA(Hinfluenzae,N.meningitidis)Diagnosis第十九頁，共四十二頁，2022年，8月28日5.Differentialdiagnosis

PurulentmeningitiscausedbydifferentpathogensNeissriameningitidis:Occurinepidemics(typeA,C),whichismorecommoninspring,orsporadicalltheyear(typeB,C,Y)Suddenonsetwithvariouscutaneoussigns(petechiae,purpura,oranerythematousmacularrash)

第二十頁，共四十二頁，2022年，8月28日Streptococcuspneumoniae:Younginfants(<1yr)aremostsusceptiblepopulationPeakseason:springandwinterEasiertohavesubduraleffusionand

hydrocephalusEasilyhaveaprotractedcourseandrelapseDifferentialdiagnosis第二十一頁，共四十二頁，2022年，8月28日

HaemophilusinfluenzaeOccurspredominantlyininfants2moto2yrofageManycasesareinwinterHigherincidenceofsubduraleffusion

Otherspathogens:staphylococcusaureus,gramnegativeentericbacilliSpecialsusceptiblepopulation:neonate,<3moinfants,malnutrition,immunodeficiencySevereinfection,difficulttotreatDifferentialdiagnosis第二十二頁，共四十二頁，2022年，8月28日

Meningitiscausedbyothermicroorganisms

Viralmeningitis/encephalitis:

Lessseveresystemicinfectioussymptoms

Usuallynotdevelopafter2-3weeks

CSF:normalglucose

Differentialdiagnosis第二十三頁，共四十二頁，2022年，8月28日Tuberculousmeningitis

Subacuteonsetandprogress

AhistoryofclosecontactwithknowncasesoftuberculosisEvidenceofacuteorhealedtubercularinfectiononchestx-rayTuberculinskintest:OT,PPDCSFDifferentialdiagnosis第二十四頁，共四十二頁，2022年，8月28日DiseasePressure(Kpa)aspectTotalWBC(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)Gram’sstain++TuberculousmeningitisNormalorcloudy(MN)AFBstain+Viralmeningitis/encephalitisNormalorNormalNormalor(MN)Normalor(<1)normal-FungalmeningitisNormalorNormalorcloudy(MN)Indiainkprep+Cerebrospinalfluidinneurologicinfection第二十五頁，共四十二頁，2022年，8月28日6.Complicationsandsequelae6.1SubduraleffusionDefinitivediagnosis:volumeoffluidinsubduralspace>2ml,protein>0.4g/L,Incidence:developin10-30%ofpatients,asymptomaticin85-90%ofpatients;especiallycommonininfants4-6monthofage(rareinchildrenover1yr);第二十六頁，共四十二頁，2022年，8月28日Causativeorganisms:45%ofcasesofmeningitiscausedbyHinfluenzae,30%bySpneumoniae,9%byNmeningitidissubduraleffusion第二十七頁，共四十二頁，2022年，8月28日

Indications:NoresponsetoasensitiveantibiotictherapyProlongedfeverorfeverreoccurringafteranafebrileintervalwitheffectivetreatmentBulgingfontanel,wideningofsutures,enlargingheadcircumference,emesis,seizure,alteredconsciousness.ImprovedCSFprofilewithmoreseriousclinicalmanifestationssubduraleffusion第二十八頁，共四十二頁，2022年，8月28日Diagnosismethods:

CranialtranslucenttestBultrasonicexaminationandCTSubduralspacepuncturesubduraleffusionnormalsubduraleffusion第二十九頁，共四十二頁，2022年，8月28日6.2Ventriculitis6.3hydrocephalusComplications第三十頁，共四十二頁，2022年，8月28日Circulationofcerebrospinalfluid(CSF)第三十一頁，共四十二頁，2022年，8月28日6.2VentriculitisUsuallyoccursinneonatesandinfants(<1yr),withsevereprognosisThemaincauseisdelayeddiagnosisandtreatmentofmeningitis.

Complications第三十二頁，共四十二頁，2022年，8月28日Diagnosis:Bultrasonicexaminationorneuroimagingstudies(CT,MRI):enlargedlateralventricleLateralventriclepuncture:bacteriaandinflammatorycellsinventricularfluid,WBC>50x106/L,Glucose<1.6mmol/L,orprotein>400mg/L.Ventriculitis第三十三頁，共四十二頁，2022年，8月28日Circulationofcerebrospinalfluid(CSF)第三十四頁，共四十二頁，2022年，8月28日6.3hydrocephalus:Communicatinghydrocephalus:adheredordestroyedarachnoidgranulationaroundthecisternatthebaseofthebrainObstructivehydrocephalus:followingobstructedofthecerebralaqueduct,ortheforaminaofMagendieandLuschka6.4others:Deafness,blindness,paralysis,epilepsy,mentalretardationComplications第三十五頁，共四十二頁，2022年，8月28日Treatment7.1AntibacterialtherapyTherapyprinciples:earlytreatment,antibioticssusceptibletopathogensandwithhighpermeabilitythroughBBB,givenintraveninously,enoughdose,enoughcourseofantibiotictherapy

第三十六頁，共四十二頁，2022年，8月28日SusceptibletopathogensFirstchoice:Cefotaxime,Ceftriaxone(3drgenerationofcephalosporins,highpermeabilitythroughBBB,productsofmetabolismalsohaseffect,CSFsterilizationwithin24h)Otherchoice:Penicillin,Chloromycin,Cefuroxime,Ceftazidime(delayedeffecttomakeCSFsterile,highincidenceofrelapseanddeafness)Antibacterialtherapy第三十七頁，共四十二頁，2022年，8月28日EtiologyStandardantibioticsofchoiceDurationoftherapyH.influenzaeCefotaxime/Ceftriaxone7-10daysN.meningitidisCefotaxime/Ceftriaxone