化脓性脑膜炎.pptwxy.ppt

Case report Boy, 6 yrs, admitted in 23, Apr. 2007. CC: Fever, headache and vomiting for 2 days. HPI: Fever (T 39℃), headache, malaise, anorexia, vomiting (2), no convulsion skin rash. PMH: “Bacterial meningitis” (2 times in 17 months). PE: Left hearing loss, obvious neck stiffness with positive Brudzinskis and Kernigs signs. BR: WBC 14.56×109/L, N 86%, Hb 120g/L Q1: What disease does this boy suffer from? Diagnosis differential diagnosis for this boy Fever------infection, connective tissue diseases, malignancy (leukemia), Kawasaki disease …… Headache vomitting------intracranial hypertension, digestive tract infection, influenza (GI type) …… Neck stiffness with Brudzinskis and Kernigs signs (+) ------ meningeal irritation (meningitis or hemorrhage of subarachnoid space) BR: WBC↑, N↑------bacterial infection Bacterial meningitis 化脓性脑膜炎(急性细菌性脑膜炎) Objectives Definition Etiology Pathway of invasion Pathology Pathogenesis Clinical manifestations (CSF findings) Complications and their managements Essentials of diagnosis Differential diagnosis with viral, tuberculous cryptococcal meningitis Treatment 定义 感染途径 发病机制 病理 What is meningitis? (pathology) Congestion, fibrous exudation, neutrophil infiltration, angioedema and cytotoxic edema Focal hemorrhage (necrosis of vessel wall) Focal brain infarction (obliterating vasculitis) 1.前驱症状 年龄：90%5岁，1岁以下是患病高峰。 季节：一年四季均可发生，但肺炎链球菌冬春季多见，脑膜炎双球菌和流感嗜血杆菌春秋季发病多。 起病：大多急性起病，病前数日可有上呼吸道或胃肠道感染病史。 暴发型流脑 起病急骤。 2. 感染中毒症状 主要表现为高热 年长儿：可有头痛、肌肉痛、关节酸痛、疲乏无力、皮肤出血点、瘀斑或充血性皮疹、精神萎靡等； 婴幼儿：表现为易激惹、不安，或反应低下 脑膜炎双球菌脑膜炎（流脑）的暴发型：起病更加急骤，迅速出现进行性休克、皮肤出血点或瘀斑、DIC及中枢神经系统功能障碍。 3. 神经系统表现 颅内压增高 惊厥 脑膜刺激征：颈强直、Kernig征、Brudzinski征阳性。 意识障碍 限局性神经系统：颅神经 受累、肢体瘫痪等 Skin petechiae in epidemic cerebrospinal meningitis 新生儿和年龄3月的小婴儿化脑表现多不典型 1．体温可高可低，或不发热，甚至体温 不升 2．颅压增高表现可不明显 3．惊厥可不典型 4．脑膜刺激征不明显 脑积水 多见于治疗不恰当的6个月的小婴儿 由于发生粘连而引起脑脊液循环障碍发生脑积水 表现：颅内压增高、头围增大、脑功能障碍等 头颅影像学检查可确诊 脑性低钠血症/抗利尿激素异常分泌综合征 炎症累及下丘脑和垂体后叶，引起抗利尿激素不适当分泌 低钠血症和血浆渗透压降低 表现为食欲减退、恶心、呕吐、尿少、水肿、全身软