suppurative meningitis
Introduction
Introduction to purulent meningitis Purulent meningitis (purulent meningitis), a meningeal inflammation caused by various pyogenic infections, is one of the serious intracranial infections, often accompanied by purulent encephalitis or brain abscess, children, especially infants Children are common. The most common pathogens of purulent meningitis are meningococcus, pneumococci and Haemophilus influenzae type B, followed by Staphylococcus aureus, streptococcus, Escherichia coli, Proteus, anaerobic bacteria, and sand Bacteria, Pseudomonas aeruginosa (Pseudomonas aeruginosa) and the like. Meningococcal bacteria are most often invading children, but adults can also develop disease. Influenza bacilli meningitis occurs in children under 6 years of age. Pneumococcal meningitis occurs in the elderly and infants. E. coli is the most common pathogen of neonatal meningitis. Staphylococcus aureus and Pseudomonas aeruginosa meningitis are often secondary to lumbar puncture and neurosurgery. Since the use of antibiotics, the mortality rate has dropped from 50% to 90% to less than 10%, but it is still one of the serious infectious diseases in children. Among them, meningococcal bacteria are the most common, can occur epidemic, clinical manifestations have their own specificity, called epidemic cerebrospinal meningitis. basic knowledge The proportion of illness: 0.003% Susceptible people: good for infants and young children Mode of infection: respiratory transmission Complications: brain abscess cerebral infarction intracranial venous sinus thrombosis septic arthritis diffuse intravascular coagulation epilepsy hydrocephalus
Cause
Cause of purulent meningitis
Causes:
Suppurative meningitis can be caused by any purulent bacteria. The most common pathogens are meningococcus, haemophilus influenzae and pneumococcus, followed by Staphylococcus aureus, streptococcus, Escherichia coli, Proteus, Salmonella And Pseudomonas aeruginosa, etc., other rare, neonatal meningitis is more common with Escherichia coli and hemolytic streptococcus, most of the open brain injury caused by staphylococcus, streptococcus and Pseudomonas aeruginosa, infection pathway:
1. Caused by adjacent suppurative lesions, including paranasal sinusitis, otitis media, mastoiditis, tonsillitis, suppurative lesions of the neck, skull osteomyelitis, epidural, subdural abscess, and brain abscess .
2, caused by craniocerebral injury, including open brain injury and skull base fracture.
3, caused by distant bloody infections of purulent lesions, including bacterial endocarditis, purulent infection of the lungs, bacteremia and other distant purulent lesions.
4, some congenital lesions, such as brain swelling or the meninges, when the spinal cord bulges and rupture, the infection can also directly enter the subarachnoid space, if the skin-like cysts communicate with the outside world, it can also cause direct infection.
5. Surgery caused by infection after neurosurgery, including surgery of the brain and spinal cord.
Pathogenesis
The pathological changes of purulent meningitis caused by various pathogenic bacteria are generally similar. In the early stage, only the blood vessels on the surface of the brain were dilated and congested, and the inflammation rapidly spread along the subarachnoid space, and a large amount of purulent exudate was covered. The surface of the brain and the basal part of the brain, the brain pool and the brain, sometimes inflammation can also affect the ventricles. The color of the pus is related to the pathogen type, such as meningococcus, Staphylococcus aureus, Escherichia coli and deformation. The pus of the bacillus is often gray or yellow, the pus of pneumococci is pale green, the pus of Pseudomonas aeruginosa is grass green, etc. After several weeks of onset, the cerebrospinal fluid absorption disorder and circulation are blocked due to meningeal adhesion, causing traffic Sexual or non-communicating hydrocephalus, such as complicated cerebral arteritis, can cause cerebral ischemia or cerebral infarction. In addition, it can cause intracranial venous sinus thrombosis, epidural abscess, subdural abscess or brain abscess. Under the microscope, there are inflammatory cell infiltration in the meninges and even the ependymal and choroid plexus. The polymorphonuclear leukocytes are mainly used, and sometimes pathogenic bacteria can be found. In addition, blood vessels in the meninges and cortex can be seen. Thrombosis or blood, brain edema, degeneration of neurons and hyperplasia of glial cell performance.
Prevention
Suppurative meningitis prevention
Pediatric prevention:
1. Establish a good living system, pay attention to keep warm, see more sunshine, absorb more fresh air, carry out necessary outdoor activities to enhance the body's resistance, and less contact with patients with respiratory infections to prevent respiratory infections. This is extremely important to reduce the recurrence of pneumococcal meningitis.
2, the prevention of neonatal meningitis is related to perinatal health care, and should be completely treated for maternal infection. If the newborn is exposed to a heavily polluted environment, antibiotics should be used.
Adult prevention:
1. Exercise the body, enhance physical fitness, and prevent the invasion of disease and evil.
2, prevention of various infectious diseases, vaccination before the epidemic period.
3. Early detection of disease and active treatment.
4. Children who are in close contact with the child may take preventive medicine. Such as eating raw garlic 2 to 5 petals per day, for 1 week; or dandelion, radix isatidis, honeysuckle each 30 grams, decoction, and even served for 5 days; or rifampicin, daily 20 mg / kg, take 4 days .
5. During the epidemic period, it is necessary to strengthen prevention and publicity work, and to less public places, wear masks when going out, and gargle with light salt water.
6, active treatment of adjacent sites of suppurative lesions, open brain injury and skull base surgery for neurosurgery, should pay attention to aseptic operation and reasonable anti-inflammatory treatment, help prevent purulent meningitis.
Complication
Septic meningitis complications Complications brain abscess cerebral infarction intracranial venous sinus thrombosis septic arthritis diffuse intravascular coagulation epilepsy hydrocephalus
Common complications include: subdural effusion, empyema, brain abscess, cerebral infarction, venous sinus thrombosis and other intracranial suppurative infections and bacterial endocarditis, pneumonia, septic arthritis, nephritis, eye Extracranial lesions such as ciliary body inflammation and even diffuse intravascular coagulation, sequelae include epilepsy, hydrocephalus, aphasia, limb paralysis and cranial nerve palsy.
Symptom
Suppurative meningitis symptoms Common symptoms High fever chills Meningeal irritation Symptoms Irritability Appetite Loss Skin Spot muscle soreness edema
The clinical manifestations of brains caused by various bacteria are similar, which can be summarized as infection, increased intracranial pressure and meningeal irritation. Its clinical performance depends to a large extent on the age of the child. The clinical performance of older children is similar to that of adults. Infants and young children are generally more insidious or atypical.
Early childhood brain disease, high fever, headache, vomiting, loss of appetite and mental wilting. When I am sick, my mind is generally awake, and my condition can progress to drowsiness, paralysis, convulsions and coma. In severe cases, convulsions and coma occurred within 24 hours. Physical examination showed that the child had disturbance of consciousness, paralysis or coma, neck stiffness, Klinefelter and Brine's sign. If not treated in time, the neck stiffness increases the back of the head, the back muscles are stiff and even the horns are reversed. When there are symptoms of central respiratory failure such as respiratory rhythm irregularity and abnormal breathing, accompanied by pupillary changes, it indicates that cerebral edema has caused cerebral palsy. Herpes is more common in the late stage of the flow of the brain, but Streptococcus pneumoniae, influenza bacillus meningitis can occasionally occur.
Infants and children have a mixed onset of brain disease. Because the anterior iliac crest has not been closed, the suture can be split, and the intracranial pressure and meningeal irritation appear later, and the clinical manifestations are not typical. Often start with irritability, irritability, pale, loss of appetite, and then fever and respiratory or digestive symptoms such as vomiting, diarrhea and mild cough. Followed by lethargy, head tilted back, feeling allergic, crying sharp, eyes stunned, binocular gaze, sometimes with his head and shaking his head. Parents are often noticed and treated after a convulsion. The anterior sputum is full and the Brinell sign is an important sign, sometimes the skin scratch test is positive.
The clinical manifestations of newborns, especially immature children, are clearly different. Insidious onset, often lacking typical symptoms and signs. Less common intrauterine infections can manifest as irreversible shock or apnea at birth and die soon. The more common situation is that the baby is normal at birth, and after a few days, there are non-specific symptoms such as low muscle tone, low movement, weak crying, poor sucking power, refusal to eat, vomiting, jaundice, cyanosis, irregular breathing, and fever with or without. Even the body temperature does not rise. In the examination, only the tension of the anterior iliac crest was increased, and there were few signs of meningeal irritation. The anterior humerus also appeared late and was easily misdiagnosed. Only a lumbar puncture to check the cerebrospinal fluid can confirm the diagnosis.
Examine
Examination of purulent meningitis
1, laboratory inspection
(1) Blood: The peripheral white blood cell count is significantly increased, and neutrophils are dominant.
(2) Cerebrospinal fluid: The cerebrospinal fluid is turbid, the number of cells can reach 10×106/l or more, polymorphonuclear leukocytes predominate, protein increases, and sugar and chloride decrease significantly. Before the antibacterial treatment, cerebrospinal fluid smear staining microscopic examination, about half of the patients in the white blood cells can be seen in the pathogenic bacteria.
(3) Bacterial culture: Cerebrospinal fluid was taken for bacterial culture and drug sensitivity test before antibiotic treatment. Can be diagnosed and help choose antibacterial drugs. However, it takes a long time and the results cannot be obtained in time.
(4) rapid pathogen detection: 1 immunofluorescence test. The cerebrospinal fluid is detected by a known antibody labeled with fluorescein, and the pathogenic bacteria can be quickly detected, and the specificity and sensitivity are better. 2 enzyme-linked immunosorbent assay (elisa). The undetermined antigen (pathogenic bacteria) can be detected by known antibodies with good specificity and sensitivity. 3 convection immunoelectrophoresis. Certain soluble antigens of pathogenic bacteria in cerebrospinal fluid are detected using known antibodies.
2, other auxiliary inspection
(1) X-ray examination: 1 chest plate in patients with purulent meningitis is particularly important, can find pneumonia lesions or abscesses. 2 skull and sinus flat film can be found in skull osteomyelitis, paranasal sinusitis, mastoiditis, but the above lesions CT examination is more clear.
(2) CT, MRI examination: early CT or craniocerebral MRI examination of the lesion can be normal, neurological complications can be seen in the ventricle enlargement, sulnar narrowing, brain swelling and brain shift and other abnormal manifestations. Ependymitis, subdural effusion, and localized brain abscess can be found. Enhanced MRI scan is more sensitive to the diagnosis of meningitis than enhanced CT scan, and can show meningeal exudation and cortical response when MRI scan is performed. Appropriate technical conditions can be used to show venous occlusion and infarction at the corresponding site.
Diagnosis
Diagnosis and differentiation of purulent meningitis
1. The onset of this disease is generally more urgent. The appearance of cerebrospinal fluid is slightly hairy or mildly turbid. The number of white blood cells is more than ten to several hundred per ml. The number of early multinucleated cells is slightly increased, but the mononuclear cells are mainly followed by mild protein. Increased, sugar, chloride is normal. Attention should be paid to the epidemiological characteristics and clinical special performance to help identify. In some early stages of viral encephalitis, especially enterovirus infection, the total number of cerebrospinal fluid cells can be significantly increased, and polynuclear white blood cells are dominant, but the sugar content is generally normal, cerebrospinal fluid IgM, lactate dehydrogenase and its isoenzyme (LDH4, LDH5) does not increase to help identify.
2, the onset is more slow, often first 1 to 2 weeks of general symptoms of systemic discomfort. There are also sudden onsets, especially those with miliary tuberculosis. Typical tuberculous meningitis Cerebrospinal fluid has a glassy appearance, sometimes yellow due to high protein content. The number of white blood cells is 200 to 300 × 10 6 /L, and occasionally exceeds 1000 × 10 6 /L, and monocytes account for 70% to 80%. Sugar and chloride were significantly reduced. The protein is increased by up to 1~3g/L, and the acid-fast bacilli can be found in the smear of the cerebrospinal fluid. Patients should be carefully asked about the history of tuberculosis exposure, check for tuberculosis in other parts of the body, tuberculin test, tuberculosis in the stomach and stomach to assist in diagnosis. For patients who are highly suspected and are not easily diagnosed, anti-spasmodic drugs should be given to observe the treatment response.
3, its clinical manifestations, disease course and cerebrospinal fluid changes similar to tuberculous meningitis, slow onset symptoms are more hidden, longer course, the condition can be aggravated. It was confirmed by the cerebrospinal fluid Indian ink staining to see the bright bulb-shaped cells of the thick capsule, and there was a new type of cryptococcus growth on the Sabouraud medium.
4, but the general brain abscess is slower to start, sometimes with symptoms of the development, cerebrospinal fluid pressure increased significantly, the number of cells is normal or slightly increased, the protein is slightly higher. When the brain abscess ruptures into the subarachnoid space or ventricles of the spleen, it can cause a typical brain. Head B ultrasound, CT, MRI and other tests can help further diagnose.
5, its course of disease is longer, after more insidious, generally have a high blood pressure of the skull, and may have abnormal local neurological signs, often lack of infection. More rely on CT, nuclear magnetic resonance examination and identification.
6, the general brain symptoms caused by acute infections and toxins, mostly caused by cerebral edema, rather than the pathogen directly acts on the central nervous system, it is different from central nervous system infection. Its clinical features are convulsions, convulsions, coma, and may have meningeal irritation or cerebral palsy. Cerebrospinal fluid only increased pressure, other changes were not obvious.
7, Mollaret's meningitis is rare, characterized by benign recurrence, see pneumococcal meningitis.
