Meningeal irritation symptoms
Introduction
Introduction Meningeal irritation is a series of symptoms caused by meningeal lesions, including cervical rigidity, Kernig's sign, and Brudzinski's sign. 1 neck stiffness is an important objective sign of meningeal irritation, which is mainly manifested by varying degrees of muscle rigidity, especially extensor muscles. The head flexion is obviously restricted, that is, the passive flexion neck encounters resistance, and the head side bend is also subject to certain Restricted, the head rotation movement is limited to light, and the head back is not strong. Found in various types of meningitis, subarachnoid hemorrhage, increased intracranial pressure, cervical disease and so on. The 2Kernig sign is also called the flexor and knee extension test. The patient's supine position bends the knee joint into a right angle, and then passively bends the flexed leg. When the knee joint cannot be straightened, resistance and pain occur and the knee joint forms an angle of less than 135°. When the K sign is positive. Kernig sign positive in addition to suggesting that there are signs of meningeal irritation, it is suggested that the posterior root is stimulating, lumbosacral radiculopathy, the pain is limited to the waist and the affected limb, while the meningeal stimulation sign Kernig sign is bilateral, and the same intensity, pain Located on the chest and back and not limited to the waist and affected limbs. 3Brudzinski patients with supine supine, bilateral flexion and knee flexion when flexing the neck; compression of the bilateral cheeks caused by double upper arm abduction and elbow flexion; slamming their pubic symphysis with double lower limb flexion and Adduction, said to be positive for Brudzinski.
Cause
Cause
First, infectious meningitis
It is common in the inflammation of the soft brain (spine) caused by bacteria, viruses, spirochetes, fungi and parasites.
1, bacterial meningitis
1 purulent meningitis: such as meningococcus, pneumococci, streptococci, staphylococcus, Escherichia coli, Pseudomonas aeruginosa, Proteus, Neisseria gonorrhoeae, aerobacteria, Klebsiella.
2 non-suppurative bacterial meningitis: such as Mycobacterium tuberculosis, Brucella and so on.
2. Viral meningitis such as enterovirus, sputum disease, arbovirus, and mumps virus.
3. Other biological infective meningitis such as cryptococcus, leptospira, rickettsia, toxoplasmosis, amoeba, cysticercosis, schistosomiasis, etc.
Second, non-infectious brain arachnoiditis
1. Trauma: Brain trauma can cause inflammatory reactions in hard, soft meningitis and arachnoid.
2, blood cerebrospinal fluid: subarachnoid hemorrhage or lumbar puncture wounded blood vessels caused by bloody brain ketone.
3, cancerous meningitis: such as cancer meningeal metastasis, leukemia, lymphoma meningeal infiltration.
4, reactive meningitis: secondary to systemic infections, poisoning, as well as infections such as the ear and nose.
5, ventricle or intrathecal injection of drugs or contrast agents whether water-soluble or water-insoluble as a chemical factor, animal tests confirmed that meningitis response.
Examine
an examination
Related inspection
Brain CT examination brain MRI examination brainstem reflex examination
Cerebrospinal fluid culture + susceptibility test - CSF culture + susceptibility test is an examination of cerebrospinal fluid infection.
Cerebrospinal fluid glucose (CSF-Glu) A method of examination of cerebrospinal fluid.
Cerebrospinal fluid cell classification and counting: Microscopic examination of cerebrospinal fluid, generally based on cell count and white blood cell classification. Cerebrospinal fluid does not contain red blood cells, no white blood cells or very small amounts of white blood cells. In the case of central nervous system diseases, the number of cells in the cerebrospinal fluid increases, and the types of elevated white blood cells change. Therefore, doing cerebrospinal fluid microscopy can reflect the different nature of the disease.
Cerebrospinal fluid pathogen test (CSF): It is important to perform cerebrospinal fluid pathogen examination in patients with meningeal irritation and suspected nervous system infectious diseases.
Anti-B encephalitis virus antibody (EPBV-AB): Patients with acute encephalitis B can produce specific anti-B encephalitis virus antibody IgM (EPBV-IgM) on the seventh day after onset, reaching a peak of 2 to 3 weeks Therefore, the detection of EPBV-IgM is helpful for the early diagnosis of acute Japanese encephalitis. At the time of examination, 2 ml of venous blood was not allowed to coagulate, and 2 ml of serum or cerebrospinal fluid was separated for measurement.
Brain ultrasound examination
1, B-type ultrasound brain examination method:
It is mainly used for children under the age of 2 who are not closed, and they are scanned through the Tuen Mun as a "sound window".
2. Transcranial color Doppler imaging:
Through the sputum window, pillow window, and sacral window exploration, the cerebral arteries can be explored, and the diagnosis and classification of cerebrovascular diseases can be classified according to the flow velocity, bandwidth, abnormal flow direction or abnormal audio of the intracranial blood vessels.
Urine Vitamin B6 (VitB6): Vitamin B6 is a component of certain coenzymes in the human body and is involved in various metabolic reactions, especially in relation to amino acid metabolism. The long-term lack of vitamin B6 can cause damage to the skin, central nervous system and hematopoietic institutions. The symptoms of vitamin B6 deficiency in animals are dermatitis, phlegm, anemia, and the like. Simple vitamin B6 deficiency is rare in humans. Clinical application of vitamin B6 preparations to prevent pregnancy vomiting and radiation sickness and vomiting.
Cerebrospinal fluid protein electrophoresis: Cerebrospinal fluid protein electrophoresis is mainly used for the diagnosis of multiple sclerosis, neurosyphilis and subacute sclerosing panencephalitis.
Diagnosis
Differential diagnosis
First, fever with meningeal irritation
(a) purulent meningitis
Suppurative meningitis is a common acute intracranial infectious disease, often associated with purulent encephalitis or brain abscess. Fever, headache, vomiting, meningeal irritation positive; CSF appearance turbid or purulent, mainly neutrophils, sugar and chloride decreased, protein increased. Common causes of meningococcal and influenza bacilli are more common in children. Pneumococci are more common in the elderly and infants. Also found in Staphylococcus aureus, Streptococcus, Proteus, Anaerobe, Salmonella, Pseudomonas aeruginosa, Escherichia coli, Group B hemolytic streptococcus.
1. Characteristics of suppurative meningitis in adults or adolescents
1 Most are fulminant or acute onset.
2 The acute phase is characterized by systemic chills and fever, general malaise and symptoms of Shangbo Peng infection.
3 headache is a prominent symptom, accompanied by vomiting. Psychiatric symptoms are excitatory, embarrassing, and later blurred, slumbering and even coma. About 1 / 4 patients with epilepsy. 4 check the body neck stiffness, meningeal stimulation sign positive.
5 If the treatment is not timely, the progression of the disease can cause coma, convulsions, abnormal breathing, pupillary changes, and further increase in cerebral edema, which can cause brain fatigue.
6 skin bleeding points, more common in the late stage of purulent meningitis.
7 patients with cranial nerve palsy, III, IV, VI, VII for the common brain nerves, but also may occur hemiplegia, single sputum, aphasia, papilledema, pathological reflex positive.
2, the characteristics of infants with purulent meningitis
1 onset is generally more insidious or atypical.
2 Common respiratory or digestive symptoms such as vomiting, diarrhea, cough, fever. Followed by drowsiness, irritability, feeling allergies, J gods, and so on.
3 About 50% of patients have seizures, and the incidence of influenza bacilli meningitis is higher.
4 When the front bony is not closed, the suture can be split, so that the symptoms of high intracranial pressure and meningeal irritation appear later, and there may be cranial nerve palsy such as drooping eyelids, diplopia, facial paralysis, deafness, and aphasia.
5 About 1/3 of patients may have rash, skin mucosa has defects, and severe cases with disseminated intravascular coagulation (DIC) and cutaneous vasculitis are most common in meningococcal infection.
3. Auxiliary inspection
1 The total number of white blood cells and neutrophils increased significantly.
2 blood, CSF culture in the early stage without antibiotic treatment can get positive results.
3 cerebrospinal fluid: high pressure, turbid appearance or thin rice soup, increased white blood cell count, decreased sugar and chloride, increased protein content. Cytological examination of early neutrophils was above 0.90, and granulocytes rapidly decreased one week after antibiotic treatment. The CSF immunoglobulin content is increased.
4 brain CT examination: when there are neurological complications, ventricular enlargement, brain swelling, subdural effusion, brain abscess, epidural abscess, etc., and low density abnormalities around the ventricles during ependymitis.
5 brain MRI examination: early signs of meningitis can show cerebrospinal fluid signal changes, subarachnoid dilatation and diffuse cerebral edema, subcortical infarction and hemorrhage, or subdural effusion.
(two) tuberculous meningitis
Tuberculous meningitis is a non-suppurative inflammation of the meninges caused by Mycobacterium tuberculosis, often secondary to miliary tuberculosis and lymph nodes. Tuberculosis such as intestines, bones and kidneys. 81% of lung miliary tuberculosis complicated by tuberculous meningitis, especially in children. Subacute or occult onset, headache, vomiting and meningeal irritation positive, as well as cranial nerve palsy, epilepsy, limb paralysis and so on. More often accompanied by fever, night sweats, fatigue, loss of appetite and other symptoms of tuberculosis. Early diagnosis and timely treatment can improve efficacy and reduce mortality.
1, typical tuberculous meningitis: adult symptoms such as headache, vomiting and other increased intracranial pressure. Children often have seizures, the front buff is full, and the body temperature is about 38 °C. With the development of the disease, drowsiness and even coma can occur, and the meningeal irritation sign is positive.
2, atypical tuberculous meningitis: patients may have no fever, headache is not obvious, there may be visual impairment, diplopia, hearing loss and other symptoms of cranial nerves. Late inflammation spreads to the reticular tunica, causing the spinal cord to produce root canal lesions, paraplegia, quadriplegia, and cross-caries with urinary dysfunction. Severe patients gradually become comatose and hyperthermia, ventricular obstruction may have epileptic seizures, papilledema, irregular breathing, or cerebral palsy and death.
3. Auxiliary inspection
(1) Lumbar puncture CSF: The pressure is increased, and the appearance is mostly frosted glass. After 24 hours, the film is often formed. Leukocytosis is predominantly lymphocytes. The biochemical protein content is moderately increased, and sugar and chloride are reduced. Tuberculosis PCR, high sensitivity, specificity of 98.4%, can be detected early, the positive rate is about 88.8%, tuberculosis specific antibody positive. The increase in immunoglobulin is markedly marked by an increase in IgG.
(2) Brain CT and MRI more suggestive changes of hydrocephalus, cerebral infarction, tuberculoma, miliary cerebral tuberculosis, skull base proliferative meningitis, calcification.
4. Differential diagnosis: clinical manifestations of cryptococcal meningitis and tuberculous meningitis are similar; CSF routine and biochemical changes are also basically the same, so tuberculous meningitis should be differentiated from cryptococcal meningitis, but the two are different in some respects. Where.
1 Both are slow onset, but the brain is slower.
2 tuberculous meningitis patients often have a history of close exposure to tuberculosis or tuberculosis.
In patients with cryptococcal meningitis, there is often a history of long-term use of antibiotics or immunosuppressive agents, or other parts of mold infection, or the history of raising poultry.
3 cryptococcal meningitis patients with meningeal irritation without tuberculous meningitis, but headache. Often accompanied by personality changes such as euphoria, there are often brain damage, especially visual impairment. CSF smear, culture, cytology ink staining examination of cryptococcal meningitis can find cryptococcus, and tuberculous meningitis can be found in tuberculous meningitis.
Five CT, MRI, and occult brain abnormalities were rare, while tuberculous meningitis was more common in hydrocephalus, cerebral infarction, and tuberculoma.
(3) Viral meningitis
Viral meningitis is also known as aseptic meningitis or serous meningitis. It is caused by a variety of viral infections. It is an acute or subacute onset for a benign and self-limiting disease. It is more common in patients under 30 years of age. The coxsackie virus and MECHO virus are the most common, and viral meningitis caused by enterovirus is more common in summer and autumn. Mumps virus meningitis is more common in winter and spring. Lymphocytic choroidal meningitis is more common in winter, while herpes simplex meningitis has no obvious seasonality. Clinical manifestations often have upper respiratory tract infections and intestinal symptoms or general malaise, sore throat, nausea, vomiting, lethargy, photophobia, back pain, muscle pain or chills, diarrhea and other prodromal symptoms. The onset of symptoms, headache, fever, neck stiffness and other meningeal irritation as the main symptoms, no other positive signs. Occasionally, rash, myopathy and myocarditis can occur. A team-specific antibody to the virus can be detected in some viral meningitis cerebrospinal fluid.
(4) Lyme disease meningitis
Lyme disease meningitis is rare, clinically positive for headache, vomiting, and meningeal irritation, which may be one of the manifestations of Lyme disease. Lumbar cerebrospinal fluid pressure is normal, mononuclear cells increase, protein increases, sugar, chloride normal. The spirochete can be isolated in the CSF. Serological examination of Lyme disease antibody IgM, IgG titer 1:64 or more positive.
(5) Lymphocytic choriomeningitis
Lymphocytic choriomeningitis is an acute non-suppurative meningitis caused by a specific virus. The main source of infection is the excretion of viruses in the excrement of house mice. The pathogen is an RNA virus belonging to the salad virus. Clinically, the incubation period is 1-3 weeks, and more acute onset. Forequarters symptoms are similar to upper respiratory tract infections or pandemic-like symptoms. Fever, accompanied by general malaise or soreness, listlessness, loss of appetite, sore throat, cough, etc. This symptom can last from a few days to 2-3 weeks. Most of the neurological symptoms after the recovery period, after 1-2 d body temperature rose again, reaching 39-4O ° C, accompanied by central nervous system symptoms. Headache, vomiting, abdominal pain, irritability, lethargy, who is paralyzed, neck stiffness, meningeal irritation positive, and knee reflexes weakened. Young children can have horror. A small number of patients affect the brain parenchyma, cranial nerves and spinal nerves, which can be manifested as encephalomyelitis type, with diplopia, aphasia, muscle spasm, facial paralysis, and sensory disturbances. It usually improves quickly after several days to 1-2 weeks. Cerebrospinal fluid pressure is normal or slightly higher, the appearance is transparent or slightly turbid, the number of cells is increased by lymphocytes, protein is increased, sugar and chloride content is normal.
The diagnosis is mainly based on the history of eating food contaminated by rats. The laboratory of non-suppurative meningitis found that the cellular components in the cerebrospinal fluid increased with lymphocytes. Naturally restored without special treatment. In the initial stage of the disease and in the recovery period, double serum is taken, and the complement fixation test and the neutralization test are performed separately, and if it is positive, the diagnosis can be confirmed.
Second, fever is not obvious with meningeal irritation
(a) brain arachnoiditis
Cerebral arachnoiditis, also known as localized adhesion brain arachnoiditis, is a non-specific arachnoid chronic inflammation secondary to a variety of pathogenic factors. Clinically visible at any age, but more common in middle age, with acute, subacute, or chronic onset. There have been cases of trauma, surgery, tuberculous meningitis or other encephalitis or a history of intrathecal or intraventricular injections. Can be divided into two types:
1. Diffuse brain arachnoiditis
(1) acute brain arachnoiditis: low fever, chills, headache and meningeal irritation, similar to acute meningitis, but the symptoms are mild.
(2) chronic brain arachnoiditis: mainly headache, vomiting, papilledema, with abductor nerve, oculomotor nerve or facial nerve paralysis, no fever and meningeal irritation. The course of the disease is prolonged, and it can fluctuate and gradually increase.
2, local brain arachnoiditis according to the location, meningeal irritation can be not obvious.
(1) cerebral hemisphere arachnoiditis: often manifests epilepsy, single sputum. Hemiplegia, aphasia or sensory impairment. Damage to the frontal lobe can lead to mental and behavioral abnormalities, with increased intracranial pressure.
(2) Arachnoiditis at the base of the cross cranial:
1 Mainly forehead, collar or eyeball headache, vision loss.
2 fundus papillary edema or primary or secondary optic atrophy.
3 visual field irregularity defect, centripetal narrowing, central dark spot, hemianopia.
4 eye movement disorders or dysosmia.
5 When the brain is affected, it can cause polydipsia, fatness, lethargy, and abnormal glucose metabolism.
(3) posterior cranial fossa:
1 Cerebellar medullary cavity: arachnoid adhesions and cyst formation, blocking the outlet of the fourth ventricle, causing infarct hydrocephalus. Acute onset, headache, vomiting, papilledema and other symptoms of increased intracranial pressure. As well as signs of nystagmus, ataxia, and development of nerve palsy.
2 cerebellopontine angle: more chronic onset, V, VII, VIII see symptoms and signs of damage to the brain. There may be abduction of nerve palsy and cerebellar signs, similar to the symptoms of acoustic neuroma, but the course of surgery without auditory neuroma is procedural.
3, auxiliary examination: high waist penetration pressure, a slight increase in the number of cells, increased protein content, gas cerebral angiography can be found that the adhesion site is less inflated, or because of adhesion does not enter the human ventricular system. Ventricular angiography showed obstruction and enlarged ventricles. Brain CT can be seen in the occlusion of the skull base and ventricle enlargement. Brain MRI can be seen on the surface of the brain or at the base of the skull, and the brain parenchyma can appear irregular abnormal signals.
(two) reactive meningitis
Reactive meningitis, also known as vaginal meningitis, is mainly seen in some patients with acute infections, such as the infection of the cranial cavity near the body, lungs or facial features, accompanied by a series of meningitis such as headache, vomiting, and meningeal irritation. Symptoms and signs. In addition to the higher pressure, the cerebrospinal fluid examination showed a clear and transparent appearance, a slight increase in the number of cells or normal, and normal biochemical tests such as sugar and chloride. The prognosis of vaginal meningitis is generally good, often automatically improved, reduced or healed with the control, improvement or cure of systemic infection.
(3) Subarachnoid hemorrhage (SAH)
The rupture of blood vessels at the base of the brain or on the surface of the brain that causes blood to flow directly into the subarachnoid space is called primary SAH. Cerebral parenchymal hemorrhage, blood penetrating brain tissue flowing into the human ventricle and subarachnoid space is called secondary SAH. Common causes are intracranial aneurysms, cerebral vascular malformations, hypertension, atherosclerosis, and blood diseases. Collagen disease Thymoma destroys blood vessels, abnormal vascular network of the skull base, that is, moyamoya disease.
Clinical features:
1, can occur at any age, more common in 30-4O years old, a little more men. There are often pre-existing causes such as emotional excitement, physical labor, coughing, forced bowel movements, drinking, and sexual intercourse.
2, the main clinical manifestations are sudden severe headache, vomiting, disturbance of consciousness, meningeal irritation and blood cerebrospinal fluid. The severity of the symptoms depends on the location of the lesion, the amount of bleeding, and the age of onset.
3, may have a history of headache, dizziness, dizziness, blurred vision and so on. When a patient has a migraine with ocular paralysis, the possibility of an aneurysm should be considered.
4, auxiliary inspection
(1) Fundus change examination: visible side or bilateral papilledema, venous congestion, subcapsular hemorrhage.
(2) Cerebrospinal fluid examination: the pressure is increased, and the cerebrospinal fluid is uniform and bloody and has no clot. 2h after hemorrhage, due to the presence of oxyhemoglobin, the supernatant was red or orange-red after centrifugation; after hemorrhage for 24h, oxyhemoglobin was degraded to bilirubin, cerebrospinal fluid was yellowish red or yellow; after hemorrhage, the red blood cells in cerebrospinal fluid became onset for 12 hours. Can be raised. In the early stages of the inflammatory response, the chest is neutrophils and lymphocytes.
(3) Brain CT: No high-density lesions were found, suggesting that the amount of bleeding was small, mostly micro-aneurysm rupture. A larger aneurysm or arteriovenous rupture. Large aneurysms or arteriovenous malformations or intracranial tumor hemorrhages in ruptured aneurysms. There is a high density stove nearby. Aneurysm ruptures at the basilar artery, blood clots accumulate in the cerebral cistern or base, and CT shows a high-density shadow across the cerebral pools on both sides. The reverse flow of blood into the lateral ventricle or the fourth ventricle leads to a high density lesion in the ventricles.
(4) Brain MRI: The high-density area of the hematoma mass in the brain parenchyma is mostly ventricular hemorrhage or arteriovenous malformation and rupture of infectious aneurysm. Hemorrhage forms hematoma in the brain parenchyma.
(5) cerebral angiography: 80% of aneurysms can show, the location, size, number, shape of the aneurysm and the presence or absence of vasospasm and vascular displacement, the establishment of collateral circulation can be displayed.
(4) Cerebral cysticercosis meningitis
May have headache, vomiting, meningeal irritation positive, generally lighter. Lumbar puncture pressure is increased, and CSF is characterized by an increase in eosinophils. Blood and cerebrospinal fluid cystice test positive.
(5) Nodular meningitis: nodular meningitis, also known as Boeck nodules, Benoner-Baeck disease, benign lymphogranulomatosis. Can involve any part of the nervous system.
Clinical manifestations can occur at any age, common in adolescents, acute or chronic onset, may have extracranial lesions such as hilar lymphadenoma, ocular gonitis, visible diffuse nodules on the skin, and enlarged lymph nodes, or History of nodule disease. Meningitis often occurs in the later stages of sarcoidosis. There may be symptoms of increased intracranial pressure such as headache, vomiting, and fundus papilledema. Can be associated with cranial nerve damage to the facial nerve, optic nerve, glossopharynx, vagus nerve and auditory nerve are common. In addition, it can also invade the hypothalamus, the third ventricle area and the pituitary gland, and there are central hyperthermia, lethargy, obesity, personality changes, and diabetes insipidus. Invasion of peripheral nerves, manifested as single neuritis, multiple radiculopathy, Guillain-Barré syndrome. Invasion of brain parenchyma appears as a placeholder. Rare symptoms of granulomatosis and cerebral blood vessels can cause stroke-like episodes. Brain CT showed a slight increase in the density of the diseased area. After enhancement, the lesions are uniformly enhanced. Edema can occur around them. Occasionally, it has a low density on ordinary CT, but it can be strengthened. The ventricle is enlarged and occluded. Multiple granulomas on the surface of the brain and extensive hypertrophy of the meninges. Sarcoidosis antigen test grading. In swollen lymph node biopsy, it is seen that epithelial cells and regional cells are infiltrated without cheese necrosis.
