結(jié)核性腦膜炎英文

1、結(jié)核性腦膜炎英文第1頁，共47頁，2022年，5月20日，19點25分，星期二EPIDEMIOLOGY - TBM Tuberculous Meningitis (TBM) The younger the children, the more readily to develop TBM. 60% in Children aged 1-3 years Death rate: 15-30%2第2頁，共47頁，2022年，5月20日，19點25分，星期二TBM (Tuberculous meningitis) TBM is the most serious complication of tube

2、rculosis in children and is usually fatal without treatment. TBM always be a part of systemic disseminated tuberculosis. TBM often occurs within 1 year of initial infection, especially in the first 2 to 6 months of infection.3第3頁，共47頁，2022年，5月20日，19點25分，星期二Tuberculous BacilliPrimary ComplexBacteremi

3、aRich FociSubarachnoid SpaceBrain or Spinal Cord PerenchymaTuberculomasMeningitisPATHOPHYSIOLOGYTrauma/Diseases measles, pertussis Miliary TB4第4頁，共47頁，2022年，5月20日，19點25分，星期二PATHOLOGICAL EFFECTSMeningesDiffuse HyperemiaEdemaInflammatory Exudates Conformation of Tubercles 5第5頁，共47頁，2022年，5月20日，19點25分，

4、星期二PATHOLOGICAL EFFECTSSubarachnoid SpaceA large amount of thick gelatinous exudates concentrate to the pavimentum cerebri, optic chiasma, bridge of varolius, bulbus rhachidicus and Sylvian fissure. Basal meningitis accounts for the frequent dysfunction of cranial nerves III, VI, and VII.6第6頁，共47頁，2

5、022年，5月20日，19點25分，星期二PATHOLOGICAL EFFECTSCerebral ParenchymaTuberculous meningoencephalitisswelling and hyperemia of the parenchyma contribute to the intracranial hypertension, then ischemia of parenchyma occur, finally lead to the foci of encephalomalacia and necrosis. Hemiplegia may be present bec

6、ause of this change. Meninges, spinal, and spinal nerve root also involvement. The later always leads to paraplegina.7第7頁，共47頁，2022年，5月20日，19點25分，星期二PATHOLOGICAL EFFECTSCerebral VesselsThe bacteria invade the adventitia directly in the early stage and initiate the process of acute vasculitis. Progre

7、ssive destruction of adventitia, disruption of elastic fibers, and finally intimal destruction (endoarteritis), lead to the obliterative vasculitis, which may facilitate the ischemia, encephalomalacia and necrosis of parenchyma. 8第8頁，共47頁，2022年，5月20日，19點25分，星期二Circulation of CSFChoroid plexusLateral

8、 ventricleInterventricular foramenthe 3rd ventricleCerebral aqueduct4th ventricle2 Lateral foramina1 Medial foramenSubarachnoid spaceArachnoid granulationsDural sinusVenous drainage9第9頁，共47頁，2022年，5月20日，19點25分，星期二PATHOLOGICAL EFFECTSHydrocephalusHyperemia of choroids overproduction of CSF Inflammato

9、ry adherence of Meningedefective absorption of CSF Communicating hydrocephalus CSF flow is obstructed on the route before the cerebral aqueduct and the 4th ventricleNoncommunicating hydrocephalus10第10頁，共47頁，2022年，5月20日，19點25分，星期二In tuberculous meningitis there is a tendency for the exudate to be pri

10、marily located on the under surface of the brain, particularly over the ventral surface of the brain stem. 11第11頁，共47頁，2022年，5月20日，19點25分，星期二CLINICAL MANIFESTIONS A. Prodrome (1-2 week)Fever, fatigue, malaise, myalgia, drowsiness, headache, vomitingMental status changesFocal neurologic signs are abs

11、entCSF abnormity 12第12頁，共47頁，2022年，5月20日，19點25分，星期二CLINICAL MANIFESTIONSB. Meningeal Irritation Stage (1-2 week) More serious TB toxic symptomsIntracranial hypertension: severe headache, irritation, projectile vomiting, seizures; Bulging of anterior fontanelle, widening of cranial sutures in infant

12、Meningeal Irritation : nuchal rigidity, hypertonia Kernig sign or Brudzinski sign Cranial nerve abnormalities: 3, 6, 7Some children have no evidence of meningeal irritation but may have signs of encephalitis: disorientation, abnormal movements and speech impairment 13第13頁，共47頁，2022年，5月20日，19點25分，星期二

13、CLINICAL MANIFESTIONSC. Coma Stage (1-3 week)Frequent convulsion, progressive altered state of consciousness: lethargy, confusion, semicoma, deep coma, decerebrate or decorticate posturingDepletion: extremely maransis, constipation, urinary retention progressive abnormalities of vital signs, and eve

14、ntual die from cerebral hernia 14第14頁，共47頁，2022年，5月20日，19點25分，星期二Characteristics of TBM in infants and young childrenA rapid onset with convulsion, abruptly high feverAtypical miningeal irritationIntracranial hypertension manifests as bulging of anterior fontanelle and widening of cranial sutures in

15、 infant 15第15頁，共47頁，2022年，5月20日，19點25分，星期二PROGNOSIS The prognosis of tuberculous meningitis correlates most closely with the clinical stage of diagnosis and treatment. Age: infants or younger children are generally worse than that of older children Drug resistant strain Variation of host immunity Ap

16、propriate therapeutic regimen Completion of the antituberculor agent regimen16第16頁，共47頁，2022年，5月20日，19點25分，星期二It is imperative that antituberculosis treatment be considered for any child who develops basilar meningitis and hydrocephalus, cranial nerve palsy, or stroke with no other apparent etiology

17、.17第17頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS HistoryClinical Symptoms and SignsAuxiliary Examinations18第18頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS - History Elucidate the following:Medical and social history, including recent contact with patients with TBNegative history for Bacille Calmette-Guerin (B

18、CG) vaccinationHistory of immunosuppression from a known disease or drug therapy19第19頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS Symptoms and signs A gradual onset Fever, headache, alternant of irritability and drowsiness, vomiting, constipation of unknown originAltered mental status20第20頁，共47頁，2022年，5月2

19、0日，19點25分，星期二DIAGNOSIS Tuberculin Skin Test Purified protein derivative (PPD)Injected intradermally on the volar surface of the forearmReaction peaks at 48 to 72 hoursA nonreactive result does not exclude M. tuberculosis infection or disease, the tuberculin skin test is nonreactive in up to 50% of c

20、ases21第21頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS Spinal Tap Cerebrospinal FluidGross appearanceClear or slightly turbida fine clot resembling a pellicle or cobweb may formCell counts, differential count50-500cells/mm3Lymphocytic predominancebut Polymorphonuclear cells may predominate early GlucoseHyp

21、oglycorrhachiaProteinHigh protein level with 1-3g/L22第22頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS Spinal Tap Cerebrospinal FluidChloridate：low Acid-fast stain (+), Gram stain, India inkCulture for M tuberculosis (+) ELISA test for Specific PPD-IgM and PPD-IgG in CSF ELISA test for Specific TB-antigen i

22、n CSF is a sensitive and rapid method23第23頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS Spinal Tap Cerebrospinal Fluid Total IgG, IgA and IgM PCR : specific PCR to detect the gene of M tuberculosis bacilli can provide a rapid and reliable diagnosis of TBM, although false-negative results potentially occur2

23、4第24頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS Chest X-ray Chest x-ray: Posteroanterior and lateral views may reveal the followingHilar lymphadenopathySimple pneumoniaInfiltratePleural effusion/pleural scar25第25頁，共47頁，2022年，5月20日，19點25分，星期二DIAGNOSIS CT or MRI CT scan and MRI of the brain reveal hydrocep

24、halus, basilar meningeal thickening, infarcts, edema, and tuberculomas, all these are helpful clues, but nonspecific MRI and CT scan lack specificity, but help in monitoring complications that require neurosurgery, making the differentiations, and knowing the prognosis26第26頁，共47頁，2022年，5月20日，19點25分，

25、星期二DIFFERENTIAL DIAGNOSISViral Meningocephalitis Pyogenic Meningitis CNS Cryptococcosis27第27頁，共47頁，2022年，5月20日，19點25分，星期二DIFFERENTIAL DIAGNOSISViral Meningocephalitis Mumps, polio, enteroviruses, Measles, Herpes viruses, EBV, and Japanese encephalitis virus, etcCSF examination is the most important

26、test in differentiating the cause of meningitis:Clear appearanceCells: 50 -200 cells/mm3 , Mononuclear cell predominanceProtein: slightly elevated or normal Glucose and Chloridate : normal 28第28頁，共47頁，2022年，5月20日，19點25分，星期二DIFFERENTIAL DIAGNOSISPyogenic MeningitisClinical manifestationAcute onset of

27、 intense headache, fever, nausea, vomiting, photophobia, and stiff neck Group B streptococci, Neisseria meningitidis,Streptococcus pneumoniae, Haemophilus influenzae, and Staph. aureus, etc.Pyogenic foci located other sites of the hostTypical rash of meningococcal infectionExamination of CSF 29第29頁，

28、共47頁，2022年，5月20日，19點25分，星期二DIFFERENTIAL DIAGNOSISPyogenic MeningitisTypical CSF abnormalities in meningitisinclude the following:Appearance is turbidPleocytosis of PMN ( WBC counts always above 1000, even to a very high level as 10,000 cells/mm3, predominantly neutrophils)Decreased glucose concentra

29、tionIncreased protein concentration Gram stain and culture of CSF identify the etiological organism30第30頁，共47頁，2022年，5月20日，19點25分，星期二Brain surface (Pyogenic meningitis )31第31頁，共47頁，2022年，5月20日，19點25分，星期二TBM32第32頁，共47頁，2022年，5月20日，19點25分，星期二DIFFERENTIAL DIAGNOSISCNS CryptococcosisCryptococcosis is th

30、e most common fungal infection of the central nervous system It is the fourth most common cause of opportunistic infections in patients with AIDSDisease onset is usually insidious and has a longer latent periodFever always be absent at beginning of disease Very notable intracranial hypertension: sev

31、ere headacheVisual disturbances and papilledema are common33第33頁，共47頁，2022年，5月20日，19點25分，星期二DIFFERENTIAL DIAGNOSISCNS CryptococcosisCSFAppearance can be clear or turbid.Protein levels exceed Glucose and ChloridateMononuclear pleocytosis , numbers vary from 50 to 500 mononuclear cells/mm3.It is easy

32、to get the positive result for C neoformans of CSFIndia ink stain is positive CSF or serum cryptococcal antigen tests are positive34第34頁，共47頁，2022年，5月20日，19點25分，星期二Cryptococcus is a cause of meningitis, a common complication in AIDS. The organisms are usually easy to demonstrate histologically. In t

33、his slide they are the circular-to-ovoid structures with thick capsules. 35第35頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENT Supportive treatment Antituberculous drugs Decreasing intracranial pressure Corticosteriods Symptomatic treatment Follow-up visit 36第36頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENTSupportive

34、 treatmentBed rest and close respiratory contacts Nutritional support are paramount Keep good hygiene for the coma children to prevent of secondary infections, help them to change position frequently to prevent decubital Management of electrolyte abnormalities AntipyreticsControl of seizures: Diazep

35、am (Valium) 37第37頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENTAntituberculous drugsisoniazid INH, rifampin RIF, pyrazinamide PZA, streptomycin SM, and sometimes ethambutol EMB.INH and RIF are bactericidal for all M. tuberculosis population in any milieu.SM is most effective against rapidly multiplying orga

36、nisms.PZA is most effective against organisms found in macrephages.enter CSF readily in the presence of meningeal inflammation. 38第38頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENTAntituberculous drugs Any regimen must contain multiple drugs In addition, the therapy must be taken regularly and continued for

37、a sufficient period. 39第39頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENTAntituberculous drugsintensification chemotherapy stage: 3-4 months INH (15-25mg/kg) , RFP, PZA, SMconsolidation chemotherapy stage: with total course 1 year at least in order to prevent relapse, permit elimination organisms persistent

38、exist in the host INH, RFP or EMB (ethambutol)40第40頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENT Decreasing intracranial pressureDehydrant: Mannitol (MNT)Diuretic agent: Acetazolamide Decreasing CSF secretion by the choroid plexus Ventricular tap or Open ventricular drainage Repeat LPs and intrathecal inje

39、ctionShunting: to establish a communication between the CSF (ventricular or lumbar) and a drainage cavity. Performed only in cases of communicating hydrocephalus. Ventricular shunt to cisterna magna41第41頁，共47頁，2022年，5月20日，19點25分，星期二TREATMENTCorticosteriods Children should be treated for 6-8 weeks More effective in early stage Decrease the immflamatory exudat