epidemic cerebrospinal meningitis dr. huijian zhou dept. of infectious disease ruijin hospital

Epidemic cerebrospinal meningitisEpidemic cerebrospinal meningitis

Dr. Huijian ZhouDept. Of Infectious Disease

Ruijin Hospital

General descriptionGeneral description

Epidemic cerebrospinal meningitis is acute infectious Epidemic cerebrospinal meningitis is acute infectious disease caused by disease caused by meningococcusmeningococcus 脑膜炎奈瑟菌脑膜炎奈瑟菌 ..

The characteristics of ECM are fever,The characteristics of ECM are fever, headache, vomiting , petechiaeheadache, vomiting , petechiae 淤点淤点 or or

ecchymosisecchymosis 淤斑淤斑 , and meningeal irritation , and meningeal irritation signs. CSF is signs. CSF is purulentpurulent 化脓性化脓性 ..

Air pathwayAir pathway Season: from winter to springSeason: from winter to spring High incidenceHigh incidence in childin child

EtiologyEtiology

Pathogen is Neisseria meningitidis (meningococcusPathogen is Neisseria meningitidis (meningococcus ））脑膜炎奈瑟脑膜炎奈瑟菌，又称脑膜炎双球菌菌，又称脑膜炎双球菌

G- diplococcusG- diplococcus, , kidney formkidney form ，， The organism can be detected in patient’s nasopharynx, blood, The organism can be detected in patient’s nasopharynx, blood,

CSF, petechiae in skinCSF, petechiae in skin 鼻咽部、血清、淤点淤斑、脑脊液带菌鼻咽部、血清、淤点淤斑、脑脊液带菌 Pathogenic factor: Pathogenic factor: endotoxinendotoxin ,autolysis by autolysin in vitro ,autolysis by autolysin in vitro 内毒素，内毒素，

自溶酶自溶酶 The organism grow by incubationThe organism grow by incubation

on blood,chocolate in 5~10%CO2,PH 7.4~7.6;on blood,chocolate in 5~10%CO2,PH 7.4~7.6; 专性需氧，巧克力专性需氧，巧克力平板培养平板培养

The organism is susceptible to dry,The organism is susceptible to dry,

heat , chill and disinfectantheat , chill and disinfectant 对外界抵抗力低对外界抵抗力低);

EtiologyEtiology

EtiologyEtiologyA, B, C, D, E29, H, I, K, L, W135, X, Y Z

More than 90%

Serogroups of meningoccus

EpidemiologyEpidemiology

Source of infectionSource of infection 传染源传染源 The routes of transmissionThe routes of transmission 传播途径传播途径 Susceptibility of populationSusceptibility of population 易感人群易感人群 Epidemiologic featureEpidemiologic feature 流行特征流行特征

EpidemiologyEpidemiology

The routes of transmission :The routes of transmission :

1) air borne 1) air borne

2) closed contact transmission2) closed contact transmission

EpidemiologyEpidemiology

Source of infection: Source of infection:

patients and patients and carrierscarriers

EpidemiologyEpidemiology

Susceptibility of population:Susceptibility of population:

1) universal susceptible, 1) universal susceptible, especial 6m-2yrespecial 6m-2yr

2) stable and persistent 2) stable and persistent immunityimmunity

EpidemiologyEpidemiology

Epidemiologic featureEpidemiologic feature1)Season: November – May1)Season: November – May

2)high peak: March – April2)high peak: March – April

3)age: 6 months to 2 years old3)age: 6 months to 2 years old

– Carriers:60~70%Carriers:60~70%– Patients:1%Patients:1%

PathogenesisPathogenesis

meningococci nasopharynx

upper respiratory tract infection

host resistance

Bacteria virulence

carriers meningococcemia

period

cerebrospinal infectioncerebrospinal infection

pyogenic meningitis 1%

other organs

pericarditis or arthritis etc

extinguished

60 - 70%20 -30%

septicemia

Pathogenesis (fulminant type) Pathogenesis (fulminant type)

endotoxin microcirculatory failure

petechia 瘀斑shock

DICBleeding

brain edema

brain purulence

coma brain hernia

PathologyPathology

Septicemic stageSepticemic stage

vascular endothelial vascular endothelial injuryinjury

cardiomyopathyand

lung edema

vascular wall vascular wall inflammation, necrosisinflammation, necrosis

thrombosisthrombosis 血栓血栓 ,perivascular bleedingperivascular bleeding

skin , mucous membranes

or organs bleeding

PathologyPathology ((fulminant meningoencephlitis typefulminant meningoencephlitis type))

Meningitis stageMeningitis stage

leptomeninxleptomeninxand

arachnoidarachnoid

congestion, bleeding, congestion, bleeding, swelling of meningeal vesselswelling of meningeal vessel

intracranial hypertension

FP 、 NE 、 plasma exosmosis purulent CSF

Inflammation,Conglutination

at the bottom of skull

injured cranial nerves

SiteSite

PathoanatomyPathoanatomy

PathoanatomyPathoanatomy

PathologyPathology

Meningitis stageMeningitis stage

FulminantFulminant typetype brain tissue

congestion, bleeding, edema

necrosis

intracranial hypertensionbrain hernia

Chronicpatients

ventricle hole脑室孔block

CSF circle obstacle

hydrocephalus

endotoxin

CT exhibitionCT exhibition

Clinical ManifestationClinical Manifestation

Incubation period: Incubation period: 1~10 days(2~3days)1~10 days(2~3days)

Clinical ManifestationClinical Manifestation

common typecommon type( ( >90%>90% cases ) cases ) URT infectious stageURT infectious stage

– Persist 1~2dPersist 1~2d– URT infectious symptomsURT infectious symptoms– Most patients have no these symptomsMost patients have no these symptoms

septicemic stage (toxemia symptoms)septicemic stage (toxemia symptoms)– acute and high fever39~40℃acute and high fever39~40℃– headacheheadache– petechiae, purpura or ecchymosispetechiae, purpura or ecchymosis 淤点紫癜淤淤点紫癜淤

斑斑

Clinical ManifestationClinical Manifestation

petechiaepetechiae

Clinical ManifestationClinical Manifestation common typecommon type

meningitis stage:meningitis stage: – High fever and septicemic symptomsHigh fever and septicemic symptoms– CNS symptoms: headache,vomiting,CNS symptoms: headache,vomiting,– meningeal irritation: nuchal rigidity; meningeal irritation: nuchal rigidity;

Kerning’signs and Brudzinski’signs are Kerning’signs and Brudzinski’signs are positivepositive

– Consciousness obstacleConsciousness obstacle 、 、 ConvulsionsConvulsions 抽搐抽搐– Persist 2~5dPersist 2~5d

Convalescent stage:5~7days fromConvalescent stage:5~7days from– T normalT normal ，， symptoms disappearsymptoms disappear– lucky herpeslucky herpes 幸福疱疹幸福疱疹

Clinical ManifestationClinical Manifestation

Fulminant types: 3 formsFulminant types: 3 forms shock form:the most dramatic formshock form:the most dramatic form 败血症休克型败血症休克型

– wildly petechiae, purpura, ecchymosiswildly petechiae, purpura, ecchymosis 瘀点瘀斑广瘀点瘀斑广泛，融合泛，融合

– severe toxic symptoms (shock): pallor,extremities severe toxic symptoms (shock): pallor,extremities cold, cyanosis, hypotension, pales quicklycold, cyanosis, hypotension, pales quickly

– DIC,MOFDIC,MOF– Meningeal irritant signs is absent, CSF is normal;Meningeal irritant signs is absent, CSF is normal;– Blood Culture of meningococcusBlood Culture of meningococcus

Clinical ManifestationClinical Manifestation

ecchymosisecchymosis

Clinical ManifestationClinical Manifestation

Fulminant typesFulminant types:: Meningoencephalitis typeMeningoencephalitis type

– Severe headache;projectile vomitingSevere headache;projectile vomiting– Papillar edemaPapillar edema– respiratory failurerespiratory failure– encephaloceleencephalocele 脑疝脑疝

枕骨大孔疝枕骨大孔疝 : : 小脑扁桃体疝小脑扁桃体疝 昏迷加深，双瞳孔散大，上肢内旋，下肢强直，迅速出昏迷加深，双瞳孔散大，上肢内旋，下肢强直，迅速出

现呼衰现呼衰 天幕裂孔疝天幕裂孔疝：颞叶海马回或沟回疝：颞叶海马回或沟回疝 昏迷，同侧瞳孔散大，眼球固定或外展，对侧肢体瘫痪昏迷，同侧瞳孔散大，眼球固定或外展，对侧肢体瘫痪

mixed typemixed type

Clinical ManifestationClinical Manifestation

severe case ： nuchal rigidity nuchal rigidity 角弓反张

Clinical ManifestationClinical Manifestation

The chronic meningococcemia formThe chronic meningococcemia form– Rarely, in adult populationRarely, in adult population– Course: weeks~monthsCourse: weeks~months– Intermitted high fever, tetter Intermitted high fever, tetter 皮疹、 皮疹、

purulent arthritispurulent arthritis ，， swelling of spleenswelling of spleen

– Diagnosis:once more bacteria cultureDiagnosis:once more bacteria culture

Clinical ManifestationClinical Manifestation

The mild formThe mild form Fever,arthralgia,URT infectious symptoms Fever,arthralgia,URT infectious symptoms Rare tetterRare tetter CSF normalCSF normal Frequently happen in younger and older Frequently happen in younger and older

populationpopulation

Laboratory FindingsLaboratory Findings Blood pictures: Blood pictures:

WBC↑↑↑WBC↑↑↑ ，， NE↑↑NE↑↑PLT is decrease in PLT is decrease in DICDIC

CSF (important)CSF (important) suppurativesuppurative ，， WBC>1000X10WBC>1000X1066/L/L ，， ANCANC

为主为主 Pr↑, Glu↓ ClPr↑, Glu↓ Cl--↓↓

PressurePressure↑ ↑

Laboratory FindingsLaboratory Findings lumbarlumbar puncturepuncture 腰穿腰穿

Laboratory FindingsLaboratory Findings

Bacteriology Bacteriology SmearSmear

Laboratory FindingsLaboratory Findings

BacteriologyBacteriology Culture Culture (gold standard)(gold standard)

Laboratory FindingsLaboratory FindingsCerebrospinal fluidCerebrospinal fluid CSF: CSF: septic meningitisseptic meningitis

normalnormal Viral meningitisViral meningitis purulent purulent

meningitismeningitis

tuberculous tuberculous meningitismeningitis

appearanceappearance transparenttransparent transparent or transparent or slightly cloudyslightly cloudy

cloudycloudy Ground glass Ground glass alikealike

pressurepressure((cm cm HH22O)O)

5-125-12 may be elevatedmay be elevated >20>20 may be elevatedmay be elevated

pleocytosispleocytosis /L/L 0~8 x 100~8 x 1066 50~5050~5000××106/106/

LL

>1000 x 10>1000 x 1066 100-500 x 10100-500 x 1066

proteinprotein(g/L)(g/L) 0.15~0.450.15~0.45 may be elevated may be elevated mildlymildly

~1~1 1~2 ou >21~2 ou >2

glucoseglucose((mmol/L)mmol/L) 2.8~4.22.8~4.2 normalnormal ↓↓ ↓↓

((mmol/Lmmol/L)) 120~130120~130 normalnormal ↓↓ ↓↓

smearsmear -- -- ++ ++

Laboratory FindingsLaboratory Findings

Immunologic testImmunologic test

antigenantigen

antibodyantibody OtherOther

CSF-β2MCSF-β2M globinglobin LLTLLT

E.C.ME.C.M Diagnosis and differential diagnosisDiagnosis and differential diagnosis

– diagnosisdiagnosis seasonseason ，， suddenlysuddenly high feverhigh fever ，， headacheheadache ，，

vomitingvomiting petechiapetechia ， ， meningeal irritationmeningeal irritation bloodblood 、、 CSF testsCSF tests ，， bacteria culturebacteria culture

– differential diagnosisdifferential diagnosis Other purulent meningitisOther purulent meningitis TB meningitis ,Epidemic encephalitis B,etcTB meningitis ,Epidemic encephalitis B,etc SepticemiaSepticemia

TreatmentTreatment

Common typeCommon type– General treatmentGeneral treatment– Pathogenic treatmentPathogenic treatment ： ： 1.penicillin G1.penicillin G

2 .Chloramycin:2 .Chloramycin:

3.Ceftriaxone,Cefotaxime3.Ceftriaxone,Cefotaxime– symptomatic therapysymptomatic therapy ：： defervescensedefervescense 退热退热， ，

Decrease intracranial hypertensionDecrease intracranial hypertension 降颅压降颅压

TreatmentTreatment

FulminantFulminant typetype– Shock formShock form ：：1.1. pathogenic therapypathogenic therapy

2.2. Anti-shockAnti-shock

3.3. Steroid, hydrocoticosterone, etcSteroid, hydrocoticosterone, etc

4.4. AntiAnti-DIC-DIC

5.5. Protect major organsProtect major organs

Treatment

FulminantFulminant typetype -Meningoencephalitis typeMeningoencephalitis type

1. Antibiotics1. Antibiotics

2. Decrease intracranial 2. Decrease intracranial hypertensionhypertension ，， prevent prevent brain hernia

3. Steroid3. Steroid

4. Anti-respiratory failure4. Anti-respiratory failure

5. Symptomatic treatment: management 5. Symptomatic treatment: management of fever ,convulsionof fever ,convulsion 惊厥惊厥

PreventionPrevention

Isolation source of infectionIsolation source of infection Cut the route of transmissionCut the route of transmission Protect susceptible populationProtect susceptible population1.Chemoprophylaxis: SMZ CO or Rifampicin1.Chemoprophylaxis: SMZ CO or Rifampicin

2. 2. VaccinationVaccination