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