MENINGITIS

A B B D E F G And K L M N O U R C T Y P X C H W E I

MENINGITIS - inflammation of the brain and spinal cord, usually of infectious origin. Meningitis is classified by etiology (bacterial, viral, fungal, etc.), the nature of the inflammatory process (purulent, serous), current (acute, subacute, chronic), origin (primary and secondary, occurring against the backdrop of another disease - otitis media, sinusitis , traumatic brain injury, and so on. d.).

The clinical picture of meningitis constitute intense diffuse headache , nausea , vomiting , confusion or depression of consciousness up to coma, fever , malaise, tachycardia , myalgia and meningeal syndrome. Meningeal syndrome include stiffness in the neck muscles, preventing passive flexion of the head, Kernig symptom (inability to fully straighten the knee leg, pre-bent at right angles at the hip and knee), upper symptom Brudzinskogo (flexion of the femur and tibia when checking the rigidity of the neck muscles) and lower symptom Brudzinskogo (flexion of the femur and tibia when checking symptom Kernig on the other foot), general hypersensitivity (intolerance to bright lights, loud noises, touching the skin). Meningeal symptoms often can be detected even in a coma, but in the first hours of the disease, as well as in children and the elderly are sometimes missing persons. In elderly patients with meningitis may manifest itself by a combination of fever with confusion or increasing oppression of consciousness. On the other hand, the rigidity of the neck muscles in the elderly may be due not meningitis and cervical degenerative disc disease or parkinsonism. In contrast to these states of meningitis is difficult only flexion of the neck, but not its rotation or extension. In young children hanging define symptom Lessazha (armpits raised a child running out legs to his stomach and throws back his head). In infants can identify a large bulging fontanelle and termination of the ripple caused by increased intracranial pressure. In addition to meningitis, meningeal symptoms ( "meningismus") can be detected with subarachnoid hemorrhage, intracranial hypertension, bulky lesions of the posterior fossa (hematoma or abscess of the cerebellum), intoxication, traumatic brain injury, neuroleptic malignant syndrome.

Development of meningitis often preceded by upper respiratory tract infection. Prior use of antibiotics often smoothes clinic meningitis. In patients with weakened immune systems meningitis occurs either as a mild infection with a headache and mild fever, or how quickly growing coma .

Crucial in the diagnosis of meningitis is the study of cerebrospinal fluid. Danger lumbar puncture is associated with herniation (see. Intracranial hypertension). In the absence of congestive optic disc or other signs of a sharp rise in intracranial pressure or volumetric process, lumbar puncture is required at the slightest suspicion of meningitis. The pressure of the cerebrospinal fluid in meningitis is usually increased. When purulent meningitis turbid liquor, contains a large number of neutrophils and the total number of cells (cell count) is greater than 1 in 1000 ml. When serous meningitis cerebrospinal fluid is clear and opalescent, it contains mostly lymphocytes and cell count is typically a few hundred cells in 1 mm. However, at an early stage in purulent meningitis cytosis can be low, with a predominance of lymphocytes, whereas serous meningitis in the cerebrospinal fluid (CSF) may prevail neutrophils, and only allow repeated puncture in this case, to avoid diagnostic errors.

Purulent meningitis. Pathogens are usually the bacteria (Haemophilus influenzae, pneumococcus, meningococcus), which penetrate the CNS hematogenous route (with septicemia or metastasis of infectious foci in the heart, lungs) or by contact (with sinusitis, mastoiditis, osteomyelitis, traumatic brain injury, brain abscess ). Most cases of meningitis caused by Haemophilus influenzae, occur in children under 6 years old, but occasionally occur in older age, usually on a background of predisposing factors (sinusitis, pneumonia, otitis media, traumatic brain injury with liquorrhea, diabetes, alcoholism, splenectomy ).

Meningococcal meningitis (see. Meningococcal infection). In severe cases of meningococcal meningitis, flowing with fulminant meningococcemia, there is a characteristic hemorrhagic rash. At first, the rash may be erythematous or spotty, but then she quickly transformed into a petechial. It often takes the form stars of various sizes and shapes, and is localized on the trunk and lower extremities (in the buttocks, thighs, legs). Petechiae may also be in the mucous membranes, conjunctiva, and sometimes on the palms and soles. A similar rash may also occur with meningitis caused by enteroviruses, Haemophilus influenzae, staphylococcus, listeria, pneumococcus, as well as bacterial endocarditis, rikketsiozah, vasculitis.

Pneumococcal meningitis - the most common variant of meningitis V chip older than 30 years. Pneumococcal meningitis frequently develops as a result of infection from distant foci. Pneumonia is detected in 25 - 50% of patients (pneumonia, otitis media, mastoiditis, sinusitis, endocarditis). Particularly severe infection occurs in patients with reduced reactivity (in alcoholism, diabetes, after splenectomy, multiple myeloma, against the background of corticosteroid therapy, hemodialysis, liver cirrhosis). Streptococcus pneumoniae is the causative agent is often post-traumatic meningitis in patients with a fracture of the skull base and liquorrhea. Pneumococcal meningitis runs hard, often causing depression of consciousness and focal simtomatiku (hemiparesis, paresis gaze, cranial nerves), epileptic seizures can recur and often ends in death.

Recurrence of bacterial meningitis is usually caused by an anatomical defect that violates insulation subarachnoid space and is often a complication of traumatic brain injury (the causative agent in this case is often the pneumococcus) or immunocompromised. For the detection of CSF fistulas are conducting a study of discharge from the nose (high levels of glucose characteristic of CSF).

Focal neurologic symptoms associated with meningitis involving the cranial and spinal nerves, at least - of the brain substance. Very often suffer oculomotor nerves, but, as a rule, the movement of the eyeballs recovered within a few days or weeks. The defeat of the auditory nerve is less common, but more often irreversible. Inflammation or thrombosis of the vessels on the base of the skull can lead to a stroke. Increased intracranial pressure due to cerebral edema and hydrocephalus is accompanied by inhibition of consciousness, persistent vomiting, hiccups, seizures, eye movement disorders, hypertension and bradycardia.

The complication of bacterial meningitis can also be a shock (usually occurring on the background of bacteremia or meningococcemia), a bleeding disorder (mild thrombocytopenia deployed to DIC), endocarditis , suppurative arthritis , adult respiratory distress syndrome. Often complications are pneumonia , thrombosis of deep venous lower leg, thromboembolism of the pulmonary artery, electrolyte disorders.

Diagnosis. At the slightest suspicion of purulent meningitis shows the lumbar puncture. If its implementation is not possible to conduct bacteriological examination of blood, skin rashes and discharge start antibiotic therapy. Required direct microscopic and bacteriological studies of cerebrospinal fluid in order to identify the pathogen and determine its sensitivity to antibiotics. The survey includes the Gram stain, a study on AFB, India ink stain (to detect cryptococci). In addition, the study is to find out whether parameningealnoy pockets of infection (eg, inflammation of the paranasal sinuses, middle ear, mastoiditis) or distant sites of infection (eg, pneumonia), as well as CSF fistulas.

Treatment. 1) After taking the CSF and blood samples for bacteriological examination immediately prescribe antibiotics. Pending the results of bacteriological tests conducted empirical antibiotic therapy. Neonates Refer a combination of ampicillin and cefotaxime (or ampicillin and gentamicin), in children older than 2 months - III generation cephalosporin (cefotaxime or tseftriaksoi) or a combination of ampicillin and chloramphenicol. In adults with normal immunity shows the use of penicillin or ampicillin, however, taking into account the emergence of strains of pneumococcus and meningococcus are resistant to penicillin, are increasingly prescribed III generation cephalosporins in recent years. At an allergy to penicillin or cephalosporin use chloramphenicol. In elderly persons and in patients with reduced immunity suitable combination of III generation cephalosporin with ampicillin. If allergy to penicillin instead in this case, parenterally administered trimethoprim-sulfamethoxazole (Biseptol).

After receiving the results of bacteriological tests CSF antibiotic may be changed taking into account the sensitivity of the isolated strain and clinical effect. All preparations expedient administered intravenously, the dose indicated in the table. Intramuscular administration is allowed in mild cases.

Typically, a significant improvement in the temperature and can achieve normalization in the first two days. After normalization of temperature antibacterial therapy should be continued 10-14 days. When parameningealnoy infection and meningitis caused by Gram-negative bacteria and listeria, treatment duration should be increased to 3-4 weeks. Before the abolition of antibiotics to ensure sanitation CSF, spend control puncture. Antibiotics canceled if the CSF is sterile, contains less than 100 cells from which cells make up at least 75%. If fever persists despite antibiotic therapy, 2 - 5 days or re-emerged, it is necessary to think about the possibility of complications, inadequate treatment, phlebitis, metastatic infection (septic arthritis, pericarditis, endocarditis, etc...) Or the toxic effect of antibiotics. In the absence of the effect of the re-investigation of the CSF should be performed 24-48 hours.