PREPARATIONS APPLICABLE FOR PUSHAL MENINGITES
MAIN ANTIBACTERIAL DRUGS USED IN THE PURULENT MENINGITIES To reduce intracranial pressure with clinically significant intracranial hypertension, administration of mannitol (0.25-0.5 g / kg i / v drip for 15-20 min) or glycerol is indicated. The headboard should be raised at an angle of 30 °. Excessive administration of furosemide and fluid restriction, causing dehydration and lowering blood pressure, reduces cerebral blood flow and increases the risk of cerebral thrombosis. And severe cases resort to mechanical ventilation in hyperventilation mode.
2) Corticosteroids are used to reduce edema and prevent inflammatory complications. Dexamethasone is administered 20 minutes before the first dose of antibiotics at a dose of 4 mg IV, then repeated every 6 hours for 4 days. Subject to the early use of the drug reduces the likelihood of development in children of sensorineural hearing loss. When treating with dexamethasone, care should be taken to protect the stomach (antacids, H2-receptor block-tori). Corticosteroids are not recommended to be administered in cases where the fungal or tuberculous etiology of meningitis cannot be ruled out (with subacute or gradual predominance of lymphocytes in the CSF, the presence of eosinophils or atypical lymphocytes in it, the normal level of glucose).
3) Maintenance of water and electrolyte balance. It is necessary to scrupulously measure the volume of injected and excreted fluid, in severe cases - to regularly determine the sodium content in the blood and the serum osmolarity. It is necessary to avoid both dehydration, timely and completely compensating for the lack of fluid (especially with persistent vomiting), and overhydration, while maintaining normovolemia. When hyponatremia (sodium content below 135 meq / l) should be limited to a quarter the volume of fluid injected - up to 1000-1200 ml / day, and as the sodium level increases, gradually increase the daily volume to 1500 - 1700 ml. It is preferable to introduce saline solution, ringer's solution with the addition of potassium (40 mEq / l). Infusion solutions containing a lot of free water (for example, 5% glucose solution) that aggravate brain swelling should be avoided.
4) Due to impaired autoregulation of cerebral blood flow, it is necessary to monitor the stability of blood pressure. In case of hypovolemia, it is necessary to replenish the bcc with crystalloid and colloid solutions, in case of arterial hypotension - the appointment of vasopressors (dopamine).
5) It is important to recognize and conduct targeted treatment of systemic complications in time: shock, DIC, myocardial infarction, heart rhythm disturbances, pneumonia, and pulmonary embolism. Heparin , fresh frozen plasma, fibrinolysis inhibitors (trasilol, contrycal) are used in DIC syndrome.
6) In epileptic seizures, 5-10 mg of diazepam (Relanium) is administered intravenously, while monitoring possible respiratory depression and decreased blood pressure. At the same time, care should be taken to maintain the airway and pass oxygen. Metabolic disorders (hypoglycemia or hyponatremia), which can cause seizures and require correction, should be excluded.
7) Patients with suspected meningococcal meningitis should be isolated for 24 hours after initiation of antibiotic therapy. Patients with meningitis of a different etiology do not require isolation.
Residual neurological symptoms persist in about one third of patients, neurosensory hearing loss is most often noted, paresis, epileptic seizures are often observed, and in children, mental development disorder.
Chemoprophylaxis. Prevention of meningococcal meningitis is recommended for all who are in close contact with the patient. Hospital staff, if not breathing mouth to mouth, does not need chemoprophylaxis. Rifampicin is used: in adults, 600 mg every 12 hours for 2 days (or a single dose of ciprofloxacin, 750 mg), in children, 10 mg / kg every 12 hours for 2 days. In pregnant women and children up to 2 years, ceftriaxone is used (a single injection of 250 mg IM in adults or 125 mg in children). Chemoprophylaxis is indicated in mothers who have, in addition to the sick, a child under 4 years old. For meningitis caused by hemophilic bacilli, if there is a child under 2 years old in the family, chemoprophylaxis is also recommended (rifampinin, 20 mg / kg / day - up to 600 mg / day for 4 days).
Acute serous meningitis is more often the result of a viral infection. Lymphocytic pleocytosis, moderate increase in protein content, normal glucose, negative bacteriological test, benign course with spontaneous recovery are characteristic of serous meningitis. Depression of consciousness is usually shallow. Uncomplicated viral meningitis is not typical: sopor or coma , epileptic seizures, cranial nerve damage and other focal symptoms.
Enteroviruses are the most common cause of viral meningitis, most often the disease occurs in the summer months in children under 15 years of age. On examination, a maculopapular, vesicular or petechial rash, herpangina, hemorrhagic conjunctivitis can be detected. Meningitis caused by the virus of mumps, occurs more often in late autumn or early spring, 3 times more often occurs in males. Characterized by the presence of orchitis, oophoritis, mumps, pancreatitis with increased activity in the blood lipase and amylase. Lymphocytic choriomeningitis often occurs in late autumn and winter. Infection occurs as a result of contact with objects contaminated by feces or nasal mucus from domestic mice. Some patients have a rash, infiltration in the lungs, alopecia , parotitis, orchitis , myopericarditis. Characterized by leukopenia , thrombocytopenia, and abnormal liver function tests. In the CSF, high pleocytosis is sometimes detected (above 1000 in 1 μl) and low glucose. Meningitis caused by the herpes simplex virus type II, often occurs against the background of the first aggravation of genital herpes. Meningitis caused by the herpes zoster virus can be suspected in the presence of a characteristic rash. Epstein — Barr virus can cause meningitis , which is accompanied or not accompanied by clinical manifestations of infectious mononucleosis. The diagnosis is confirmed in the presence of atypical leukocytes in the blood and CSF. Meningitis can also be caused by tick-borne encephalitis virus.
Diagnostics. The causative agent can sometimes be isolated from the CSF, feces (enteroviruses), blood (lymphocytic choriomeningitis virus), urine (mumps virus), nasopharyngeal flushing (enteroviruses and adenoviruses). Some viruses, in particular, herpes simplex or herpes zoster viruses, can be identified in the CSF using the polymerase chain reaction. More often, the pathogen is determined retrospectively by increasing the titer of specific antibodies in the study of paired sera. More quickly, the pathogen can be determined by the ratio of specific antibodies in CSF and serum.
Symptomatic treatment : rest, bed rest, analgesics, nonsteroidal anti-inflammatory drugs. Repeated lumbar puncture is necessary only if the fever and meningeal symptoms do not diminish within a few days or there is a suspicion in favor of a different diagnosis. If bacterial meningitis cannot be ruled out, empiric antibiotic therapy should be prescribed. In severe meningitis caused by herpes viruses or herpes zoster, intravenous administration of acyclovir is possible. In adults, complete recovery usually occurs. Occasionally, headaches, general weakness, discoordination, impaired attention and memory persist from several weeks to several months.
Chronic meningitis . Chronic meningitis is usually diagnosed in cases where the symptoms persist for more than 4 weeks against the background of persistent inflammatory changes in the CSF. The clinical picture is characterized by persistent headache, meningeal symptoms, damage to the cranial nerves and roots of spinal nerves, mental disorders that occur against the background of fever, general malaise, anorexia. Chronic meningitis can be caused by carcinomatosis of the meninges, neuroleukemia, Lyme disease, tuberculosis, a fungal infection or parasitic invasion, granulomatous diseases (sarcoidosis, hypereosinophilic syndrome), drug meningitis (when taking ibuprofen, cyprofloxacin, cyprofloxacin). It is important to exclude the presence of such sources of infection as otitis , sinusitis , heart disease with discharge of blood from right to left, chronic pulmonary infection.
Tuberculous meningitis is more often a manifestation of hematogenous disseminated tuberculosis. The primary focus may be in the lungs, retroperitoneal lymph nodes, bones. Often it can not be found. The disease is more common in children and the elderly, as well as in patients with immunodeficiency (including AIDS, alcoholism and drug addiction, malnutrition). Initial manifestations are nonspecific: malaise, apathy, anorexia , subfebrile condition, unstable headaches, night sweats, weight loss, then the headache becomes constant, vomiting , drowsiness, meningeal signs appear. Symptoms gradually increase, confusion, signs of cranial nerves (oculomotor, facial, auditory, visual), epileptic seizures appear. Untreated tuberculous meningitis is fatal for 4–8 weeks. Pleocytosis from 10 to 500 / μl is detected in the cerebrospinal fluid, neutrophils may first dominate, but after about a week, pleocytosis becomes lymphocytic. The protein content is often increased to 5 - 10 g / l, the level of glucose drops. The diagnosis is confirmed by staining a smear on acid-resistant bacteria, as well as by seeding liquor (if indicated - sputum, urine, gastric contents). Mandatory chest radiography, tuberculin test.
Treatment begins with three drugs (isoniazid, rifampicin , pyrazinamide). Additionally, prescribe vitamin B6, warning isoniazid polyneuropathy. With a good effect, after 2 - 3 months, pyrazinamide is canceled, and isoniazid and rifampicin are kept for at least another 10 months. In severe cases, an additional prescribed streptomycin.