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1、结核性脑膜炎英文第1页，此课件共47页哦EPIDEMIOLOGY-TBM Tuberculous Meningitis(TBM)u The younger the children,the more readily to develop TBM.u 60%in Children aged 1-3 yearsu Death rate:15-30%2第2页，此课件共47页哦TBM(Tuberculous meningitis)u TBM is the most serious complication of tuberculosis in children and is usually fatal
2、 without treatment.u TBM always be a part of systemic disseminated tuberculosis.u TBM often occurs within 1 year of initial infection,especially in the first 2 to 6 months of infection.3第3页，此课件共47页哦Tuberculous BacilliPrimary ComplexBacteremiaRich FociSubarachnoid SpaceBrain or Spinal Cord Perenchyma
3、TuberculomasMeningitisPATHOPHYSIOLOGYTrauma/Diseases measles,pertussis Miliary TB4第4页，此课件共47页哦PATHOLOGICAL EFFECTSMeningesuDiffuse HyperemiauEdemauInflammatory Exudates uConformation of Tubercles 5第5页，此课件共47页哦PATHOLOGICAL EFFECTSSubarachnoid SpaceuA large amount of thick gelatinous exudates concentr
4、ate to the pavimentum cerebri,optic chiasma,bridge of varolius,bulbus rhachidicus and Sylvian fissure.u Basal meningitis accounts for the frequent dysfunction of cranial nerves III,VI,and VII.6第6页，此课件共47页哦PATHOLOGICAL EFFECTSCerebral ParenchymaTuberculous meningoencephalitisuswelling and hyperemia o
5、f 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 because of this change.uMeninges,spinal,and spinal nerve root also involvement.The later always leads to paraplegina.7第7页
6、，此课件共47页哦PATHOLOGICAL EFFECTSCerebral VesselsuThe bacteria invade the adventitia directly in the early stage and initiate the process of acute vasculitis.uProgressive destruction of adventitia,disruption of elastic fibers,and finally intimal destruction(endoarteritis),lead to the obliterative vascul
7、itis,which may facilitate the ischemia,encephalomalacia and necrosis of parenchyma.8第8页，此课件共47页哦Circulation of CSFChoroid plexusLateral ventricleInterventricular foramenthe 3rd ventricleCerebral aqueduct4th ventricle2 Lateral foramina1 Medial foramenSubarachnoid spaceArachnoid granulationsDural sinu
8、sVenous drainage9第9页，此课件共47页哦PATHOLOGICAL EFFECTSHydrocephalusHyperemia of choroids overproduction of CSF Inflammatory adherence of Meningedefective absorption of CSF Communicating hydrocephalus CSF flow is obstructed on the route before the cerebral aqueduct and the 4th ventricleNoncommunicating hy
9、drocephalus10第10页，此课件共47页哦In tuberculous meningitis there is a tendency for the exudate to be primarily located on the under surface of the brain,particularly over the ventral surface of the brain stem.11第11页，此课件共47页哦CLINICAL MANIFESTIONS A.Prodrome(1-2 week)1.Fever,fatigue,malaise,myalgia,drowsines
10、s,headache,vomiting2.Mental status changes3.Focal neurologic signs are absent4.CSF abnormity 12第12页，此课件共47页哦CLINICAL MANIFESTIONSB.Meningeal Irritation Stage (1-2 week)1.More serious TB toxic symptoms2.Intracranial hypertension:severe headache,irritation,projectile vomiting,seizures;Bulging of anter
11、ior fontanelle,widening of cranial sutures in infant 3.Meningeal Irritation:nuchal rigidity,hypertonia Kernig sign or Brudzinski sign 4.Cranial nerve abnormalities:3,6,75.Some children have no evidence of meningeal irritation but may have signs of encephalitis:disorientation,abnormal movements and s
12、peech impairment 13第13页，此课件共47页哦CLINICAL MANIFESTIONSC.Coma Stage(1-3 week)1.Frequent convulsion,progressive altered state of consciousness:lethargy,confusion,semicoma,deep coma,decerebrate or decorticate posturing2.Depletion:extremely maransis,constipation,urinary retention 3.progressive abnormalit
13、ies of vital signs,and eventual die from cerebral hernia 14第14页，此课件共47页哦Characteristics of TBM in infants and young children1.A rapid onset with convulsion,abruptly high fever2.Atypical miningeal irritation3.Intracranial hypertension manifests as bulging of anterior fontanelle and widening of crania
14、l sutures in infant 15第15页，此课件共47页哦PROGNOSISu The prognosis of tuberculous meningitis correlates most closely with the clinical stage of diagnosis and treatment.u Age:infants or younger children are generally worse than that of older childrenu Drug resistant strain u Variation of host immunityu Appr
15、opriate therapeutic regimenu Completion of the antituberculor agent regimen16第16页，此课件共47页哦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第17页，此课件共47页哦DIAGNO
16、SIS HistoryClinical Symptoms and SignsAuxiliary Examinations18第18页，此课件共47页哦DIAGNOSIS-History Elucidate the following:1.Medical and social history,including recent contact with patients with TB2.Negative history for Bacille Calmette-Guerin(BCG)vaccination3.History of immunosuppression from a known di
17、sease or drug therapy19第19页，此课件共47页哦DIAGNOSIS Symptoms and signs uA gradual onset uFever,headache,alternant of irritability and drowsiness,vomiting,constipation of unknown originuAltered mental status20第20页，此课件共47页哦DIAGNOSIS Tuberculin Skin Test Purified protein derivative(PPD)1.Injected intradermal
18、ly on the volar surface of the forearm2.Reaction peaks at 48 to 72 hours3.A nonreactive result does not exclude M.tuberculosis infection or disease,the tuberculin skin test is nonreactive in up to 50%of cases21第21页，此课件共47页哦DIAGNOSIS Spinal Tap Cerebrospinal Fluid1.Gross appearanceClear or slightly t
19、urbida fine clot resembling a pellicle or cobweb may form2.Cell counts,differential count50-500cells/mm3Lymphocytic predominancebut Polymorphonuclear cells may predominate early 3.GlucoseHypoglycorrhachia4.ProteinHigh protein level with 1-3g/L22第22页，此课件共47页哦DIAGNOSIS Spinal Tap Cerebrospinal Fluid5.
20、Chloridate：low 6.Acid-fast stain(+),Gram stain,India ink7.Culture for M tuberculosis(+)8.ELISA test for Specific PPD-IgM and PPD-IgG in CSF9.ELISA test for Specific TB-antigen in CSF is a sensitive and rapid method23第23页，此课件共47页哦DIAGNOSIS Spinal Tap Cerebrospinal Fluid10.Total IgG,IgA and IgM11.PCR:
21、specific PCR to detect the gene of M tuberculosis bacilli can provide a rapid and reliable diagnosis of TBM,although false-negative results potentially occur24第24页，此课件共47页哦DIAGNOSIS Chest X-ray Chest x-ray:Posteroanterior and lateral views may reveal the followinglHilar lymphadenopathylSimple pneumo
22、nialInfiltratelPleural effusion/pleural scar25第25页，此课件共47页哦DIAGNOSIS CT or MRIu CT scan and MRI of the brain reveal hydrocephalus,basilar meningeal thickening,infarcts,edema,and tuberculomas,all these are helpful clues,but nonspecificu MRI and CT scan lack specificity,but help in monitoring complica
23、tions that require neurosurgery,making the differentiations,and knowing the prognosis26第26页，此课件共47页哦DIFFERENTIAL DIAGNOSISuViral Meningocephalitisu Pyogenic Meningitisu CNS Cryptococcosis27第27页，此课件共47页哦DIFFERENTIAL DIAGNOSISViral Meningocephalitis Mumps,polio,enteroviruses,Measles,Herpes viruses,EBV
24、,and Japanese encephalitis virus,etcCSF examination is the most important test in differentiating the cause of meningitis:lClear appearancelCells:50-200 cells/mm3,Mononuclear cell predominancelProtein:slightly elevated or normal lGlucose and Chloridate:normal 28第28页，此课件共47页哦DIFFERENTIAL DIAGNOSISPyo
25、genic MeningitisClinical manifestationAcute onset of intense headache,fever,nausea,vomiting,photophobia,and stiff neck Group B streptococci,Neisseria meningitidis,Streptococcus pneumoniae,Haemophilus influenzae,and Staph.aureus,etc.lPyogenic foci located other sites of the hostlTypical rash of menin
26、gococcal infectionlExamination of CSF 29第29页，此课件共47页哦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)Decre
27、ased glucose concentrationIncreased protein concentration Gram stain and culture of CSF identify the etiological organism30第30页，此课件共47页哦Brain surface(Pyogenic meningitis)31第31页，此课件共47页哦TBM32第32页，此课件共47页哦DIFFERENTIAL DIAGNOSISCNS CryptococcosisuCryptococcosis is the most common fungal infection of th
28、e central nervous system uIt is the fourth most common cause of opportunistic infections in patients with AIDSuDisease onset is usually insidious and has a longer latent perioduFever always be absent at beginning of disease uVery notable intracranial hypertension:severe headacheuVisual disturbances
29、and papilledema are common33第33页，此课件共47页哦DIFFERENTIAL DIAGNOSISCNS CryptococcosisCSFlAppearance can be clear or turbid.lProtein levels exceed lGlucose and ChloridatelMononuclear pleocytosis,numbers vary from 50 to 500 mononuclear cells/mm3.lIt is easy to get the positive result for C neoformans of C
30、SFlIndia ink stain is positive CSF or serum cryptococcal antigen tests are positive34第34页，此课件共47页哦Cryptococcus is a cause of meningitis,a common complication in AIDS.The organisms are usually easy to demonstrate histologically.In this slide they are the circular-to-ovoid structures with thick capsul
31、es.35第35页，此课件共47页哦TREATMENTu Supportive treatment u Antituberculous drugsu Decreasing intracranial pressureu Corticosteriodsu Symptomatic treatmentu Follow-up visit 36第36页，此课件共47页哦TREATMENTSupportive treatmentuBed rest and close respiratory contacts uNutritional support are paramount uKeep good hygi
32、ene for the coma children to prevent of secondary infections,help them to change position frequently to prevent decubitalu Management of electrolyte abnormalities uAntipyreticsuControl of seizures:Diazepam(Valium)37第37页，此课件共47页哦TREATMENTAntituberculous drugsuisoniazid INH,rifampin RIF,pyrazinamide P
33、ZA,streptomycin SM,and sometimes ethambutol EMB.uINH and RIF are bactericidal for all M.tuberculosis population in any milieu.uSM is most effective against rapidly multiplying organisms.uPZA is most effective against organisms found in macrephages.uenter CSF readily in the presence of meningeal infl
34、ammation.38第38页，此课件共47页哦TREATMENTAntituberculous drugsu Any regimen must contain multiple drugsu In addition,the therapy must be taken regularly and continued for a sufficient period.39第39页，此课件共47页哦TREATMENTAntituberculous drugs1.intensification chemotherapy stage:3-4 months INH(15-25mg/kg),RFP,PZA,
35、SM2.consolidation chemotherapy stage:with total course 1 year at least in order to prevent relapse,permit elimination organisms persistent exist in the host INH,RFP or EMB(ethambutol)40第40页，此课件共47页哦TREATMENT Decreasing intracranial pressureuDehydrant:Mannitol(MNT)uDiuretic agent:Acetazolamide Decrea
36、sing CSF secretion by the choroid plexus uVentricular tap or Open ventricular drainage uRepeat LPs and intrathecal injectionuShunting:to establish a communication between the CSF(ventricular or lumbar)and a drainage cavity.Performed only in cases of communicating hydrocephalus.Ventricular shunt to c
37、isterna magna41第41页，此课件共47页哦TREATMENTCorticosteriodsu Children should be treated for 6-8 weeks u More effective in early stageu Decrease the immflamatory exudates,there fore lower the intracranial pressure.Relieve the meningeal irritation.Improve the CSF circulation Reduce the adherence and prevent
38、the hydrocephalus.u Dexamethasoneu pay attention to the side effects of corticosteriods42第42页，此课件共47页哦Criteria for RecoveryFollow-up visit u Disappearance of all clinical manifestationsu CSF examination is normalu No relapse within 2 years after completion of antituberculosis treatment43第43页，此课件共47页
39、哦Which symptom should be excluded in the early stage of TBM?a)Drowsinessb)Low fever,night sweat,poor appetite,loss of weightc)Personality changesd)Headachee)Recurrent convulsion 44第44页，此课件共47页哦A baby who was definited as TBM when he was 1 years old and began to receive regular treatment with antitub
40、erculosis drugs.How old is he when he can be definited as full recovery?a)11/2 yb)2 yc)21/2 yd)3 ye)4 y 45第45页，此课件共47页哦Which one is the typically cellular characteristics of CSF in TBM?a)50-500 cells/mm3,with neutrophils predominanceb)50-500 cells/mm3,with mononuclear predominancec)0-50 cells/mm3,with mononuclear predominanced)1000,sometimes can above 10,000 with neutrophil predominancee)0-50cells/mm3 with neutrophils predominance46第46页，此课件共47页哦THNAK YOU!47第47页，此课件共47页哦