细菌性脑膜炎

化脓性脑膜炎--病因和发病机制
• 发病率：1.5人/10万/年 • 病原菌：
– – – – 成年人：肺炎链球菌（50%），脑膜炎双球菌（25%） 儿童：流感嗜血杆菌（50%），脑膜炎双球菌（30%） 新生儿：B组链球菌(50%)，大肠杆菌（20%） 腰穿、脑室引流和颅脑手术：金葡、绿脓
• 感染途径
– 血行播散 – 直接扩散 – 经脑脊液
化脓性脑膜炎--病理
• 大体：大量脓性渗出物，血管扩张 • 镜下：
– 脑膜：炎细胞浸润 – 蛛网膜下腔：中性粒细胞，纤维蛋白渗出物 – 室管膜和脉络膜：炎细胞浸润，充血 – 脑实质：偶见小脓肿
化脓性脑膜炎--临床表现
• • • • • 感染症状：寒战，发热 脑膜刺激征：颈强，克氏征，布氏征阳性 颅内高压：头痛，呕吐，意识障碍 局灶症状：偏瘫，失语 其他症状：出血性皮疹
定位诊断
定性诊断
诊断依据
如何求证
定义、解剖和病原学
• • • • • • • 病毒 细菌 真菌 寄生虫 螺旋体 立克次体 朊蛋白
细菌性脑膜炎
• 化脓性脑膜炎 • 非化脓性脑膜炎
– 细菌：结核性脑膜炎 – 非细菌：病毒性脑膜炎，隐球菌脑膜炎，螺旋 体（神经莱姆病）等
化脓性脑膜炎
• • • • • • • 病因和发病机制 病理 临床表现 实验室检查 诊断和鉴别诊断 治疗 预后
wenku.baidu.com
病例
病情演变
• Shortly after the patient’s arrival at the hospital, T rose to 39.8, and the fever was accompanied by somnolence • On the 2nd hospital day, T rose to 39.5. When questioned, she knew the month but not the date or year or the ages of her children • Later on the 2nd day, she became more lethargic and responded to questions only with “yes.” • During the night, the patient’s mental status improved and she was able to follow simple commands • On the 3rd hospital day, the maximal T 39.2. The patient was more responsive to commands than she had been on the previous day, although she could not distinguish the right hand from the left.
中枢神经系统感染性疾病
浙江大学医学院附属邵逸夫医院 神经内科 邵宇权
病例
现病史
• A 38-year-old woman was admitted to the hospital because of fever and confusion • The patient had been well until four days earlier, when a headache gradually developed and increased in intensity, accompanied by mild photophobia and stiffness of the neck. • Two days before admission, she believed that she was mildly febrile. • The day before admission, she was examined at another facility, where she was told she had a “viral illness.” She was given fluids intravenously and was discharged. • On the morning of admission, she awoke with shaking chills and a temperature of 40°C. • During the day she was aware of a rapid heartbeat, lightheadedness, and lethargy. • Her husband observed that she was confused, and she was brought to this hospital and admitted.
病例
体检
• T 36.4, HR 99bpm, RR 20, BP90/60 mmHg. SaO2 99% • The neck was rigid, and Kernig’s sign (+) • She was alert and oriented but spoke in phrases of two to four words, rather than complete sentences. • The neurologic examination otherwise revealed no abnormalities.
病例
辅助检查--CSF
第一天 第五天
病例
辅助检查--器械
• MRI showed a subtle hyperintensity on T2 images in both hippocampal regions and possible slight meningeal enhancement. • EEG revealed generalized low-amplitude slowing and continuous focal slowing over the entire left hemisphere; no epileptiform activity