Neonatal suppurative meningitis

Introduction to neonatal purulent meningitis Purulent meningitisofnewborn, referred to as the brain, is a meningeal inflammation caused by neonatal septic. The brain is a common disease that threatens the life of newborns. This disease is often part of sepsis or secondary to sepsis. Its clinical symptoms are often atypical (especially premature infants), mainly characterized by irritability, crying screaming, irritability. Severe coma convulsions, sometimes symptoms such as low response, lethargy, refusal to milk, etc., suspected of purulent meningitis should check cerebrospinal fluid early, early diagnosis, timely and thorough treatment, reduce mortality and sequelae. basic knowledge Sickness ratio: 0.05% Susceptible people: young children Mode of infection: non-infectious Complications: hydrocephalus, ventricular inflammation, respiratory failure, cerebral palsy

Causes of neonatal purulent meningitis

Immature immune function (15%):

The immune function of newborns, especially premature infants, is still immature. It is not possible to get enough IgG from the mother when it is delivered too early. It is prone to low immunoglobulinemia after birth and cause serious infection. When the newborn is seriously infected, it will lead to serum. The concentration of IgG and its subclass decreased, and the activity of interleukin-2 (IL-2) also decreased.

Poor blood-brain barrier function (15%):

Neonatal blood-brain barrier permeability is high, complement concentration is low, neutral polymorphonuclear granulocyte phagocytosis and chemotaxis function is poor, blood circulation is relatively strong, pathogens easily form brain through the blood-brain barrier.

High risk factors for disease (10%):

Most cases of neonatal meningitis are caused by blood-borne dissemination, and a few are caused by pathogens directly invading the meninges, such as pneumococcal meningitis.

Disease factors (15%):

Such as umbilical inflammation, pneumonia, enteritis, skin impetigo, otitis media and so on.

Perinatal factors (5%):

Such as premature infants, neonatal asphyxia, premature rupture or contamination of the amniotic fluid, mothers have infection or fever during childbirth.

Other factors (8%):

There may be meningocele, neural tube defects, congenital sinus, fetal scalp blood collection specimen penetrating injury, or caused by adjacent intramural ECG monitoring caused by dissemination.

(two) pathogenesis

The immune function is immature, prone to infection and spread to the whole body. In addition, the blood-brain barrier function of the newborn is poor, the blood circulation is relatively strong, and the pathogen can easily form a brain through the blood-brain barrier.

Recent studies have shown that bacterial invasion of cerebrospinal fluid proliferates, spreads and degrades, releasing toxins (gram-negative bacilli) or teic acid (gram-positive bacilli), which stimulate inflammatory responses, activate astrocytes, and capillary endothelium. Cells and ependymal cells release cytokines such as TNF-, IL-1, platelet activating factor (PAF), etc., causing polymorphonuclear granulocytes to adhere to capillary endothelial cells, releasing oxidative substances to damage endothelial cells, allowing capillary passage Increased permeability, increased permeability of the blood-brain barrier, eventually cerebral edema, increased intracranial pressure, and slower cerebral blood flow.

Purulent exudate is covered with meninges and ependymal membranes. Almost all children with death have ventriculitis; about 50% of children have hydrocephalus. In China, about 20% of children will have subdural effusion, all suffering Children have varying degrees of phlebitis and arteritis, sometimes leading to cerebral infarction, liquefaction and formation of cysts, and in some cases, brain abscess can be seen.

Neonatal suppurative meningitis prevention

Preventing the occurrence of brain, focusing on preventing bacteria from invading the body and spreading to the brain, such as prevention and treatment of respiratory tract, gastrointestinal tract and skin infection, timely treatment of sinusitis, otitis media and neonatal umbilical infection.

Neonatal suppurative meningitis complications Complications hydrocephalus ventriculitis respiratory failure cerebral palsy

Due to poor neonatal resistance and atypical symptoms of meningitis, there are certain difficulties in early diagnosis and timely treatment. Therefore, complications and sequelae are relatively more. Complications include subdural effusion, empyema is more common, and sequelae It is more common to use hydrocephalus and mental retardation.

1. Subdural effusion: Cerebrospinal fluid examination improved during treatment, while body temperature continued to retreat, clinical symptoms did not disappear; after the condition improved, there was high fever, convulsions, vomiting, sputum fullness or bulging; subdural puncture with yellow liquid >1ml; skull transillumination and skull CT, help diagnosis.

2. Ventricular inflammation: the incidence rate can reach 65% to 90%, or even 100%, the younger the age, the worse the diagnosis and treatment of the brain, the higher the incidence, the clinical manifestations may be after the child has been treated regularly. The curative effect and test results are not improved; the condition is critical, frequent convulsions, respiratory failure or cerebral palsy, cerebrospinal fluid culture of rare bacteria (Escherichia coli, influenza bacillus, Proteus, etc.), increased intracranial pressure, has been excluded from the subdural Patients with recurrent effusion and purulent meningitis must be diagnosed with cerebrospinal fluid by cerebral puncture.

Neonatal suppurative meningitis symptoms Common symptoms Abdominal local body twitching jaundice increased intracranial pressure, easy to cause sleepiness, eyeball upturn and fixed shock squint pale

1. General performance

The clinical manifestations of neonatal purulent meningitis are often atypical, especially in premature infants. The general performance includes pale complexion, poor response, less crying, less movement, decreased milk or reduced milk, vomiting, fever or body temperature, jaundice, Liver, bloating, shock, etc.

2. Special performance

(1) nervous system symptoms: irritability, irritability, startle, sudden screaming and lethargy, stagnation, etc., visible binocular gaze, strabismus, eyeball upturn, eyelid twitching, facial muscle pumping like sucking, can also be burst Sexual bruising, apnea, twitching of one or part of the limb.

(2) Increased intracranial pressure: the front sputum is tense, full or bulging, and the suture is separated. Because the neonatal cervical muscle development is poor, the neck stiffness is less common.

Diagnosis can be made based on the above clinical manifestations and laboratory tests.

Examination of neonatal purulent meningitis

1. Peripheral blood: white blood cell count and neutrophil elevation, severe cases of white blood cells decreased below 4 × 109 / L, platelet count decreased.

2. Bacterial culture: bacterial culture of blood culture and lesion secretion, blood culture positive rate can reach 45% to 85%, especially in early-type sepsis and early treatment without antibiotics, urine culture and lesion secretion The culture can sometimes be positive.

3. Cerebrospinal fluid examination: If the neonatal sepsis is ineffective for more than 48h after regular treatment, or if there is poisoning symptoms in acute infectious diseases, the condition will not recover smoothly after treatment, and if there is no reason to explain, the cerebrospinal fluid should be taken early for lumbar puncture. .

(1) Cerebrospinal fluid routine examination: appearance turbid or ground glass, but also bloody, a few can be clear; white blood cell count> 20 × 106 / L, polymorphonuclear cells accounted for > 60%; pressure > 2.94 ~ 7.84kPa: (30 ~ 80mmH20), Pan's experiment is often positive.

(2) Cerebrospinal fluid biochemical examination: protein > 1.5g / L, if > 6g / L, the incidence of hydrocephalus is high; glucose <1.1 ~ 2.2mmol / L, or less than 50% of the blood sugar at that time; chloride < 100mmol / L; lactate dehydrogenase (LDH) > 1000U / L, of which LDH4, LDH5 increased, LDHl, LDH2 decreased.

(3) Cerebrospinal fluid smear and culture examination: Escherichia coli and GBS smear are easy to find bacteria, the positive rate can reach 61% ~ 78% and 85%, respectively, culture positive can help to confirm the diagnosis.

(4) Cerebrospinal fluid immunological detection: detection of corresponding antigens with known antibodies, such as latex agglutination (LA) test, convective immunoelectrophoresis (CIE), application of immunofluorescence technology.

(5) Polymerase chain reaction (PCR): Recently, it has been reported that PCR can provide a more accurate pathogen diagnosis basis for neonatal purulent meningitis.

4. Transcranial transillumination, skull B-ultrasound and CT: skull transillumination, skull B-ultrasound and CT examination can help diagnose ventriculitis, subdural effusion, brain abscess, hydrocephalus and so on.

5. Radionuclide brain scan: valuable for multiple brain abscesses.

6. Magnetic resonance imaging (MRI): a large value for multi-atrial and multiple small abscesses.

Diagnosis and differentiation of neonatal purulent meningitis

Diagnostic criteria

History

A history of purulent infection before onset.

2. Clinical features

Acute onset, fever, vomiting, central nervous system dysfunction, meningeal irritation positive, elevated intracranial pressure, etc., severe cases can occur cerebral palsy, even respiratory failure, or can cause shock.

3. Laboratory inspection

(1) Blood: The total number of white blood cells and the proportion of neutrophils are significantly increased.

(2) Cerebrospinal fluid: the pressure is increased, the appearance is turbid or pus-like, the number of cells is obviously increased, the neutrophils account for the majority, the sugar is reduced, the protein is significantly increased, and the cerebrospinal fluid smear can detect the pathogenic bacteria.

Differential diagnosis

1. Tuberculous meningitis: slow onset, low fever, mild to moderate rise in cerebrospinal fluid cells, and significant reduction in sugar and chloride, which can be found in tubercle bacilli.

2. Viral encephalitis: how low or low, the number of cells in the cerebrospinal fluid is normal or slightly elevated; while the suppurative meningitis is hyperthermia, the number of cells in the cerebrospinal fluid is significantly increased, and the sugar content is decreased, lactic acid, lactate dehydrogenase, lysobacteria The increase in enzyme and the decrease in pH can be identified.

3. Others: Brain tumors, subarachnoid hemorrhage, metabolic encephalopathy and other diseases caused by other symptoms of the nervous system, using imaging examination methods such as CT, MRI, etc., to make a differential diagnosis is generally not difficult.

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