Pneumococcal meningitis

Introduction to pneumococcal meningitis Pneumococcal meningitis is scattered, more common in winter and spring, especially in infants and elderly or patients with chronic diseases, but adults are not uncommon. The disease is often secondary to pneumonia or pneumococcal sepsis, followed by otitis media, mastoiditis and sinusitis. Some patients are secondary to traumatic brain injury or after brain surgery. Lesion. basic knowledge The proportion of illness: 0.006% Susceptible people: no special people Mode of infection: contagious Complications: hydrocephalus, brain abscess, epilepsy

The cause of pneumococcal meningitis

(1) Causes of the disease

Pneumococcal meningitis is one of the pneumococcal infectious diseases. This disease is often secondary to pneumonia or pneumococcal sepsis, followed by otitis media, mastoiditis and sinusitis. Some patients are secondary to craniocerebral trauma. After fractures or after brain surgery, there were no clear primary lesions in a few cases.

(two) pathogenesis

The primary lesion is pneumonia or both with sepsis. The pathogen causes meningitis through the blood circulation to the meninges. In patients with otitis media, the pathogen can destroy the slate scale and the blood vessels communicating with the meningeal vessels through the inflammation or the inner ear canal. When it spreads to the meninges and ethmoid sinusitis, the pathogens infect the meninges through nerve sheath or thrombophlebitis. The pathogens of patients with craniocerebral trauma can directly invade the meninges from the wounds. Congenital malformations, such as middle ear malformations, mastoid development When it is bad, when the meninges bulge, the bacteria are easy to invade the meninges, splenectomy and spleen dysfunction, prone to fulminant sepsis and meningitis caused by capsular bacteria, pneumococci account for 1/2 to 2/3, because The spleen has the function of filtering and phagocytizing granules, while the capsular bacteria have strong anti-phagocytic ability. In addition, the spleen still has humoral and cellular immune functions. Once splenectomy, these bacteria cause fulminant sepsis, meningitis and DIC. Etc., the pneumococcal bacteria in patients with cerebrospinal fluid rhinorrhea can be infected with recurrent meningitis. Pneumococcal invades the meninges and causes capillary blood in the brain. Expansion, congestion, increased permeability, fibrin exudation, inflammatory cell infiltration, a large number of inflammatory exudates are widely distributed in the subarachnoid space, with more surface on the top of the brain, less involvement in the skull base and spinal cord, due to a large number of fibers Protein and inflammatory exudate deposit in the subarachnoid space, causing adhesions and entrapment abscesses, and even subdural effusion or empyema, so that antibiotics are not easy to infiltrate, which is a factor that causes recurrence and treatment difficulties, such as the course of the disease. When it is longer, it can cause cerebral spinal fluid circulation obstruction, ventricular dilatation, and even ventricular hydrops or empyema, so that secondary intracranial pressure increases, and severe cases can lead to brain plug formation.

Pneumococcal meningitis prevention

Active treatment of primary lesions such as otitis media, sinusitis, ethmoid sinusitis, and radical cure to prevent recurrence.

Pneumococcal meningitis complications Complications hydrocephalus brain abscess epilepsy

Concurrent hydrocephalus, brain abscess, cranial nerve damage, epilepsy after meningitis.

Pneumococcal meningitis symptoms Common symptoms Cerebrospinal fluid rhinorrhea intracranial high-pressure horns anti-expansion fever convulsions irritability

Pneumococcal meningitis occurs more than 1 week after the primary disease, secondary to traumatic brain injury, can occur in 10 days to more than 1 month, clinical manifestations including primary disease and meningitis performance, the onset of the disease Urgent, fever, severe headache, vomiting, weak body, altered consciousness, neck resistance, Kelnigues and Bruzinski signs and other signs of meningeal irritation and intracranial hypertension, rash is not common, sometimes in the skin Or a small bleeding point in the mucous membrane, which is different from the cerebral palsy, which has a wide range of sputum, fewer ecchymoses, and different psoriasis meningitis in infants. It is characterized by extreme irritability, convulsions, lethargy, anorexia, and spurting. Sexual vomiting, sometimes angulation, physical examination can often find cardia bulge, but severe vomiting, dehydration, cardia bulge can not be obvious, elderly patients with meningeal irritation is not obvious, secondary to otitis media, mastoiditis and other meningitis Patients, more rapid development, can quickly appear disturbance of consciousness, the disease is often due to serious illness, or diagnosed later, or improper treatment of complications, common subdural effusion, empyema or brain accumulation Water, etc.; followed by cranial nerve damage, mainly involving the brain, nerves, face, trochle and abduction, such as pneumonia or sepsis, can also have empyema, lung abscess, pericarditis, endocarditis and Brain abscess, etc., a small number of patients can recurrent, this is one of the characteristics of this disease, patients with recurrent meningitis often have the following reasons:

1 congenital anatomical defects, such as congenital stenosis, congenital skin-like sinus, meninges or spinal cord bulging, bacteria can directly reach the meninges.

2 head trauma, due to skull fracture (the most common type of plate fracture), cerebrospinal fluid rhinorrhea, bacteria from the nasopharynx directly into the subarachnoid space and the incidence of sugar in the nasal secretions suggest cerebrospinal fluid in the nasal fluid, can further Quantification of sugar, or injection of methylene blue from the spinal canal, to observe whether there is methylene blue in the nasal secretions to confirm, can be detected by brain cell emission tomography (ECT) to determine the cerebrospinal fluid rhinorrhea and mouthwash, Conducive to further radical treatment, for the examination of radionuclide-free, can be enhanced by coronal CT scan or thin-slice CT scan of the skull base, X-ray film is also an important diagnostic method.

3 There are infections near the meninges, such as chronic mastoiditis or sinusitis.

4 host immune function defects, such as congenital gamma globulin deficiency or immunosuppressive patients and childhood splenectomy or spleen atrophy, are prone to recurrent pneumococcal meningitis.

5 cerebrospinal fluid is extremely thick, easy to form adhesions and purulent encapsulation, affecting the efficacy of drugs, is also one of the causes of recurrence, the mortality rate of pneumococcal meningitis remains above 30%.

Examination of pneumococcal meningitis

Laboratory examination showed that the total number of white blood cells increased significantly in most patients, neutrophils increased, cerebrospinal fluid pressure increased, cerebrospinal fluid was cloudy, even purulent, protein (Pan) positive, cells hundreds to thousands Above, the classification is mainly multinucleated granulocytes, but there are also routine examinations of normal cerebrospinal fluid and positive bacterial culture in the early stage of the disease, which is mild with changes in cerebrospinal fluid in the early stage of the disease, irregular application of antibiotics before cerebrospinal fluid examination, and adsorption of leukocytes by fibrin in cerebrospinal fluid. Related, if the cerebrospinal fluid is normal and the patient is still suspected of the disease, the lumbar puncture can be repeated after 12 to 24 hours. At this time, abnormal findings are often found.

X-ray computed tomography (CT): CT scan of bacterial meningitis is closely related to the morning and evening of the disease course. In the early stage of bacterial meningitis, CT examination usually has no specific changes, and patients with satisfactory clinical treatment generally do not need to perform CT examination, when the condition is critical or the treatment effect is not satisfactory, CT examination should be carried out in time to guide the clinical selection of a reasonable treatment plan, and it is also important for judging the prognosis.

Bacterial meningitis CT findings:

1 In the early stage, no abnormal findings were found. The progression of the lesion showed basal pool, the density in the lateral fissure pool increased, and the symmetry of the ventricle was enlarged.

2 enhanced scan showed obvious enhancement in the cerebral cistern, part or all of the basal pool and lateral fissure pool;

3 The cerebral cortex area may have irregular low-density areas, which is the manifestation of meningoencephalitis;

4 can form subdural empyema or effusion, can be combined with brain abscess;

5 cerebral vascular involvement can form cerebral infarction; 6 forms hydrocephalus in the late stage, meningitis sequelae often have brain softening, brain atrophy.

Magnetic resonance imaging (MRI):

1 In the early stage, there is no abnormality, the lesion develops, and abnormal signals can appear in the subarachnoid space. The T1-weighted image signal is slightly higher, the brain pool is blurred, and the T2-weighted image is high. It is visible in the cerebral cortex when it is combined with meningoencephalitis. Long T1 long T2 abnormal signal lesions.

2 enhanced scanning showed irregular enhancement of the subarachnoid space or linear enhancement of the meninges.

3 The rest of the performance is the same as CT performance.

Once the diagnosis of bacterial meningitis is clear, the corresponding antibiotic treatment should be taken immediately. The treatment principles are as follows:

1 Check out the pathogen as soon as possible and conduct a drug susceptibility test to select the appropriate antibiotics;

2 use fungicide;

3 use drugs that easily penetrate the blood-brain barrier;

4 develop a reasonable dosage plan;

5 courses of treatment vary with different pathogens. The indications for withdrawal are that the number of cells in the cerebrospinal fluid and various biochemical indicators are basically restored to normal, and the bacteria smear and culture turn negative.

Diagnosis and identification of pneumococcal meningitis

diagnosis

Patients with pneumonia, otitis media, mastoiditis, sinusitis, craniocerebral trauma, skull base fractures, brain surgery and other medical history, or some congenital defects, fever, headache with meningeal irritation, intracranial pressure When the performance is increased, the disease should be considered, especially in the winter and spring pneumonia epidemic season and in infants and the elderly. The reliable early diagnosis method is cerebrospinal fluid examination, cerebrospinal fluid is purulent, sometimes contains blocks, and the number of cells Increased protein content, decreased sugar and chloride, and cell protein separation in advanced diseases such as cerebrospinal fluid, indicating that subarachnoid obstruction is about to occur or has occurred. For example, puncture of the cisterna magna, a large number of pus cells can be seen in the cerebrospinal fluid. Cerebrospinal fluid smear can find Gram-positive diplococcus or short-chain cocci, such as a sufficient amount of bacteria in the cerebrospinal fluid, using mixed pneumococcal antiserum for capsular swelling test, can immediately identify whether it is pneumococcal, cerebrospinal fluid culture 80% The above pathogens can be obtained, and specific bacterial antigens can also be found by convective immunoelectrophoresis, thereby making it possible to quickly make Broken, the activity of lactate dehydrogenase in cerebrospinal fluid can be significantly increased, and the concentration of TNF-2 and IL-1 in cerebrospinal fluid is higher. The PCR-nucleic acid probe hybridization technique is used to detect pneumococcal bacteria in cerebrospinal fluid, which is highly sensitive. Sexual characteristics, can be used for the auxiliary diagnosis of negative cerebrospinal fluid culture, radiological examination can be used for chest fluoroscopy or chest X-ray, if necessary, can be used for sinus, mastoid or sieve X-ray, if from the medical history, clinical Performance (such as optic disc edema) suspected local lesions (such as brain abscess, subdural empyema), should be used for radionuclide examination, brain CT, MRI or cerebral angiography, etc., to confirm the diagnosis as early as possible, infant brain membrane Inflammation should be performed on the skull X-ray and subdural puncture to detect subdural effusion early.

Differential diagnosis

Application of other bacterial meningitis such as streptococci, meningitis, Staphylococcus aureus meningitis, intestinal Gram-negative bacilli meningitis identification.

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