儿科学-结核性脑膜炎(英文)

Tuberculosismeningitis

（TBM）结核性脑膜炎1Children<15yearswithTB:

ExtrapulmonaryDisease

Themostseriouscomplication,usuallyfatal

Apartofsystemicdisseminatedtuberculosis<1yrofinitialinfection,especiallythefirst3–6m,60%inchildrenaged1-3yrsDeathrate:15-30%Epidemiology3TuberculousBacilliPrimaryComplexBacteremiaMeningitisPathophysiologyMiliaryTBMeningesDiffuseHyperemiaInflammatoryExudatesEdemaConformationofTuberclesPathologicaleffects5Intuberculousmeningitisthereisatendencyfortheexudatetobeprimarilylocatedontheundersurfaceofthebrain,particularlyovertheventralsurfaceofthebrainstem.Pathology

Pathologystage1Prodromestage3stage2MeningealIrritationStageComaStageClinicalmanifestations8Fever,fatigue,malaise,drowsiness,headache,vomitingClinicalmanifestationsStage1:Prodrome(1-2weeks):

CSFabnormityMentalstatuschangesFocalneurologicsignsareabsent

MoreseriousTBtoxemiaIntracranialhypertensionClinicalmanifestationsMeningeal

IrritationCranialnervedysfunctionEncephalitissignssevereheadacheirritationprojectilevomitingseizuresBulgingofanteriorfontanelle,wideningofcranialsuturesininfantNuchalrigidity,HypertoniaKernigsignorBrudzinskisignFacialnerveOculomotornerveAbducentnerveDisorientationAbnormalmovementSpeechimpairmentStage2:MeningealIrritationStage(1-2weeks)

101543ClinicalmanifestationsFrequentconvulsionStage3:ComaStage(1-3weeks)

Progressivealteredstateofconsciousness:LethargyConfusionSemicomaDeepcomaDecerebrate

Decorticateposturing2

ConstipationUrinaryretentionProgressive

abnormalitiesofvitalsignsCerebral

hernia11CharacteristicsofTBMininfantsandyoungchildrenArapidonsetwithconvulsion,abruptlyhighfeverAtypicalminingealirritationIntracranialhypertensionmanifestsasbulgingofanteriorfontanelleandwideningofcranialsuturesininfantRadialDiagramsGangnamSalesOfficePutsomethinghereContentsorconceptsThisisforpresentaionsandmyco-workersMedicalandsocialhistory:

TBcontact,ContagionHistoryNegativehistoryforBCG

vaccinationHistoryofimmunosuppression

fromaknowndiseaseordrugtherapyDiagnosis

1

3

2Diagnosis

SymptomsandsignsAgradualonsetFever,headache,alternantofirritabilityanddrowsiness,vomiting,constipationofunknownoriginAlteredmentalstatus14CerebrospinalfluidGrossappearanceClearorslightlyturbidafineclotresemblingapellicleorcobweb——groundglass50-500cells/mm3LymphocyticpredominanceADAHypoglycorrhachiaHighproteinlevelwith1-3g/LChloridate：low

PCRAcid-faststain(+)CultureforMtuberculosis(+)TB-IgMTB-IgG

TB-antigenDiagnosisDiagnosisPPD

+

ishelpfulintradermally

volarsurfaceforearmReactionpeaksat48-72hrsnonreactiveinupto50%ofcases

CTMRIAddYourTextDiagnosisCXRAbnormal,sometimesmiliarypatternHydrocephalusBasilarexudatesandinflammationTuberculomaCerebraledemaCerebralinfarction171234DifferentialdiagnosisViralMeningitisPyogenicMeningitisCryptococcalmeningitisCerebraltumor18DifferentialdiagnosisPyogenicMeningitisClinicalmanifestationAcuteonsetofintenseheadache,fever,nausea,vomiting,photophobia,andstiffneckGroupBstreptococci,Neisseria

meningitidis,Streptococcuspneumoniae,etc.PyogenicfocilocatedothersitesofthehostTypicalrashofmeningococcalinfectionBrainsurface(Pyogenicmeningitis)Differentialdiagnosis1.PyogenicMeningitis：TypicalCSFabnormalitiesinmeningitisAppearanceisturbidPleocytosisofPMN(WBCcountsalwaysabove1000,eventoaveryhighlevelas10,000cells/mm3,predominantlyneutrophils)DecreasedglucoseconcentrationIncreasedproteinconcentrationGramstainandcultureofCSFidentifytheetiologicalorganism2.ViralMeningitis：

Mumps,polio,enteroviruses,Measles,Herpesviruses,EBVCSFexaminationisthemostimportanttestindifferentiatingthecauseofmeningitis:ClearappearanceCells:50-200cells/mm3,MononuclearcellpredominanceProtein:slightlyelevatedornormalGlucoseandChloridate:normalDifferentialdiagnosisDifferentialdiagnosis3.Cryptococcalmeningitis：CryptococcosisisthemostcommonfungalinfectionofthecentralnervoussystemItisthefourthmostcommoncauseofopportunisticinfectionsinpatientswithAIDSDiseaseonsetisusuallyinsidiousandhasalongerlatentperiodFeveralwaysbeabsentatbeginningofdiseaseVerynotableintracranialhypertension:severeheadacheVisualdisturbancesandpapilledemaarecommonDifferentialdiagnosis3.

Cryptococcalmeningitis：CSF

Appearancecanbeclearorturbid.ProteinlevelsexceedGlucoseandChloridatedecreaseMononuclearpleocytosis,numbersvaryfrom50to500mononuclearcells/mm3.ItiseasytogetthepositiveresultforCneoformansofCSFIndiainkstainispositiveCSForserumcryptococcalantigentestsarepositiveCryptococcusisacauseofmeningitis,acommoncomplicationinAIDS.Theorganismsareusuallyeasytodemonstratehistologically.Inthisslidetheyarethecircular-to-ovoidstructureswiththickcapsules.Cryptococcus:Differentialdiagnosis4.Cerebraltumor:NofeverCSFisusuallynormalPPD:negativeCTorMRIishelpful26TuberculosismeningitisPyogenicmeningitisViralmeningitisCryptococcalmeningitisAppearanceGroundglassTurbidClearSlightlyturbidPressureWBC（10^6/L）TenstohundredsmononuclearcellHundredstotensofthousandsneutrophilsTenstohundredsmononuclearcellTenstohundredsmononuclearcellProteinGlucoseNormalChloride

NormalorNormal

SmearAcid-faststain(+)PyogenicbacteriaNegativeInkstain(+)27IntensivePhaseContinuationPhaseIsoniazid

RifampinPyrazinamideStreptomycin3-4monthsIsoniazid

Rifampin9-12monthsTreatment:Long-termchemotherapyStartassoonasthereissuspicionforTBmeningitis

SameGuidelinesasthoseforpulmonaryTBTreatment:AdjunctiveTherapyGlucocorticoidsIndicatedwith:rapidprogressionfromonestagetothenextElevatedICP,CTevidenceofcerebraledemaworseningclinicalsignsafterstartingantiTBmedsGlucocorticoidDosing:Dexamethasone12mg/dx3weeksfollowedbyaslowtaperSurgery:Ventriculostomy

CriteriaforRecoveryFollow-upvisitDisappearanceofallclinicalmanifestationsCSFexaminationisnormalNorelapsewithin2yearsaftercompletionofantituberculosistreatmentPrognosisOverallPoorTheprognosisoftuberculousmeningitiscorrelatesmostcloselywiththeclinicalstageofdiagnosisandtreatment.PtspresentinginStageIhave19%mortalityPtspresentinginStageIIIhave69%mortalityOnly1/3-1/2ofpatientsdemonstratecompleteneurologicrecoveryUpto1/3ofpatientshaveresidualsevereneurologicdeficitssuchashemiparesis,blindness,seizurePrognosisAge:infantsoryoungerchildrenaregenerallyworsethanthatofolderchildrenDrugresistantstrainVariationofhostimmunityAppropriatetherapeuticregimen

PrognosisCompletionoftheantituberculoragentregimenItisimperativethatantituberculosistreatmentbeconsideredforanychildwhodevelopsbasilarmeningitisandhydrocephalus,cranialnervepalsy,orstrokewithnootherapparentetiology.33CompanyLOGOSummaryTBdiagnosisisdi