Purulent meningitis
The content of the article:
- Causes and risk factors
- Forms of the disease
- Symptoms of purulent meningitis
- Diagnostics
- Treatment
- Possible complications and consequences of purulent meningitis
- Forecast
- Prevention
Purulent meningitis is one of the most serious diseases of the central nervous system, occupying a leading position in the structure of mortality from the consequences of neuroinfections [from 5 to 30% (according to other sources - up to 50%) in different age groups]. With this form of meningitis, pathogenic microflora penetrates to the meninges with the subsequent development of purulent inflammation in them.
Purulent meningitis is an inflammation of the meninges of bacterial etiology
The severity of the disease is due to several factors:
- inadequate early diagnosis of purulent meningitis before the patient is admitted to a specialized department of the hospital;
- frequent cases of lightning current;
- high risk of developing life-threatening complications;
- insufficient effectiveness of drug treatment in some cases;
- unpredictability of the outcome.
The incidence of purulent meningitis is high both among adult patients and among children: according to foreign researchers, morbidity rates in pediatric practice vary from 5 to 10 per 100,000 children, with up to 90% of all cases occurring at the age of 5 years.
Inflammatory changes in purulent meningitis affect, most often, the arachnoid and soft membrane of the brain, sometimes the brain substance is involved in the pathological process.
Causes and risk factors
Purulent meningitis in the vast majority of cases is bacterial in nature. The decisive role in the development of the disease of 3 main pathogens has been proven (they account for about 90% of all bacterial meningitis):
- meningococci types A, B and C (about 54% of cases);
- pneumococcus (more than 10%);
- Haemophilus influenzae type B (in 20-30% of cases).
More rare is purulent meningitis, provoked by staphylococcus, mostly golden.
Purulent meningitis caused by streptococci, listeria and gram-negative rod-shaped flora is recorded sporadically.
The vast majority of cases of purulent meningitis in children and young patients are provoked by meningococci, which is facilitated by a number of features of these microorganisms:
- the presence of a protective capsule, which makes them resistant to phagocytosis (capture and destruction by cells of the immune system - phagocytes);
- the ability to produce a powerful endotoxin that provokes toxemia;
- the ability of bacteria to adhere tightly to the nasopharyngeal mucosa and meninges;
- production of a specific enzyme that destroys antibodies that protect the mucous membrane of the respiratory tract.
Purulent meningitis in adults (mature and elderly) is more often the result of pneumococcal infection.
The penetration of pathogenic microorganisms to the meninges is possible in several ways:
- hematogenous (through the bloodstream);
- lymphogenous (along the pathways of the lymph flow);
- perineural (along the perineural spaces);
- contact (when the focus of a purulent infection, located in the immediate vicinity, comes into contact with the meninges).
The source of infection with meningococcal purulent meningitis is always a sick person, infection occurs by airborne droplets or, much less often, by contact (when using common utensils, cutlery, household items and hygiene items). Most of the inhabitants of the Earth have a high resistance to meningococci, therefore, despite the high percentage of carriage of meningococcal microflora, symptoms of the disease appear in 1 out of 10 people, according to some data, for 1 patient with purulent meningitis there are from several hundred to several thousand bacterial carriers.
In adults, purulent meningitis may be due to pneumococcal infection.
Infection with purulent meningitis of pneumococcal, hemophilic, staphylococcal nature, etc. can also occur contact, hematogenous, lymphogenous and perineural.
Risk factors for the development of purulent meningitis are:
- violations of immunological reactivity (including against the background of long-term illnesses, exposure to stress agents, hypothermia, excessive physical and psycho-emotional stress, etc.);
- condition after surgery (including splenectomy);
- purulent lesions of the ENT-zone organs;
- the presence of severe chronic pathologies;
- chronic alcoholic illness;
- traumatic brain injury.
Forms of the disease
Depending on the etiological factor, the following forms of purulent meningitis are distinguished:
- primary (developed in the absence of foci of purulent inflammation in other organs and tissues);
- secondary purulent meningitis, developing against a background of primary purulent inflammation of a different localization (purulent otitis media, sinusitis, pneumonia, endocarditis and osteomyelitis) or sepsis.
In accordance with the intensity of the inflammatory process:
- fulminant;
- acute;
- subacute.
The severity of the course of purulent meningitis:
- lung;
- medium-heavy;
- heavy;
- extremely severe course.
Symptoms of purulent meningitis
Despite the fact that the manifestations of purulent meningitis caused by different pathogens are somewhat different, there are a number of common symptoms characteristic of the disease:
- acute onset;
- a rapid rise in body temperature to 38-39 ºС (moreover, hyperthermia does not respond well to taking antipyretic drugs);
- excruciating headache that spreads to the back of the neck, aggravated by loud sounds, touching and other external influences;
- nausea and uncontrolled "cerebral" vomiting (fountain), which does not bring relief, not accompanied by other dyspeptic disorders;
- photophobia;
- soreness in the eyeballs, aggravated by averting the gaze to the side;
- hypersensitivity to stimuli (hyperesthesia);
- seizures or high convulsive readiness;
- the presence of meningeal symptoms [the most indicative are the stiffness of the occipital muscles, positive symptoms of Kernig, Brudzinsky, in young children, Lessage's symptom (suspension symptom) is often positive];
- a specific meningeal posture (a “cop dog” or a “cocked cock”) with a thrown back head, an arched back, a retracted (scaphoid) abdomen and legs brought to it;
- various forms of oppression of consciousness (from confusion to coma);
- severe symptoms of intoxication (dizziness, general weakness, muscle and joint pain, weakness, lack of appetite, lethargy, drowsiness).
Purulent meningitis is characterized by an acute onset and a rapid rise in temperature to critical levels
Characteristic features of meningococcal purulent meningitis:
- hemorrhagic, roseolous or papular stellate rash, elements of which have different degrees of severity, shape, color intensity; more often located on the lateral surface and lower abdomen, on the shoulders, outer surfaces of the lower extremities, buttocks, feet, oropharyngeal mucosa;
- an indication of a prior acute respiratory illness;
- pyramidal disorders: difference in reflexes on different limbs, clonus of the feet (sharp, rhythmic movements), trembling of the upper limbs;
- signs of damage to the cranial nerves, which is manifested by asymmetry of the face, strabismus, drooping of the upper eyelid (with a severe form of the disease).
Pneumococcal meningitis is characterized by less violent symptoms (a full clinical picture can form for several days), early impairment of consciousness, meningeal symptoms are less pronounced, there is no characteristic rash, but the course is more severe, the prognosis is less favorable.
Purulent meningitis caused by Haemophilus influenzae is rare, can demonstrate both acute and prolonged course, and has no characteristic features.
Diagnostics
For reliable confirmation of the diagnosis, it is necessary to comprehensively evaluate the clinical picture (characteristic posture, meningeal symptoms, intense headache, accompanied by nausea and vomiting, photophobia, etc.) and the results of special studies:
- clinical blood test (accelerated ESR, neutrophilic leukocytosis with a shift to the left, up to young forms);
- blood culture for sterility (exclusion of sepsis);
- liquorological examination (analysis of cerebrospinal fluid);
- isolation of a culture of the pathogen from CSF and blood, followed by inoculation on a nutrient medium (including to identify sensitivity to antibacterial drugs);
- smear bacterioscopy;
- reaction of latex agglutination (RLA), direct and indirect hemagglutination, the method of counter immunoelectrophoresis, allowing to isolate pathogen antigens and antibodies to them.
When diagnosing purulent meningitis, a spinal tap is performed
Characteristic changes in the punctate of the cerebrospinal fluid, indicating purulent meningitis:
- pleocytosis (increase in cell concentration) more than 1000 / ml with a large number of neutrophils;
- whitish or yellow-green color, opaque, turbid liquid;
- increased pressure of cerebrospinal fluid;
- high protein content;
- high cellular-protein dissociation;
- the presence of a coarse fibrin film, sediment;
- clear or sharply positive sedimentary samples of Nonne-Apelta and Pandey (qualitative reaction to globulins).
Treatment
The basis for the treatment of purulent meningitis is rational antibiotic therapy, taking into account the sensitivity of pathogenic microorganisms.
Antibiotic therapy is started immediately after a preliminary diagnosis has been established, without waiting for the results of culture for drug sensitivity, then, as necessary, the treatment is adjusted. At the initial stage, preference is given to natural and semi-synthetic penicillins, cephalosporin drugs of 2–4 generations, the method of administration is intravenous, the duration of treatment is from 10 days.
With purulent meningitis, intravenous antibiotics are indicated
For the symptomatic treatment of purulent meningitis, the following drugs are used:
- diuretics;
- antihistamines;
- glucocorticosteroid hormones;
- detoxification parenteral agents;
- cardiac glycosides, adrenomimetics, tranquilizers, anticonvulsants, etc., as needed.
Possible complications and consequences of purulent meningitis
The consequences of purulent meningitis:
- edema of the brain, possibly with the development of wedging;
- sepsis, septic shock;
- renal, heart failure;
- backendocarditis;
- subdural empyema (accumulation of pus under the dura mater);
- episyndrome;
- sensory hearing loss;
- coma, death.
Forecast
The prognosis directly depends on the timeliness of the diagnosis and the initiation of antibiotic therapy. The later a specific treatment is started, the more likely it is to develop life-threatening complications and death.
The death rate from purulent meningitis in the absence of treatment is approximately 50%. Pneumococcal meningitis is the prognostically most unfavorable, the probability of death in which (even with timely antibiotic therapy) is recorded in 15–25% of cases.
Prevention
- Vaccination against meningococcal meningitis, hemophilic and pneumococcal infections.
- Compliance with personal hygiene measures;
- Adequate treatment of infections, especially respiratory infections (prevention of secondary purulent meningitis);
- At the first suspicious symptoms of purulent meningitis, seek immediate medical attention;
- The earliest possible isolation of the patient when making a diagnosis (prevention of the spread of meningitis).
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Olesya Smolnyakova Therapy, clinical pharmacology and pharmacotherapy About the author
Education: higher, 2004 (GOU VPO "Kursk State Medical University"), specialty "General Medicine", qualification "Doctor". 2008-2012 - Postgraduate student of the Department of Clinical Pharmacology, KSMU, Candidate of Medical Sciences (2013, specialty "Pharmacology, Clinical Pharmacology"). 2014-2015 - professional retraining, specialty "Management in education", FSBEI HPE "KSU".
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
