中枢神经系统感染-2.pptVIP专享VIP免费

TUBERCULOUSMENINGITIS结核性脑膜炎LongnanHospitalChenjing•Tuberculousmeningitisisaninfectionofthemembranes膜coveringthebrainandspinalcord(meninges).•Tuberculosis(TB)iscausedbythebacteriumMycobacteriumtuberculosis结核分枝杆菌andisannuallyresponsiblefornearlytwomilliondeathsworldwide.•Athirdoftheworld'spopulationiscurrentlyinfectedwiththeTBbacillus,andmorethaneightmillionnewcasesarediagnosedeachyear.•Tuberculousmeningitismustbeconsideredinpatientswhopresentwithaconfusionalstate,especiallyifthereisahistoryofpulmonarytuberculosis,alcoholism,corticosteroidtreatment,HIVinfection,orotherconditionassociatedwithimpairedimmuneresponses.•Itshouldalsobeconsideredinpatientsformareas(eg,Asia,Africa)orgroups(eg,thehomelessandinner-citydrugusers)withahighincidenceoftuberculosis.Causes•Riskfactorsincludeahistoryof:AIDSExcessivealcoholusePulmonarytuberculosisWeakenedimmunesystemPathogenesis&Pathology发病机制&病理•Tuberculousmeningitisusuallyresultsfromreactivationoflatentinfectionwithmycobacteriumtuberculosis.•结核性脑膜炎多是由于潜伏的结核杆菌复发感染引起的。Primaryinfection,typicallyacquiredbyinhalingbacilluscontainingdroplets,maybeassociatedwithmetastaticdisseminationofblood-bornebacillifromthelungstothemeningesandsurfaceofthebrain.Heretheorganismsremaininadormantstateintuberclesthatcanruptureintothesubarachnoidspaceatalatertime,resultingintuberculousmeningitis.原发性感染，尤其是通过吸入含菌颗粒引起的感染，可能与血源性细菌从肺部到脑膜及大脑表面的播散有关。此处的致病菌在结核结节中处于休眠状态，后期可破入蛛网膜下腔，并导致结核菌性脑膜炎。主要发现是含有大量单核细胞的脑基底部脑膜分泌物。脑膜及脑表面可见结核结节。•Themainfindingisabasalmeningealexudate渗出物containingprimarilymononuclearcells.•Tuberclesmaybeseenonthemeningesandsurfacesofthebrain.•Theventriclemaybeenlargedasaresultofhydrocephalus,andtheirsurfacesmayshowependymalexudateorgranularependymitis.Arteritiscanresultincerebralinfarction,andbasalinflammationandfibrosiscancompresscranialnerves.•脑积水可引起脑室扩大，并且脑室表面可有大量室管膜渗出物或颗粒状室管膜炎。•动脉炎可导致脑梗塞，而颅底部炎症反应和纤维化可压迫神经。•Acutetuberculousmeningitiswithmarkedinvolvementofthevesselwallsandocclusionofsmallervessels.•Thevascularinvolvementcanresultininfarction.ClinicalFindingsA.SYMPTOMS•Symptomshaveusuallybeenpresentforlessthan4weeksatthetimeofpresentationandincludefever,lethargy昏睡orconfusion,andheadache.Weightloss,vomiting,neckstiffness,visualimpairment,diplopia复视,focalweakness,andseizuresmayalsooccur.•Ahistoryofcontactwithknowncasesoftuberculosisisusuallyabsent.B.SIGNS•Fever,signsofmeningealirritation脑膜刺激征,andaconfusionalstatearethemostcommonfindingsonphysicalexamination,butallmaybeabsent.•Papilledema视乳头水肿,ocularpalsies眼肌麻痹,andhemiparesis轻偏瘫aresometimesseen.•Complicationsincludespinalsubarachnoidblock脊髓蛛网膜下腔梗阻,hydrocephalus脑积水,brainedema脑水肿,cranialneverpalsies颅神经麻痹,andstrokecausedbyvasculitisorcompressionofbloodvesselsatthebaseofthebrain因血管炎或颅底血管受压导致的卒中.结核球strokehydrocephalusLaboratoryFindings•Onlyone-halftotwo-thirdofpatientsshowapositiveskintestfortuberculosisorevidenceofactiveorhealedtubercularinfectiononchestx-ray.CSF•ThediagnosisisestablishedbyCSFanalysis.•CSFpressureisusuallyincreased,andthefluidistypicallyclearandcolorlessbutmayformaclotuponstanding...