Puncture for meningococcal infection in a child. Meningitis in children: the most useful information for parents about the disease!! Possible consequences after the procedure

Meningitis is a disease infectious course. Inflammatory processes in the membranes of the brain develop due to the ingress of harmful microbes. Any microorganism can cause meningitis. Modern infectious disease specialists came to this conclusion during research. The disease affects people at any age.

Meningitis is completely different in its development and causes of formation. Often the disease can recur for several years. Sometimes a person may get hurt once, but very seriously. Pathological condition poses a direct threat to life and is fraught with serious complications. Provoking factors can be purulent otitis media or sinusitis.

Often, a traumatic brain injury causes inflammation of the membranes of the brain and the patient’s well-being thereby worsens significantly. In most cases, the disease is characterized by the formation due to infection harmful microorganisms through entry through the bloodstream. There is a certain predisposition to the development of the disease at the level of immunity. Often entire families and generations suffer from meningitis.

Scientists have not yet identified a reliable effect of immunity on meningitis. However, the fact that boys get sick 4 times more often than girls has been proven based on statistical research. The course of the disease can be influenced by viruses, bacteria and fungi. IN last years cases are increasingly being identified. Especially dangerous condition causing complex purulent processes.

It is important to remember that young children are especially hard hit by meningitis. Moreover, the typical situation of development of the main symptoms is similar at any age:

1. The appearance of severe headaches, along with vomiting and nausea against the background of measles, rubella, chickenpox, mumps, etc.
2. A significant increase in temperature combined with pain in the neck and back, which intensifies when bending or turning the head.
3. The patient may be unconscious, experience convulsions, drowsiness, nausea, and vomiting.
4. Defeat skin rash of any nature with high temperature.
5. Infants experience monotonous crying, a feverish state, and a swollen fontanel.

The above symptoms are not a reliable basis for confirming or refuting the diagnosis. Correct diagnosis carried out in a medical clinic.

Typical signs of meningitis with to varying degrees probabilities require appropriate treatment with an exclusively individual approach to each patient. It is possible to confirm or refute the diagnosis only with the help of a spinal puncture.

A puncture is performed for spinal cord, which in medicine is called lumbar. The essence of the technique is to insert a special needle into the area between the 3rd and 4th lumbar vertebrae. The liquid is examined for the content of proteins, glucose and other specific components.

Correct techniques when preparing and performing a puncture allow the procedure to be completed quickly and with minimal pain for the patient. A puncture for meningitis will not have negative consequences if the medical personnel have sufficient experience in carrying out this diagnosis.

Compliance with all prescriptions and correct behavior after puncture is important for the patient himself. Irreversible changes in the body that result from untimely treatment can cause disability and even death. In addition to cerebral edema, complex neurological disorders occur, which does not have the best effect on a person’s life.

It is not recommended to refuse a puncture for meningitis. It is not only the only way to determine inflammation in the spinal cord, but also allows you to identify which microorganisms provoked the disease. This plays a significant role in choosing the most suitable ways treatment.

Microbiological testing to identify the pathogen is only possible through lumbar puncture. During circulation, cerebrospinal fluid from the ventricles enters the space of the brain and spinal cord. An excess of this fluid characterizes meningitis.

Lumbar puncture is performed based on the following situations:

• with the probable presence of a neuroinfection;
• for diagnosing cancer;
• to detect liquorrhea;
• in order to exclude hemorrhage into the subarachnoid space.

Possible risks and contraindications

A prerequisite for puncture is the absence of contraindications. This applies to complex conditions of the patient’s body, which can provoke a deterioration in well-being. These include:

• structural lesions of the brain of volumetric flow;
• cerebral edema;
• poor blood clotting;
• pathological disorders in the back area where the procedure should be performed.

Puncture for meningitis takes place in operating conditions. Lying on your side, with your legs pressed to your chest and your head down, allows for optimal expansion of the intervertebral spaces. The doctor will be able to perform all manipulations with maximum precision. Fat people The puncture is performed in a sitting position.

Certain anesthetics are used for pain relief. They are introduced into the puncture site in three stages. At the same time, a needle must be inserted to withdraw the test fluid. The rapid flow of liquid into the test tube indicates the presence of intracranial hypertension. If there is an admixture of blood in it, then there may be hemorrhage into the subarachnoid space.

Injury to blood vessels during puncture for meningitis can lead to the obtained fluid turning reddish. Important nuance consists also in the fact that it is necessary to carry out preliminary collection of the test liquid. All manipulations must be carried out quickly and accurately in order to avoid possible trauma to the ligaments and membranes of the spinal sections.

Puncture in children

There is no place for self-medication in children. Postponing a visit to the doctor even for hours can be dangerous unpredictable consequences. According to statistics, despite technological progress in medicine, mortality from meningitis has not decreased over the past 50 years.

The incubation period lasts about 10 days. It is especially difficult at the age of 6 months. It is often the cause of quite dangerous complications. The clinical picture of development is similar to the symptoms of the disease in adults. The first signs begin to appear suddenly.

Children aged 2 to 10 years are initially bothered by a fever, gradually turning into a drowsy state. In newborns, the fontanelle thickens. Kids become capricious and irritable. Older children, from 7 to 12 years old, may be unconscious with meningitis. This manifestation may include severe headaches, a sudden increase in blood pressure and the development of a rash on the skin.

Of primary importance in full examination has a puncture for meningitis in children. The procedure is performed under sterile conditions by inserting a needle into the lower back. The specifics of the puncture are absolutely identical to performing such a mini-operation on an adult.

Each child requires more thorough examination before carrying out such diagnostics. There are more contraindications due to a fragile growing body than in an adult. In addition to puncture for meningitis, blood tests must be performed. Almost always prescribed CT scan and electroencephalography. A comprehensive examination allows you to make an accurate diagnosis and, based on the specifics of the disease, begin adequate treatment.

After a puncture for meningitis, the child is shown a complete bed rest for up to three days. It all depends on the individual reaction to synthetic drugs used for pain relief. At first you need to lie only on your stomach to avoid pressure on the puncture site.

Recommended drinking plenty of fluids, not cold and not hot. The child should be in a room where there are no strangers and preferably under the constant supervision of adults. Sometimes intravenous plasma substitutes are prescribed.

If, after a puncture for meningitis, a child begins to complain of chills, discomfort in the neck, or a feeling of tightness, you should immediately consult a doctor. This also applies to any discharge or numbness at the puncture site.

Consequences

Stopping the disease in children in the early stages allows you to successfully restore health in a short period of time. After an appropriate period of treatment, children can lead familiar image life. Timely seeking help from a doctor does not have undesirable consequences. The child’s body recovers after just a short rehabilitation.

Puncture for meningitis in children provokes the most minimal consequences. There is no pain during the procedure. This is all thanks to unique thin needles designed for similar procedures. Gradual anesthesia with triple injection of anesthetic plays an important role here.

Very rarely, as a result of incorrect manipulations or insufficient qualifications of the doctor, a puncture for meningitis can provoke undesirable consequences:

1. Hemorrhagic complications. These consequences include internal traumatic brain injuries, which manifest themselves as hematomas. Violations of diagnostic technique during puncture can damage blood vessels and provoke bleeding.
2. Postpuncture syndrome. Intracranial vessels are displaced and dilated when epithelial cells enter the spinal cord.
3. Teratogenic factor, characterized by the formation of epidermoid tumors. IN spinal canal elements of the skin enter, and as a result, neoplasms develop. Bottom part the back, legs, and lower back begin to hurt more and more often over time.
4. Direct trauma, this condition is determined by damage nerve endings when manipulating the needle. The lesion may affect the intervertebral discs. Various infections and even another type of meningitis develop.
5. Liquorodynamic complications represent the occurrence of acute pain syndrome against the background of an existing tumor.
6. Changes in the composition of the liquor are observed when, when inserting a needle, air, chemicals, microparticles from anesthetics, etc. enter.
7. Other complications occur after a violation of the puncture technique. This is the development of radiculitis, myelitis or arachnoid. Dizziness, vomiting, and nausea may occur in the first hours after the puncture. However, they are not dangerous and pass quickly.

A puncture for meningitis is performed to extract and subsequently study the cerebrospinal fluid. Currently, this is the only possible method for correctly diagnosing dangerous disease. Doctors identify the normality or pathology of the fluid when it is directly removed.

The effectiveness of the procedure for meningitis is often influenced by extraneous factors. These include obesity, dehydration, back surgery, and more. Sometimes the lumbar puncture needs to be repeated again, with a more thorough step-by-step diagnosis.

Lumbar puncture is a manipulation in which a needle is inserted into the subarachnoid space for diagnostic or therapeutic purposes. Most often, this technique is performed for a disease such as meningitis (inflammation meninges). With this disease this manipulation is one of the key stages in diagnosis, as it allows you to confirm or exclude the presence of the diagnosis itself, as well as clarify the pathogen that caused this or that type of meningitis.

The patient in the lying and sitting position during lumbar puncture

When most patients hear the word “lumbar puncture,” they imagine a dangerous and quite painful procedure. However, it must be said that if the personnel performing this procedure have sufficient skills and the patient himself follows the rules of preparing for the puncture and following a gentle regimen after it, then usually the lumbar puncture takes place quite quickly, with less pain. And the consequences of puncture on meningitis with such correct behavior of the patient and medical staff are either absent or minimal.

General information

Meningitis is enough serious illness, which can lead to subsequent irreversible changes, disability and even death. The basis of this disease is inflammation of the membranes of the brain, as well as the spinal cord. During the inflammatory process, the production of excess cerebrospinal fluid is triggered, with damage to the brain matter, as well as a decrease in blood circulation in the microvascular bed. All this can lead to a serious complication - cerebral edema, which is already an emergency condition and requires intensive measures. In addition, meningitis is accompanied by neurological disorders, which in the future can seriously affect later life person.

If meningitis is suspected, the patient should be hospitalized as soon as possible

Meningitis itself may have various factors that trigger its development. Usually there are purulent and aseptic varieties. Purulent appearance meningitis occurs due to the action of bacteria (pneumococci, meningococci and Staphylococcus aureus as a consequence surgical interventions). The aseptic type of meningitis is caused by viruses. Aseptic meningitis can be triggered by the action of herpes viruses, enteroviruses, and choriomeningitis viruses.

Such features require specific treatment, since the therapy for bacterial or viral meningitis is different. But in order to determine the treatment method and the causative agent, a special microbiological study of the cerebrospinal fluid is necessary, which is what a lumbar puncture allows.

The puncture mechanism itself is based on the following principle. Cerebrospinal fluid (or cerebrospinal fluid) is formed in special areas of the brain - the ventricles. It is produced choroid plexuses, which are located at the bottom of the ventricles. After this, the cerebrospinal fluid circulates through the ventricular system and exits into the subarachnoid space of the spinal cord and brain. Functions cerebrospinal fluid are that it maintains constant levels of intracranial pressure, absorbs head impacts, and also performs various trophic (nutritional) functions for brain tissue. Since the cerebrospinal fluid also washes the membranes, it is a kind of reservoir for bacteria and viruses during meningitis.

Taking cerebrospinal fluid for examination

Therefore, a lumbar puncture, which allows penetration into the subarachnoid space, makes it possible to take samples of cerebrospinal fluid and examine them for the presence of an infectious or viral agent.

Indications for manipulation

Lumbar puncture must be performed when following situations:

• Suspicion of a neuroinfection. A striking example These diseases are precisely meningitis. It can also be encephalitis,
• Suspicion of hemorrhage in the subarachnoid space.
• The need to confirm or exclude oncological and metastatic processes in the structures of the brain (meninges).
• Diagnosis of conditions such as liquorrhea.
• The need to diagnose liquor fistulas. In this case, the injection of a special X-ray contrast agent is also added to the lumbar puncture.
• Prevention and exclusion of neuroleukemia in hematological oncology patients.

These indications are called absolute, that is, those in which a puncture is necessary and is key. There are also relative readings– those in which lumbar puncture is either a non-fundamental or an additional method. Usually this:

• Various processes accompanied by demyelinating processes.
• Polyneuropathy inflammatory in nature.
• Unexplained fever.

Contraindications

There are a number of contraindications to performing a lumbar puncture

However, in addition to the indications for puncture, there are also conditions whose presence requires abandoning this manipulation.

• Brain swelling. At this state A lumbar puncture will lead to changes in intracranial pressure, which in turn can lead to herniation of the cerebellum into the foramen magnum and death. This is the most important and first contraindication to lumbar puncture.
• Any large-scale processes in the structures of the brain.
• Conditions with low blood clotting ability.
• Inflammatory conditions at the puncture site.

Methodology

Lumbar puncture is performed in the following way. patient on operating table They are asked to take a characteristic position: lying on their side, their knees should be brought to their chest, and their head should be tilted forward. This position is necessary to widen the intervertebral spaces, which provides the doctor performing the procedure with greater comfort. The puncture can also be performed while sitting (especially in obese patients).

The puncture site itself is located at the level of the 3-4 lumbar vertebrae. A convenient guide for identifying the 4th vertebra is a line that can be visually drawn connecting the ridges iliac bones. The skin at the site of manipulation is treated with some kind of antiseptic, and then proceed to local anesthesia. For this, an anesthetic is used, which is administered in 3 ways sequentially: intradermal, subcutaneous and during the puncture. A needle with a mandrel is inserted parallel to the spinous processes and carefully moved forward until a feeling of failure is felt, which will mean that the needle has passed through the ligaments and hard shell, after which a test sample of liquor fluid is taken in order to confirm the correct placement of the needle. After that, a clean test tube is inserted into which the liquid is collected.

The appearance and color of the liquid, as well as the nature of its flow into the test tube, are carefully assessed.

If the fluid does not flow in the form of rare drops, but often and quickly, this indicates possible intracranial hypertension. It is also necessary to check for the presence of red coloration of the liquid, which may indicate injury to the vessel during manipulation or hemorrhage into the subarachnoid space.

Consequences

Only a specially trained doctor with the necessary tools can take a puncture correctly.

As mentioned above, if the patient correctly follows all the recommendations prescribed to him and medical personnel, complications after the puncture are minimal. However, there are still some situations that can appear even with competent manipulation. They make up a small percentage in the overall summary of all cases, but you should not forget about them:

• Herniation of brain structures or dislocation of midline structures.
• Pain syndrome with damage to the nerve roots.
• Headache.
• Hematomas that develop as a result of damage to small vessels along the puncture needle.

Also, a separate group of complications are complications of puncture when performed in pregnant women. Such patients, especially in the first trimester, may be at risk for miscarriages in response to puncture.

Patients with heart disease and a spinal puncture require close attention, since when vasovagal reactions are triggered, the consequences can be catastrophic, as breathing or cardiac activity may stop.

Features of cerebrospinal fluid in meningitis

Each meningitis is determined by the type of its pathogen, resulting in changes in the cerebrospinal fluid for each of them.

Therefore, knowing certain visual features of cerebrospinal fluid and its microbiological characteristics, you can make a correct differential diagnosis of the types of meningitis and begin correct treatment.

CSF examination confirms the diagnosis of meningitis

The bacterial type of meningitis is characterized by next view cerebrospinal fluid:

• Opaque color of the liquor.
• The predominance of the percentage of leukocytes over lymphocytes.
• The number of neutrophils and segmented cells is over 1000 per 1 cubic millimeter.
• Presence of a positive bacterial culture.
• Low glucose levels.

Aseptic or viral meningitis is characterized by the following cerebrospinal fluid:

• Clear-looking liquor.
• The predominance of the percentage of lymphocytes over leukocytes.
• No inoculated bacterial culture.

Individual diagnostic features cerebrospinal fluid has tuberculous meningitis:

• Opalescent, cloudy appearance of cerebrospinal fluid in a test tube.
• The number of lymphocytes is over 100 per cubic millimeter.
• Low glucose levels.
• Bacteria that can be identified by staining.

Microbiological examination of cerebrospinal fluid

Such features of tuberculous meningitis indicate that it is impossible to make a correct diagnosis only based on visual data of the cerebrospinal fluid, since without knowing microbiological research, you can make a diagnostic error.

Confirmation of the diagnosis is always based on a combination of the visual qualities of the cerebrospinal fluid and its microbiological properties.

Treatment control

Approximately by the third week of treatment, it is necessary to assess how meningitis regresses under the influence of drugs. For this they use repeated puncture. It is used to analyze changes cellular composition, as well as the absence of a bacterial culture in the cerebrospinal fluid, which is a sign of clinical recovery.

An acute infectious disease that occurs when microorganisms penetrate the membranes of the brain and develop an inflammatory process in the central nervous system is called meningitis. When a patient with suspected meningitis is admitted to the Yusupov Hospital, doctors carry out neurological examination and a spinal tap is performed. Only the results of a study of cerebrospinal fluid make it possible to establish an accurate diagnosis, identify the causative agent of infection, determine its sensitivity to antibacterial drugs, and select adequate antimicrobial therapy.

A blood test for meningitis reveals acute inflammatory changes. Meningococci (bacteria that cause meningitis) are found in a smear from the mucous membranes of the nasopharynx. In order to clarify the nature of the disease and determine the severity pathological process Patients undergo the following tests:

• polymerase chain reaction;
• determination of glucose in blood serum;
• general clinical examination of stool (coprogram);
• determination of creatinine, ALT, AST, total bilirubin, lactate and procalcitonin in blood serum.

If viral meningitis is suspected, immunoglobulins M to viruses are determined herpes simplex types 1 and 2 (HSV-I, II) in blood serum, Ig M to the early antigen of Epstein-Barr virus (HSV-IV) and to cytomegalovirus (HSV-V) in blood serum by immunochemiluminescence.

Patients undergo an electrocardiogram, an electroencephalogram, computed tomography and magnetic resonance imaging. All instrumental studies carried out using the latest equipment from leading global manufacturers.

After the diagnosis is established, complex therapy for meningitis begins according to Russian, European and American recommendations. Doctors when compiling individual scheme Treatment of patients takes into account the serotype of the pathogen, its sensitivity to antibacterial drugs, the severity of the disease, and the severity of symptoms. For bacterial meningitis, antibiotics begin to be administered no later than 60 minutes after initial examination patient.

If the results laboratory research do not correspond to the clinical picture of the disease, patient management tactics are discussed at a meeting of the expert council. It includes candidates and doctors of medical sciences, doctors of the highest category. They are traveling specialists in the diagnosis and treatment of infectious diseases of the central nervous system.

Cerebrospinal fluid examination for meningitis

The only reliable method quick installation The diagnosis of meningitis is a study of cerebrospinal fluid. By analyzing changes in the cerebrospinal fluid and the results of other studies, doctors make a differential diagnosis for serous and purulent meningitis, identify the causative agent of the disease, determine the severity of the intoxication syndrome, and monitor the effectiveness and treatment.

The first study of cerebrospinal fluid is carried out upon admission of the patient to the neurology clinic. Analysis results can be ready 2 hours after taking cerebrospinal fluid samples. The presence of a large number of neutrophils in the cerebrospinal fluid in most cases indicates bacterial nature diseases. After 8-12 hours, the analysis is repeated and checked to see if a lymphocytic shift has appeared. If bacteria are detected in the cerebrospinal fluid samples, the test is repeated several times. There is no need to perform a lumbar puncture when reverse development clinical signs illness, normalization of the number of cells, protein and sugar in the cerebrospinal fluid, the disappearance of microorganisms from the cerebrospinal fluid.

Due to the cause of the disease, purulent bacterial meningitis is heterogeneous. In 90% of cases, the disease is caused by Neisseria meningitis, streptococcus pneumoniae and Haemophilus influenzae. The most important feature of changes in cerebrospinal fluid during meningitis is pleocytosis. With purulent meningitis, the number of cells in the cerebrospinal fluid is more than 0.6 × 109/l. In this case, the study of cerebrospinal fluid is carried out no later than 1 hour after its collection.

With purulent meningitis, the cerebrospinal fluid is cloudy, whitish or Green colour. It is dominated by neutrophils. Number shaped elements fluctuates widely. In some cases, already in the first samples of cerebrospinal fluid, cytosis is 12 – 30 × 109/l. The severity of the inflammatory process in the membranes of the brain is judged by the nature of pleocytosis. A decrease in the relative number of neutrophils and an increase in the relative number of lymphocytes in the cerebrospinal fluid indicates a favorable course of the disease. With partial blockade of the subarachnoid space, a typical clinical picture meningitis with relatively little pleocytosis.

With purulent meningitis, the level of protein in the cerebrospinal fluid increases. It varies between 0.6-10 g/l. As the cerebrospinal fluid is freed from microorganisms, it decreases. A high concentration of protein is observed in severe forms of meningitis. If high level protein is determined during the recovery period, this indicates an intracranial complication. A particularly unfavorable prognostic sign for meningitis is the combination of low pleocytosis and high protein. The amount of glucose in the cerebrospinal fluid during purulent meningitis is below 3 mmol/l. The ratio of cerebrospinal fluid glucose to blood glucose levels in 70% of patients is less than 0.31. A favorable prognostic sign is an increase in glucose content in the cerebrospinal fluid.

In case of tuberculous meningitis, bacterioscopic examination of the cerebrospinal fluid can give negative result. A characteristic sign of tuberculous meningitis is the precipitation of a sample of cerebrospinal fluid taken during standing within 12-24 hours. The sediment is a delicate fibrin cobweb-like mesh in the form of an overturned Christmas tree. Sometimes it can be rough flakes. In most cases, tuberculosis bacilli are found in the sediment.

With tuberculous meningitis, the cerebrospinal fluid is transparent and has no color. Pleocytosis can vary over a wide range - from 0.05. Up to 3.0×109/l. If treatment is not carried out aimed at destroying Mycobacterium tuberculosis, then the number of cells in the cerebrospinal fluid constantly increases throughout the disease. A day after the first lumbar puncture, a second procedure is usually performed. CSF samples obtained during repeat lumbar puncture often show a decrease in cells.

In most cases, lymphocytes predominate in the cerebrospinal fluid during tuberculous meningitis. There are cases when, at the onset of the disease, pleocytosis is lymphocytic-neutrophilic in nature. An unfavorable prognostic sign is the presence of a large number of monocytes and macrophages in the cerebrospinal fluid. The protein concentration in tuberculous meningitis is always increased to 2-3 g/l. Its level increases before the onset of pleocytosis and decreases after a significant decrease. Biochemical studies In case of tuberculous meningitis, a decrease in the glucose level to 0.83-1.67 mmol/l is detected early. Some patients experience a decrease in chloride concentrations in the cerebrospinal fluid.

Meningococci and pneumococci have a characteristic structure, due to which they are identified using the express method during bacterioscopic examination of the cerebrospinal fluid, which is obtained during the first lumbar puncture. If the patient is examined within the first day after hospitalization, simultaneous bacterioscopic examination of the blood cerebrospinal fluid under a microscope gives 90% positive results.

With meningococcal meningitis, intracranial pressure first increases, then mild neutrophilic cytosis is detected in the cerebrospinal fluid, then changes characteristic of purulent meningitis. In this regard, in every fourth case, the cerebrospinal fluid examined in the first hours of the disease does not differ from the norm. In case of inadequate therapy, the cerebrospinal fluid may be purulent, high neutrophilic pleocytosis is observed, increased level a protein whose concentration in the cerebrospinal fluid reflects the severity of the disease. With adequate therapy, neutrophilic pleocytosis decreases and is replaced by lymphocytic.

At serous meningitis viral nature The cerebrospinal fluid is clear and there is slight lymphocytic pleocytosis. In some cases, in the initial stages of the disease, an increased content of neutrophils is detected in the cerebrospinal fluid. This indicates a more severe course of the disease and has a less favorable prognosis. With serous meningitis, protein levels may be within normal limits or moderately elevated. In some patients, protein concentrations are reduced due to excess cerebrospinal fluid production.

Serodiagnosis of viral meningitis

Unlike bacteria, viruses are biological fluids very difficult to identify. Often the diagnosis of a viral infection is made based on the difference in the results of serological tests in acute period illness and recovery. The antibody titer can be determined in the cerebrospinal fluid. This method is used to clarify the nature past illness. In most viral meningitis, antibodies to the virus are produced in the cerebrospinal fluid, therefore the ratio of specific antibodies in the cerebrospinal fluid and blood serum increases. If the ISCT is greater than or equal to 1.5, it indicates a higher relative content specific immunoglobulins in the cerebrospinal fluid than in the serum, and thereby - on infectious nature meningitis.

Oligoclonal immunoglobulins are detected by agarose gel electrophoresis or isoelectric focusing of cerebrospinal fluid gamma globulins. These immunoglobulins appear in meningitis caused by the human immunodeficiency virus, human T-lymphotropic virus type 1, Varicella Zoster virus, mumps. Identification of oligoclonal immunoglobulins helps doctors make a differential diagnosis of infectious meningitis caused by enteroviruses, arboviruses, and herpes simplex virus, in which they are usually absent.

Other studies for meningitis

In patients with symptoms of meningitis, it is necessary to identify or exclude the enteroviral nature of the disease. For this purpose, laboratory assistants at the Yusupov Hospital perform a polymerase chain reaction. The results of the study are received within a few hours. To determine the pathogen, the semi-nested polymerase technique is often used. chain reaction for parallel determination of meningococci, Haemophilus influenzae and streptococci.

Methods instrumental diagnostics for meningitis used for neuroimaging and functional assessment state of brain structures and blood flow, timely diagnosis intracranial complications, sensorineural hearing loss. All patients with suspected meningitis upon admission to the neurology clinic undergo ophthalmoscopy with assessment of the condition of the fundus. For children early age with an open large fontanel, neurosonography is performed.

If the blood supply is stable, computed tomography or magnetic resonance imaging is performed. Neuroimaging methods are necessary to carry out differential diagnosis with other diseases of the central nervous system in the presence of focal neurological symptoms. Absence of pathological changes in the brain during tomography early stages meningitis does not eliminate the risk of further development. In all patients with meningitis in the early stages of the disease, short-latency auditory evoked potentials are recorded to exclude or early detection sensorineural hearing loss. In order to get tested for meningitis, call the Yusupov Hospital.

Bibliography

• ICD-10 ( International classification diseases)
• Yusupov Hospital
• "Diagnostics". - Brief Medical Encyclopedia. - M.: Soviet Encyclopedia, 1989.
• « Clinical assessment laboratory research results”//G. I. Nazarenko, A. A. Kishkun. Moscow, 2005
• Clinical laboratory analytics. Fundamentals of clinical laboratory analysis V.V. Menshikov, 2002.

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Meningitis

A.Etiology. Meningitis is a complication of bacteremia. In children over 2 years of age, the causative agents of acute bacterial meningitis are most often Haemophilus influenzae type B (60-65%), meningococci and pneumococci. Streptococci are less common Staphylococcus aureus, gram-negative enterobacteria. With the introduction of vaccination against Haemophilus influenzae type B, the incidence of meningitis caused by this organism has decreased sharply.

b.Survey

1) In infants, the first manifestations of meningitis are nonspecific - severe crying, irritability, anorexia, vomiting, drowsiness, bulging fontanelles. Meningeal symptoms are rare and there may be no fever. Special attention refer to impaired consciousness. One of the first symptoms of meningitis may be seizures, so in combination with fever they are an indication for CSF examination.

2) In children over 1 year of age, meningeal symptoms due to meningitis are more common. The indication for lumbar puncture is Brudzinski's symptom (when the neck is flexed while lying on the back, involuntary flexion of the legs in the hip joints is observed).

3) Meningitis must be excluded in case of bacteremia.

4) If meningitis is suspected, a lumbar puncture is performed. Plasma glucose is preliminarily determined for comparison with the glucose level in the CSF.

5) Relative contraindication to lumbar puncture is disc swelling optic nerve. Before performing a puncture, a consultation with a neurosurgeon is necessary. This symptom is not typical for acute bacterial meningitis, so other diseases, such as a brain abscess, should be excluded.

6) Conduct tuberculin test, culture of blood, feces, urine, joint fluid, abscess contents, discharge from the middle ear, etc.; bacterioscopy of smears and culture from all foci of infection. The levels of BUN, electrolytes and osmolarity of plasma and urine are determined, and radiography is performed chest. For infants, head circumference is measured.

V.Diagnosis meningitis is diagnosed only on the basis of the results of a lumbar puncture.

1) In bacterial meningitis, the CSF is turbid, its pressure is increased, the number of leukocytes is more than 100 μl -1, neutrophils predominate, the protein level is increased, the glucose level is less than half its level in plasma. Bacterioscopy of a Gram-stained CSF smear reveals the pathogen. All of the listed signs are not always present, therefore, with any of them, especially if neutrophils predominate in the CSF, meningitis should be suspected. CSF culture is indicated to confirm the diagnosis.

2) Determination of capsular polysaccharide antigens allows you to quickly identify the pathogen in some bacterial meningitis.

G.Treatment. Immediately after taking material for culture, IV antibiotics are prescribed. The choice of antibiotic is determined by the results of bacterioscopy of Gram-stained CSF smears and the age of the child. If gram-negative bacilli are detected, children over 2 months of age are prescribed dexamethasone, as it prevents hearing loss due to meningitis caused by Haemophilus influenzae type B.

1) If in children older than 2 months there is no reason to suspect a rare pathogen, choose any of two treatment regimens: ampicillin (300-400 mg/kg/day IV, the dose is divided and administered every 6 hours) in combination with chloramphenicol (100 mg/kg /day intravenously, the dose is divided and administered every 6 hours); or cefotaxime (150 mg/kg/day IV, divided dose and administered every 8 hours) or ceftriaxone (75-100 mg/kg/day IV, divided dose and administered every 12-24 hours). If the pathogen is Haemophilus influenzae, sensitive in vitro to ampicillin, ampicillin is additionally prescribed. For meningitis caused by Pseudomonas aeruginosa, the drug of choice is ceftazidime. For meningococcal or pneumococcal meningitis, the drug of choice is benzylpenicillin, and third-generation cephalosporins are used as a reserve drug. We prefer the combination of ampicillin with chloramphenicol because it is the most effective and safe.

2) The duration of treatment is determined individually. Standard courses of antibiotic therapy: meningitis caused by Haemophilus influenzae - 7-10 days, meningitis caused by meningococci - 5-7 days, meningitis caused by pneumococci - 10-14 days.

3) Dexamethasone, 0.6 mg/kg/day IV (dose divided and administered every 6 hours), is prescribed during the first 4 days of antimicrobial therapy. The drug is administered simultaneously with the antibiotic or immediately after it.

4) It is necessary to identify in time arterial hypotension, bleeding and ADH hypersecretion syndrome. The latter occurs in the first 72 hours of treatment, and until it is excluded, fluid intake is limited to 3/4 of the minimum water requirement. At the same time, in most cases, patients with meningitis are admitted to the hospital 12-24 hours after the onset of the disease, when they are already developing dehydration. Therefore, before limiting fluid intake, it is necessary to restore BCC. Maintaining normal blood pressure and blood supply to the brain is more important than preventing ADH hypersecretion syndrome.

5) During the treatment period, monitor heart rate, blood pressure, respiratory rate and body temperature. A neurological examination and diaphanoscopy (if the fontanelle is open) are carried out daily, and the head circumference is measured.

6) At severe course or if therapy is unsuccessful, lumbar puncture is repeated every 24-48 hours. An indicator of the effectiveness of treatment is the disappearance of the pathogen from the CSF 24-48 hours after the start of therapy.

7) The persistence of fever is most often due to phlebitis, a reaction to medicines, hospital infection accompanying viral infection or subdural effusion. The latter occurs in the acute period of the disease in 50% of children and is often asymptomatic. Prolonged (more than 7 days) or recurrent fever is an indication for lumbar puncture. In this case, it is necessary to exclude foci of infection in the subdural space, bones, joints, pericardium and pleural cavity. In some cases, CT is indicated to confirm subdural effusion.

8) At the end of antimicrobial therapy, we do not repeat the lumbar puncture because recurrence of bacterial meningitis after stopping antibiotics is rare. For uncomplicated meningitis, at the final stage of treatment, you can switch to intramuscular administration (ceftriaxone, 50-75 mg/kg intramuscularly 1 time per day) or oral administration (chloramphenicol in the same doses as for intravenous administration). In the latter case, monitor the level of the drug in the blood.

9) Persons who have close contact at home or in day care with a patient with meningitis caused by Haemophilus influenzae type B or Neisseria meningitidis are advised to be tested and preventive treatment. If the causative agent is Haemophilus influenzae type B, the risk of meningitis for family members under 6 years of age is 0.5%, if the causative agent is Neisseria meningitidis, the risk for all ages is 0.5%.

10) All children with Haemophilus influenzae type B infections are recommended to be treated with rifampicin to eliminate nasopharyngeal carriage. The drug is prescribed at a dose of 20 mg/kg (maximum 600 mg) once a day for 4 days (Red Book, American Academy of Pediatrics, 1991).

J. Gref (ed.) "Pediatrics", Moscow, "Practice", 1997

Among the many human diseases meningitis- one of the most dangerous. You can suffer from pneumonia on your feet, you can walk with tuberculosis for years, you can, with the help of “healers,” try to recover from venereal diseases for a long time. WITH meningitis Such “numbers” do not go through - either to the hospital, or...
Meningitis- a known disease. At least, average person, without any special medical education, word " meningitis"knows and, although the features of the disease itself are not very clear, meningitis Everyone is afraid. An emergency doctor may say: “You have a sore throat (flu, pneumonia, enterocolitis, sinusitis, etc.). Get ready to the hospital quickly.” In response, he will definitely hear: “Doctor, is there no way to get treatment at home?” But if the word “meningitis” is uttered, even if not categorically: “You have meningitis!”, but with doubt: “It looks like meningitis,” you can say with confidence: a normal person will not even mention any treatment at home.
This attitude towards meningitis is generally understandable - less than 50 years have passed since the time when it became possible to treat it (meningitis). But if the mortality rate from most childhood diseases decreased during this time by 10-20 times or more, then for meningitis - only 2 times.
So what kind of disease is this, meningitis?
First of all, it should be noted that meningitis is an infectious disease. That is immediate cause diseases are caused by certain microbes. Most human infections allow us to establish a clear relationship between the name of the disease and the name of its specific pathogen. Syphilis is a pale spirochete, scarlet fever is streptococcus, salmonellosis is salmonella, tuberculosis is Koch's bacillus, AIDS is the immunodeficiency virus, etc. At the same time, there is no specific connection between meningitis and the causative agent of meningitis.
The word "meningitis" itself means inflammation of the membranes of the brain, and the cause of this inflammation can be a huge number of microorganisms - bacteria, viruses, fungi. Infectious disease experts say, not without confidence, that under certain conditions any microorganism can cause meningitis in a person of any age. From this it is clear that meningitis can be different - different in the speed of development, in the severity of the condition, in the frequency of occurrence, and, most importantly, in the methods of treatment. All meningitis has one thing in common - a real threat to life and a high probability of complications.
For meningitis to occur, a specific pathogen must enter the cranial cavity and cause inflammation of the membranes of the brain. Sometimes this occurs when foci of infection occur in the immediate vicinity of the membranes of the brain - with purulent otitis media, for example, or with sinusitis. Often the cause of meningitis is traumatic brain injury. But most often, microbes enter the cranial cavity through the bloodstream. It is obvious that the very fact of a microbe entering the blood, the very possibility of its “introduction” and subsequent reproduction on the meninges is determined by the state of immunity.
It should be noted that there are a number of, as a rule, congenital defects immune system predisposing to the occurrence of meningitis. It is not surprising that in some families all children suffer from meningitis - although this disease is not so common, in comparison, for example, with sore throat, whooping cough, chickenpox or rubella. But if the role of immunity is generally clear, then so far it has not been possible to find a convincing explanation for the fact that boys suffer from meningitis 2-4 times more often than girls.
Depending on the type of pathogen, meningitis can be viral, bacterial, or fungal. Some protozoa (such as amoeba and toxoplasma) can also cause meningitis.
The development of viral meningitis can accompany the course of well-known infections - chickenpox, measles, rubella, mumps; damage to the meninges occurs with influenza and infections caused by herpes viruses. In weakened patients, in the elderly, and in infants, meningitis caused by fungi occurs (it is clear that in these situations it is the lack of immunity that plays the leading role in the occurrence of the disease).
Of particular importance are bacterial meningitis. Any purulent focus in the body - pneumonia, an infected burn, tonsillitis, various abscesses, etc. - can cause meningitis, provided that the pathogen enters the blood and reaches the meninges with the blood flow. It is clear that pathogens are known to everyone purulent processes(staphylococci, streptococci, Pseudomonas aeruginosa, etc.) and will in this case be the causative agent of meningitis. One of the most terrible is tuberculous meningitis - almost forgotten, it is now occurring more and more often.
At the same time, there is a microorganism that causes meningitis most often (60-70% of all bacterial meningitis). No wonder it's called that - meningococcus. Infection occurs by airborne droplets, meningococcus settles on the mucous membranes of the nasopharynx and can cause a condition very similar to a common respiratory viral infection - slight runny nose, redness of the throat - meningococcal nasopharyngitis. It was not for nothing that I used the phrase “may cause” - the fact is that hitting meningococcus into the body quite rarely leads to the onset of disease - the leading role here belongs to very special individual changes in immunity. In this regard, two facts are easily explained: the first is the risk of developing meningitis during contact, for example, in children's institutions is 1/1000 and the second is the frequent detection of meningococcus in the nasopharynx in completely healthy individuals (from 2 to 5% of children are healthy carriers) .
The body's inability to localize the microbe in the nasopharynx is accompanied by the penetration of meningococcus through the mucous membrane into the blood. With the bloodstream, it enters the meninges, eyes, ears, joints, lungs, adrenal glands, and in each of these organs a very dangerous inflammatory process. It is obvious that damage to the meninges is accompanied by the development meningococcal meningitis.
Sometimes meningococcus enters the blood quickly and in huge quantities. Arises meningococcal sepsis, or meningococcemia - perhaps the most terrible of all childhood infectious diseases. The microbe secretes poisons (toxins), under their influence multiple blockages of small vessels occur, blood clotting is impaired, and multiple hemorrhages appear on the body. Sometimes, within a few hours after the onset of the disease, hemorrhage occurs in the adrenal glands, and the arterial pressure and the person dies.
There is an amazingly dramatic pattern in the emergence of meningococcemia, which is as follows. The fact is that when a microbe penetrates the blood, it begins to react with certain antibodies that try to destroy meningococcus. It has been proven that there is cross-activity of a number of antibodies, i.e. if in large quantities There are antibodies, for example, to streptococcus, pneumococcus, staphylococcus - then these antibodies can have an inhibitory effect on meningococcus. So it turns out that children who are sick, have chronic foci of infections, have had pneumonia and many other illnesses, almost never get meningococcemia. The scary thing about meningococcemia is that within 10-12 hours an absolutely healthy child who has never been sick before can die!
All the above information is not intended to intimidate readers. Meningitis is treatable. But the results (duration and severity of the disease, the likelihood of complications) are closely related to the time that will be lost before the start of adequate therapy.
Obviously, the above-mentioned "timing of initiation of adequate therapy" depends on when human subjects present for medical care. Hence the urgent need for specific knowledge, so that later there will be no excruciating pain...
The essence of specific knowledge regarding meningitis is that the appearance of certain signs indicating the possibility of this disease requires immediate medical attention.
Inflammation of the meninges is characterized by a number of symptoms, but many of them are not specific - that is, their (symptoms) may also occur in other diseases that are much less dangerous. Most often this is what happens, but the slightest suspicion of the development of meningitis does not allow you to take risks and requires immediate hospitalization and careful medical supervision.
Let us now consider the most typical situations, each of which does not allow us to exclude the development of meningitis.

If, against the background of any infectious disease - acute respiratory infections, chickenpox, measles, mumps, rubella, "fever" on the lips, etc. - perhaps not at the beginning of the disease (even more often not at the beginning), intense headache, so strong that it worries more than all other symptoms if the headache is accompanied by nausea and vomiting.

In all cases, when in the background elevated temperature body there are pains in the back and neck, aggravated by moving the head.

Drowsiness, confusion, nausea, vomiting.

Convulsions of any intensity and any duration.

In children of the first year of life - fever + monotonous crying + bulging fontanel.

Any (!!!) rash against a background of elevated temperature.

In addition to the symptoms described above, some reflexes change in a very definite way, and only a doctor can detect this.
It is important to remember and understand that common symptoms such as vomiting, nausea and headache in mandatory require a medical examination - God protects the best.
Any rash accompanied by an elevated temperature may be meningococcemia. You (or your smart neighbors) may be confident that it is rubella, measles or “diathesis”. But the doctor must see the rash, and the sooner the better. If the elements of the rash look like hemorrhages, if new rashes appear quickly, if this is accompanied by vomiting and high fever, every chance should be taken to ensure that the patient immediately ends up in the hospital, preferably immediately in the infectious diseases department. Remember: when meningococcemia The count is not by hours, but by minutes.
It should be noted that even a highly qualified doctor can diagnose meningitis with absolute certainty only in one case - when the symptoms of irritation of the meninges are combined with the typical rash, which is described above. In all other cases, the diagnosis can only be suspected with varying degrees of probability.
The only way to confirm or exclude meningitis is a spinal (lumbar) puncture. The fact is that a special cerebrospinal fluid circulates in the brain and spinal cord - cerebrospinal fluid. With any inflammation of the brain and (or) its membranes, cerebrospinal fluid accumulates inflammatory cells, the appearance of the cerebrospinal fluid (normally colorless and transparent) often changes - it becomes cloudy. The study of cerebrospinal fluid allows not only to establish a diagnosis meningitis, but also to answer the question of what kind of meningitis it is - bacterial (purulent) or viral, what has crucial in choosing a treatment option.
Unfortunately, at a purely philistine level, there is a very widespread opinion about the enormous dangers that a spinal puncture poses. In fact, these fears are absolutely unfounded - the puncture of the spinal canal is carried out between lumbar vertebrae at the level where there are no longer any branches from the spinal cord nerve trunks, so there are no mythical paralysis after this manipulation. WITH legal point vision doctor is obliged to conduct spinal tap if there is a real suspicion of meningitis. It should be noted that puncture has not only diagnostic, but also therapeutic usefulness. For any meningitis As a rule, there is an increase in intracranial pressure, the consequence of which is a severe headache. Taking a small amount of cerebrospinal fluid can reduce blood pressure and significantly alleviate the patient’s condition. During a puncture, antibiotics are often administered into the spinal canal. So, for example, when tuberculous meningitis the only chance to save the patient is frequent (often daily) punctures, during which spinal canal a special version of streptomycin is introduced.
Taking into account the above information, it becomes clear that meningitis treatment depends on the type of pathogen. The main thing in the treatment of bacterial meningitis- use of antibiotics. The choice of a specific drug depends on the sensitivity of the particular bacterium and whether the antibiotic is able to penetrate into cerebrospinal fluid. With timely use of antibacterial drugs, the chances of success are very high.
With viral meningitis the situation is fundamentally different - antiviral drugs practically none, the exception is acyclovir, but it is used only for herpetic infection(let me remind you that chicken pox- one of the variants of herpes). Fortunately, viral meningitis have more favorable course compared to bacterial ones.
But helping a patient is not limited to just influencing the pathogen. The doctor has the opportunity to normalize intracranial pressure, eliminate toxicosis, improve the functioning of nerve cells and blood vessels in the brain, and use powerful anti-inflammatory drugs.
Timely treatment started meningitis within two to three days leads to significant improvement condition, and in the future almost always to a complete cure without any consequences.
I emphasize once again: timely treatment started...