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. This conclusion was reached by modern infectious disease specialists in the course of research. The disease affects people of all ages.

Meningitis in its development and causes of education are completely different. Often the disease can recur for several years. Sometimes a person can suffer once, but very seriously. Pathological condition carries 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 meninges of the brain and the patient's well-being thereby deteriorates significantly. In most cases, the disease is characterized by the formation due to infection harmful microorganisms through entry into 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 identified a significant effect of immunity on meningitis. However, the fact that boys get sick 4 times more often than girls is proven on the basis of statistical studies. The course of the disease can be influenced by viruses, bacteria and fungi. IN last years more and more cases are being identified. Especially dangerous state causing complex purulent processes.

It is important to remember that young children are especially hard hit by meningitis. Moreover, the typical situation for the 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 in combination with pain in the neck and back, which is aggravated by tilting or turning the head.
3. The patient may be unconscious, there are convulsions, drowsiness, nausea, vomiting.
4. Defeat skin rash of any kind high temperature.
5. Infants have monotonous crying, a feverish state, and the fontanel swells.

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

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

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

Proper techniques in preparing and conducting a puncture allow the procedure to be carried out quickly and with minimal pain for the patient. Puncture for meningitis will not have negative consequences if the medical staff has sufficient experience in making this diagnosis.

Compliance with all appointments and correct behavior after the puncture is important for the patient himself. Irreversible changes in the body to which untimely treatment leads 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.

Refusing to perform a puncture for meningitis is not recommended. 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 an important role in choosing the most suitable ways treatment.

Microbiological in order to identify the pathogen is possible only through lumbar puncture. In the process of 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 likely presence of neuroinfection;
• for diagnosing oncological diseases;
• to detect liquorrhea;
• in order to exclude hemorrhage in 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 volume flow;
• cerebral edema;
• poor blood clotting;
• pathological disorders in the back area where the procedure is to be performed.

Puncture for meningitis takes place in operating conditions. In the supine position, with the legs pressed to the chest and the head to the bottom, optimal expansion of the intervertebral spaces is possible. The doctor will be able to do all the manipulations with maximum accuracy. fat people the puncture is carried out in a sitting position.

Certain anesthetics are used for pain relief. They are introduced into the puncture site in three stages. In parallel, the introduction of a needle is required to take 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 a hemorrhage in the subarachnoid space.

Injury to the vessels during a puncture for meningitis can lead to staining of the taken fluid in a reddish color. Important nuance consists in the fact that it is required to carry out a preliminary collection of test liquid. All manipulations must be carried out quickly and accurately in order to avoid possible injury to the ligaments and membranes of the spinal regions.

Puncture in children

In children there is no place for self-treatment. Postponing a visit to the doctor even for hours is dangerously possible unpredictable consequences. According to statistics, despite technological advances in medicine, deaths from meningitis have not decreased over the past 50 years.

The incubation period lasts about 10 days. At the age of up to 6 months, it is especially difficult. It is often the cause of 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 between the ages of 2 and 10 are initially troubled by fever, gradually turning into a drowsy state. In newborns, the fontanel is compacted. Babies become moody and irritable. Unconscious meningitis can be older children, from 7 to 12 years. This manifestation includes severe headaches, a sudden increase in pressure and the development of a rash on the skin.

of paramount 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 is absolutely identical to such a mini-operation in an adult.

Every child needs more thorough examination before such a diagnosis. There are more contraindications in connection with a fragile growing organism than in an adult. In addition to a puncture for meningitis, it is necessary to conduct blood tests. Almost always assigned 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's response to synthetic drugs used in anesthesia. You need to lie at first only on your stomach to avoid pressure on the puncture site.

Recommended plentiful drink not cold and not hot. The child should be in a room where there are no strangers and preferably under constant adult supervision. Sometimes intravenous plasma substitutes are prescribed.

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

Consequences

Relief of 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 habitual image life. Timely seeking help from a doctor does not have undesirable consequences. The body of the child is restored already for a short rehabilitation.

Puncture for meningitis in children provokes the most minimal consequences. Pain during the procedure does not bother. This is all thanks to the unique thin needles designed for similar procedures. An important role here is played by gradual anesthesia with triple administration of an anesthetic.

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 intra-traumatic brain injuries, which are manifested by hematomas. Violations of the diagnostic technique during puncture can damage the vessels and provoke bleeding.
2. Post-puncture syndrome. Intracranial vessels shift and dilate 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 backs, legs, lower back begin to hurt more and more often over time.
4. Immediate trauma, this condition is determined by damage nerve endings when handling the needle. The lesion may affect the intervertebral discs. Various infections develop and even another type of meningitis.
5. Liquorodynamic complications are the occurrence of an acute pain syndrome against the background of an already existing tumor.
6. A change in the cerebrospinal fluid composition is observed when air, chemicals, microparticles from anesthetics, and more enter the needle when the needle is inserted.
7. Other complications occur after a violation of the puncture technique. This is the development of sciatica, myelitis or arachnoid. Dizziness, urge to vomit, nausea may disturb in the first hours after the puncture. However, they are not dangerous and pass quickly.

Puncture for meningitis is performed to extract and then study the cerebrospinal fluid. Currently, this is the only possible method to correctly diagnose dangerous disease. Doctors reveal the norm or pathology of the fluid already with its direct removal.

The effectiveness of the procedure for meningitis is often influenced by extraneous factors. These include obesity, dehydration, back surgery and more. Sometimes a 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 with a disease such as meningitis (inflammation meninges). With this disease this manipulation is one of the key stages in the diagnosis, as it allows you to confirm or exclude the presence of the diagnosis itself, as well as to clarify the pathogen that caused one or another type of meningitis.

Patient lying down and sitting during lumbar puncture

Most patients with the word "lumbar puncture" imagine a dangerous and rather painful manipulation. However, it must be said that if the staff performing this procedure has sufficient skills and the patient himself follows the rules for preparing for the puncture and following a sparing regimen after it, then usually the lumbar puncture passes quickly enough, with less pain. And the consequences of a puncture for meningitis with such correct behavior of the patient and medical staff are either absent or minimal.

General information

Meningitis is enough serious illness that 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 starts, with damage to the medulla, 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 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 can have various factors that trigger its development. Usually, its purulent and aseptic variety is distinguished. Purulent appearance meningitis occurs due to the action of bacteria (pneumococci, meningococci and Staphylococcus aureus, as a consequence surgical interventions). The aseptic variety of meningitis is caused by viruses. Aseptic meningitis can be triggered by the action of herpesviruses, enteroviruses, choriomeningitis viruses.

Such features require specific treatment, since the therapy for bacterial or viral meningitis is different. But in order to determine the method of treatment and the pathogen, a special microbiological examination of the cerebrospinal fluid is necessary, which makes it possible to carry out the ongoing lumbar puncture.

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

Taking cerebrospinal fluid for research

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

Indications for manipulation

Lumbar puncture should be performed with the following situations:

• Suspicion of neuroinfection. A prime example These diseases are just meningitis. It can also be encephalitis,
• Suspicion of the presence of hemorrhage in the subarachnoid space.
• The need to confirm or exclude oncological and metastatic processes in brain structures (meninges).
• Diagnosis of conditions such as liquorrhea.
• The need for diagnosis of CSF fistulas. In this case, the introduction of a special radiopaque substance is also added to the lumbar puncture.
• Prevention and exclusion of neuroleukemia in oncohematological patients.

These indications are called absolute, that is, those in which puncture is necessary and it is the key. There are also relative readings- those in which the lumbar puncture is either not a fundamental or additional method. Usually this:

• Various processes accompanied by demyelinating processes.
• Polyneuropathies inflammatory nature.
• Unexplained fever.

Contraindications

There are a number of contraindications for lumbar puncture

However, in addition to indications for puncture, there are also such conditions, the presence of which requires that this manipulation be abandoned.

• Cerebral edema. At given state lumbar puncture will lead to a change in intracranial pressure, which, in turn, can lead to herniation of the cerebellum in the foramen magnum and death. This is the most important and the first contraindication to lumbar puncture.
• Any volumetric 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. Sick on operating table they are asked to take a characteristic position: lying on their side, while knees should be brought to the chest, and the head should be tilted forward. This position is necessary to expand the intervertebral spaces, which provides the doctor performing the procedure with greater convenience. Also, the puncture can be performed while sitting (especially in obese patients).

The puncture site itself is located at the level of 3-4 lumbar vertebrae. A convenient guideline for determining the 4th vertebra is a line that can be visually drawn by connecting the ridges ilium. 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 gently moved forward until a failure is felt, which will mean that the needle has passed through the ligaments and hard shell, after that, a test sampling of the liquor fluid is carried out in order to confirm the correct location of the needle. After that, a clean test tube is substituted into which the liquid is collected.

The type and color of the liquid, as well as the nature of its outflow into the test tube, are carefully evaluated.

If the fluid does not come in the form of rare drops, but often and quickly, this indicates a possible intracranial hypertension. It is also necessary to check for the presence of red staining 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, with the correct implementation by the patient of all the recommendations prescribed for him and literacy medical staff, complications after the puncture are minimal. However, there are still some situations that can appear even with well-performed manipulation. They make up a small percentage of the total summary of all cases, but you should not forget about them:

• Wedging of brain structures or dislocation of median 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 during its implementation in pregnant women. Such patients, especially in the first trimester of the term, may be at risk for miscarriages in response to a puncture.

Patients with heart disease and a lumbar puncture require close attention, since when vasovagal reactions are triggered, the consequences can be catastrophic, as respiratory or cardiac arrest can occur.

Features of cerebrospinal fluid in meningitis

Each meningitis is determined by the type of its pathogen, as a result of which the changes in the cerebrospinal fluid for each of them are different.

Therefore, knowing certain visual features of the cerebrospinal fluid and its microbiological characterization, you can make a correct differential diagnosis of the varieties of meningitis and start right treatment.

CSF examination confirms the diagnosis of meningitis

The bacterial variety of meningitis is characterized by next view liquor:

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

Aseptic or viral meningitis is characterized by the following CSF:

• Transparent-looking liquor.
• The predominance of the percentage of lymphocytes over leukocytes.
• Absence of inoculated bacterial culture.

Separate diagnostic features CSF has tuberculous meningitis:

• Opalescent, cloudy appearance of cerebrospinal fluid in a test tube.
• The number of lymphocytes is over 100 per millimeter cubic.
• Low glucose.
• 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 the 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 CSF and its microbiological properties.

Treatment control

Approximately by the third week of treatment, it is necessary to evaluate how meningitis regresses under the influence of drugs. For this use re-puncture. It is used to analyze the change 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 do a lumbar puncture. Only the results of the 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.

In a blood test for meningitis, acute inflammatory changes are determined. In a smear from the mucous membranes of the nasopharynx, meningococci (bacteria that cause meningitis) are found. 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 feces (coprogram);
• determination of creatinine, ALT, ASAT, total bilirubin, lactate and procalcitonin in serum.

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

Patients register an electrocardiogram, perform an electroencephalogram, computed and magnetic resonance imaging. All instrumental research are carried out using the latest equipment from leading world manufacturers.

After the diagnosis is established, complex therapy of meningitis is started according to Russian, European and American recommendations. Physicians at drafting individual scheme treatment of patients take into account the serotype of the pathogen, its sensitivity to antibacterial drugs, the severity of the disease, the severity of symptoms. For bacterial meningitis, antibiotics are started no later than 60 minutes after initial examination patient.

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

The study of cerebrospinal fluid in meningitis

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

The first examination of the cerebrospinal fluid is carried out upon admission of the patient to the neurology clinic. The results of the analysis can be ready 2 hours after the sampling of cerebrospinal fluid. 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 it is checked whether a lymphocytic shift has appeared. If bacteria are detected in samples of cerebrospinal fluid, the study is repeated several times. The need for a lumbar puncture is eliminated when reverse development clinical signs diseases, normalization of the number of cells, protein and sugar in the cerebrospinal fluid, the disappearance of microorganisms from the cerebrospinal fluid.

For the reason that caused 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 in 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 taking.

With purulent meningitis, the cerebrospinal fluid is cloudy, whitish or Green colour. It is dominated by neutrophils. Number shaped elements fluctuates over a wide range. 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 meninges 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 CSF 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 released from microorganisms, it decreases. A large concentration of protein is observed in severe meningitis. If high level protein is determined during the recovery period, this indicates an intracranial complication. A particularly poor prognostic sign in meningitis is the combination of low pleocytosis and high protein. The amount of glucose in the cerebrospinal fluid with purulent meningitis is below 3 mmol / l. The ratio of glucose in the cerebrospinal fluid to the level of glucose in the blood in 70% of patients is less than 0.31. A favorable prognostic sign is an increase in glucose in the cerebrospinal fluid.

In tuberculous meningitis, a 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 during 12-24 hours when it is standing. The sediment is a delicate fibrinous web-like mesh in the form of an overturned Christmas tree. Sometimes it can be coarse flakes. In most cases, tuberculosis bacilli are found in the precipitate.

With tuberculous meningitis, the cerebrospinal fluid is transparent, 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 the destruction of Mycobacterium tuberculosis, then the number of cells in the cerebrospinal fluid is constantly increasing throughout the disease. A day after the first lumbar puncture, a second procedure is usually performed. In CSF samples obtained during repeated lumbar puncture, a decrease in cells is often observed.

In most cases, lymphocytes predominate in the cerebrospinal fluid in tuberculous meningitis. There are cases when, at the beginning of the disease, pleocytosis is lymphocytic-neutrophilic in nature. An unfavorable prognostic sign is the presence in the CSF of a large number of monocytes and macrophages. The protein concentration in tuberculous meningitis is always increased to 2-3 g/l. Its level rises before the appearance of pleocytosis and decreases after a significant decrease. Biochemical research cerebrospinal fluid in tuberculous meningitis, a decrease in glucose levels to 0.83-1.67 mmol / l is detected early. In some patients, there is a decrease in the concentration of chlorides in the cerebrospinal fluid.

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

In meningococcal meningitis, intracranial pressure first rises, 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 studied in the first hours of the disease does not differ from the norm. In case of inadequate therapy, the CSF may be purulent, there is a high neutrophilic pleocytosis, elevated 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 transparent, there is a slight lymphocytic pleocytosis. In some cases, in the initial stages of the disease, an increased content of neutrophils is determined in the cerebrospinal fluid. This indicates a more severe course of the disease and has a less favorable prognosis. In serous meningitis, protein levels may be normal or moderately elevated. In some patients, the protein concentration is reduced due to excessive CSF production.

Serodiagnosis of viral meningitis

Unlike bacteria, viruses biological fluids very difficult to identify. Often the diagnosis of a viral infection is made on the basis of 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, so the index of the ratio of specific antibodies in the cerebrospinal fluid and blood serum increases. If ISST is greater than or equal to 1.5, this indicates a higher relative content specific immunoglobulins in cerebrospinal fluid than in serum, and thus 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 human immunodeficiency virus, human T-lymphotropic virus type 1, varicella zoster virus, mumps. Detection of oligoclonal immunoglobulins helps physicians to differentiate between infectious meningitis caused by enteroviruses, arboviruses, and herpes simplex virus, in which they are usually absent.

Other studies in meningitis

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

Methods instrumental diagnostics in meningitis is used for neuroimaging and functional evaluation 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 an assessment of the condition of the fundus. children early age with an open large fontanel, neurosonography is performed.

With a stable blood supply, computed or magnetic resonance imaging is performed. Neuroimaging techniques are needed to conduct 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 on early dates meningitis does not exclude the risk of development in the future. All patients with meningitis in the early stages of the disease are recorded short-latency auditory evoked potentials to exclude or early detection sensory-neural 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 results of laboratory research”//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 older than 2 years, 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 microorganism has dropped dramatically.

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 turn to a violation of consciousness. One of the first symptoms of meningitis may be convulsions, so in combination with fever they are an indication for the study of the CSF.

2) In children older than 1 year, meningeal symptoms in meningitis are more common. The indication for lumbar puncture is the symptom of Brudzinsky (when the neck is flexed in the supine position, involuntary flexion of the legs in the hip joints is observed).

3) Meningitis must be ruled out in bacteremia.

4) If meningitis is suspected, a lumbar puncture is performed. Plasma glucose is pre-determined for comparison with CSF glucose levels.

5) Relative contraindication to lumbar puncture - disc edema optic nerve. Before carrying out a puncture consultation of the neurosurgeon is necessary. This symptom is not characteristic of acute bacterial meningitis, so other diseases, such as a brain abscess, should be ruled out.

6) Spend tuberculin test, sowing blood, feces, urine, joint fluid, the contents of abscesses, separated from the middle ear, etc .; bacterioscopy of smears and sowing from all foci of infection. Determine the levels of BUN, electrolytes and osmolarity of plasma and urine, perform radiography chest. In infants, head circumference is measured.

V.Diagnosis meningitis is put 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 of its plasma level. Microscopic examination of a Gram-stained CSF smear reveals the pathogen. All of these 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 the material for sowing, antibiotics are prescribed intravenously. The choice of antibiotic is determined by the results of microscopy of Gram-stained CSF smears and the age of the child. If Gram-negative rods are detected, children older than 2 months are given dexamethasone, as it prevents hearing loss in meningitis caused by Haemophilus influenzae type B.

1) If there is no reason to suspect a rare pathogen in children older than 2 months, choose either of two treatment regimens: ampicillin (300-400 mg / kg / day / in, the dose is divided and administered every 6 hours) in combination with chloramphenicol (100 mg / kg / day in / in, the dose is divided and administered every 6 hours); or cefotaxime (150 mg/kg/day IV, divided dose given every 8 hours) or ceftriaxone (75-100 mg/kg/day IV, divided dose given every 12-24 hours). If the causative agent is Haemophilus influenzae, sensitive in vitro to ampicillin, ampicillin is additionally prescribed. For meningitis caused by Pseudomonas aeruginosa, ceftazidime is the drug of choice. In 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 as 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 detect 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 already develop dehydration. Therefore, before restricting fluid intake, it is necessary to restore the bcc. Maintaining normal blood pressure and blood supply to the brain is more important than preventing ADH hypersecretion syndrome.

5) During the treatment period, heart rate, blood pressure, respiratory rate and body temperature are monitored. A neurological examination and diaphanoscopy (with an open fontanel) are performed daily, head circumference is measured.

6) At severe course or in case of unsuccessful therapy, a 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) Persistence of fever is most often due to phlebitis, a reaction to medicines, hospital-acquired infection, concomitant 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) On completion of antimicrobial therapy, we do not repeat lumbar puncture because recurrence of bacterial meningitis after antibiotic withdrawal is rare. In uncomplicated meningitis, at the final stage of treatment, you can switch to intramuscular injection (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 facilities with sick meningitis caused by Haemophilus influenzae type B or Neisseria meningitidis should 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 carriers. The drug is prescribed at a dose of 20 mg / kg (maximum - 600 mg) 1 time per 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 endure inflammation of the lungs "on your feet", you can walk with tuberculosis for years, you can try to recover from venereal diseases with the help of "healers" for a long time. WITH meningitis such "numbers" do not pass - either to the hospital, or ...
Meningitis is 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 ambulance doctor may say: "You have a sore throat (flu, pneumonia, enterocolitis, sinusitis, etc.). Get to the hospital quickly." In response, he will definitely hear: "Doctor, can't you 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,” we can say with confidence: a normal person will not even hint at any treatment at home.
Such an attitude towards meningitis is generally understandable - even 50 years have not passed since the time when it became possible to treat it (meningitis). But if mortality from most childhood diseases has decreased during this time by 10-20 or more times, then with meningitis - only 2 times.
So what is this disease, meningitis?
First of all, it should be noted that meningitis is an infectious disease. i.e. direct cause diseases are certain microbes. Most human infections make it possible to establish a clear relationship between the name of the disease and the name of its specific pathogen. Syphilis - pale spirochete, scarlet fever - streptococcus, salmonellosis - salmonella, tuberculosis - Koch's bacillus, AIDS - immunodeficiency virus, etc. At the same time, there is no specific connection between meningitis and the causative agent of meningitis.
The term "meningitis" itself refers to inflammation of the meninges, and the cause of this inflammation can be a huge number of microorganisms - bacteria, viruses, fungi. Infectionists, not without confidence, declare that under certain conditions, any microorganism can cause meningitis in a person of any age. From this it is clear that meningitis is different - different in the speed of development, and in the severity of the condition, and in the frequency of occurrence, and, most importantly, in the methods of treatment. One thing unites all meningitis - 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 meninges. Sometimes this happens when foci of infection occur in the immediate vicinity of the meninges - with purulent otitis media, for example, or with sinusitis. Often the cause of meningitis is a traumatic brain injury. But most often, microbes enter the cranial cavity with the blood stream. It is obvious that the very fact that a microbe enters the bloodstream, the very possibility of its "drift" and subsequent reproduction on the meninges is due to the state of immunity.
It should be noted that there are a number of, as a rule, birth defects immune system predisposing to 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 tonsillitis, whooping cough, chickenpox or rubella. But if the role of immunity is generally understood, then so far it has not been possible to find a convincing explanation for the fact that boys get meningitis 2-4 times more often than girls.
Depending on the type of pathogen, meningitis can be viral, bacterial, 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 (mumps), damage to the meninges occurs with influenza, with infections caused by herpes viruses. In debilitated patients, in the elderly, in infants, meningitis caused by fungi occurs (it is clear that in these situations it is the lack of immunity that plays a leading role in the onset of the disease).
Of particular importance are bacterial meningitis. Any purulent focus in the body - pneumonia, infected burns, tonsillitis, various abscesses, etc. - can cause meningitis, provided that the pathogen enters the bloodstream and reaches the meninges with blood flow. It is clear that all known pathogens purulent processes(staphylococci, streptococci, Pseudomonas aeruginosa, etc.) and in this case will be the causative agent of meningitis. One of the most terrible is tuberculous meningitis - almost forgotten, it now occurs 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 - a slight runny nose, redness of the throat - meningococcal nasopharyngitis. It was not in vain that I used the phrase "may cause" - the fact is that a hit meningococcus into the body quite rarely leads to the onset of the 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 contacts, for example, in children's institutions is 1/1000 and the second is the frequent detection of meningococcus in the nasopharynx in perfectly 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 blood flow, it enters the meninges, eyes, ears, joints, lungs, adrenal glands, and in each of these organs a very dangerous inflammatory process. Obviously, damage to the meninges is accompanied by the development meningococcal meningitis.
Sometimes meningococcus enters the bloodstream quickly and in large quantities. Arises meningococcal sepsis, or meningococcemia - perhaps the most terrible of all childhood infectious diseases. The microbe releases poisons (toxins), under their influence, multiple blockage of small vessels occurs, blood clotting is disturbed, multiple hemorrhages appear on the body. Sometimes, within a few hours after the onset of the disease, a hemorrhage occurs in the adrenal glands, 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 enters the bloodstream, it begins to react with certain antibodies that try to destroy meningococcus. It has been proven that there is a cross-activity of a number of antibodies, i.e. if in in large numbers there are antibodies, for example, to streptococcus, pneumococcus, staphylococcus - then these antibodies can have an inhibitory effect on meningococcus. So it turns out that sick children, having chronic foci of infections, who have suffered pneumonia and many other sores, almost never get sick with meningococcemia. The fear of meningococcemia lies precisely in the fact that an absolutely healthy and never sick child can die within 10-12 hours!
All the above information is not intended to intimidate readers. Meningitis is treated. 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.
It is obvious that the aforementioned "timing of the initiation of adequate therapy" depends on when human people come for medical care. Hence the urgent need for specific knowledge, so that later it would not be excruciatingly painful ...
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 of the time this happens, but the slightest suspicion of the development of meningitis does not allow you to take risks, 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), an intense headache, so severe that it excites more than all other symptoms if the headache is accompanied by nausea and vomiting.

In all cases, when in the background elevated temperature the body has pain in the back and neck, aggravated by movement of 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 the 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 such common symptoms as vomiting, nausea and headache in without fail require a medical examination - God saves the safe.
Any rash on the background of elevated temperature may be meningococcemia. You (or your smart neighbors) can be sure it's 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 used to ensure that the patient immediately ends up in the hospital, preferably immediately in the infectious disease. Remember: when meningococcemia the account goes not on hours, but on minutes.
It should be noted that a doctor of even the highest qualification can diagnose meningitis with absolute certainty only in one case - when the symptoms of irritation of the meninges are combined with a 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 in the cerebrospinal fluid accumulate inflammatory cells, the type of 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, which 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 lumbar puncture is fraught with. In fact, these fears are absolutely unfounded - the puncture of the spinal canal is carried out between lumbar vertebrae at the level where no longer depart from the spinal cord any nerve trunks, therefore, there are no mythical paralysis after this manipulation. WITH legal point vision, the doctor must conduct lumbar puncture with real suspicion of meningitis. It should be noted that the puncture has not only diagnostic, but also therapeutic expediency. For any meningitis, as a rule, there is an increase in intracranial pressure, the consequence of the latter is a severe headache. Taking a small amount of cerebrospinal fluid can reduce pressure and significantly alleviate the patient's condition. During a puncture, antibiotics are often injected 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.
Given the above information, it becomes clear that meningitis treatment depends on the type of pathogen. Important in the treatment of bacterial meningitis- use of antibiotics. The choice of a specific drug depends on the sensitivity of a particular bacterium and on whether the antibiotic is able to penetrate into cerebrospinal fluid. With the 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 when herpetic infection(remember that chicken pox- one of the variants of herpes). Fortunately, viral meningitis have more favorable course compared to bacteria.
But helping the patient is not limited to the impact on the pathogen. The doctor has the opportunity to normalize intracranial pressure, eliminate toxicosis, improve the functioning of nerve cells and cerebral vessels, and apply powerful anti-inflammatory drugs.
Early treatment 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 again: timely treatment...