1. Epidemic cerebrospinal meningitis Dr. Huijian Zhou Dept. Of Infectious Disease Ruijin Hospital

2. General description  Epidemic cerebrospinal meningitis is acute infectious disease caused by meningococcus 脑膜炎奈瑟菌.  The characteristics of ECM are fever,  headache, vomiting, petechiae 淤点 or ecchymosis 淤斑, and meningeal irritation signs. CSF is purulent 化脓性.  Air pathway  Season: from winter to spring  High incidence in child

3. Etiology  Pathogen is Neisseria meningitidis (meningococcus ）脑膜炎奈瑟 菌，又称脑膜炎双球菌  G- diplococcus, kidney form ，  The organism can be detected in patient’s nasopharynx, blood, CSF, petechiae in skin 鼻咽部、血清、淤点淤斑、脑脊液带菌  Pathogenic factor: endotoxin,autolysis by autolysin in vitro 内毒素， 自溶酶  The organism grow by incubation on blood,chocolate in 5~10%CO2,PH 7.4~7.6; 专性需氧，巧克力平 板培养 on blood,chocolate in 5~10%CO2,PH 7.4~7.6; 专性需氧，巧克力平 板培养  The organism is susceptible to dry, heat, chill and disinfectant 对外界抵抗力低 heat, chill and disinfectant 对外界抵抗力低 ); 2.Biological features:

4. Etiology

5. Etiology A, B, C, D, E29, H, I, K, L, W135, X, Y Z More than 90% Serogroups of meningoccus

6. Epidemiology  Source of infection 传染源  The routes of transmission 传播途径  Susceptibility of population 易感人群  Epidemiologic feature 流行特征

7. Epidemiology  The routes of transmission : 1) air borne 2) closed contact transmission

8. Epidemiology  Source of infection: patients and carriers

9. Epidemiology  Susceptibility of population: 1) universal susceptible, especial 6m-2yr 2) stable and persistent immunity

10. Epidemiology  Epidemiologic feature 1)Season: November – May 2)high peak: March – April 3)age: 6 months to 2 years old –Carriers:60~70% –Patients:1%

11. Pathogenesis meningococci nasopharynx upper respiratory tract infection host resistance Bacteria virulence carriers meningococcemia period cerebrospinal infection pyogenic meningitis 1% other organs pericarditis or arthritis etc extinguished 60 - 70% 20 -30% septicemia

12. Pathogenesis (fulminant type) Pathogenesis (fulminant type) endotoxin microcirculatory failure petechia 瘀斑 shock DIC Bleeding brain edema brain purulence comabrain hernia

13. Pathology  Septicemic stage vascular endothelial injury cardiomyopathy and lung edema vascular wall inflammation, necrosis thrombosis 血栓 thrombosis 血栓, perivascular bleeding skin, mucous membranes or organs bleeding

14. Pathology ( fulminant meningoencephlitis type )  Meningitis stage leptomeninx andarachnoid congestion, bleeding, swelling of meningeal vessel swelling of meningeal vessel intracranial hypertension FP 、 NE 、 plasma exosmosis purulent CSF Inflammation, Conglutination at the bottom of skull injured cranial nerves Site

15. Pathoanatomy

16. Pathoanatomy

17. Pathology  Meningitis stage Fulminant type type brain tissue congestion, bleeding, edema necrosis intracranial hypertension brain hernia Chronic patients ventricle hole 脑室孔 block CSF circle obstacle hydrocephalus endotoxin

18. CT exhibition

19. Clinical Manifestation  Incubation period: 1~10 days(2~3days)

20. Clinical Manifestation  common type( >90% cases )  URT infectious stage –Persist 1~2d –URT infectious symptoms – Most patients have no these symptoms  septicemic stage (toxemia symptoms) –acute and high fever39~40 ℃ –headache –petechiae, purpura or ecchymosis 淤点紫癜淤 斑

21. Clinical Manifestation petechiae

22.  common type  meningitis stage: –High fever and septicemic symptoms –CNS symptoms: headache,vomiting, –meningeal irritation: nuchal rigidity; Kerning’signs and Brudzinski’signs are positive –Consciousness obstacle 、 Convulsions 抽搐 –Persist 2~5d  Convalescent stage:5~7days from –T normal ， symptoms disappear – lucky herpes 幸福疱疹

23. Clinical Manifestation  Fulminant types: 3 forms  shock form:the most dramatic form 败血症休克型 –wildly petechiae, purpura, ecchymosis 瘀点瘀斑广 泛，融合 –severe toxic symptoms (shock): pallor,extremities cold, cyanosis, hypotension, pales quickly –DIC,MOF –Meningeal irritant signs is absent, CSF is normal; –Blood Culture of meningococcus

24. Clinical Manifestation ecchymosis

25.  Fulminant types :  Meningoencephalitis type –Severe headache;projectile vomiting –Papillar edema –respiratory failure –encephalocele 脑疝  枕骨大孔疝 : 小脑扁桃体疝 昏迷加深，双瞳孔散大，上肢内旋，下肢强直，迅速出 现呼衰 昏迷加深，双瞳孔散大，上肢内旋，下肢强直，迅速出 现呼衰  天幕裂孔疝：颞叶海马回或沟回疝 昏迷，同侧瞳孔散大，眼球固定或外展，对侧肢体瘫痪 昏迷，同侧瞳孔散大，眼球固定或外展，对侧肢体瘫痪  mixed type

26. Clinical Manifestation nuchal rigidity severe case ： nuchal rigidity 角弓反张

27. Clinical Manifestation  The chronic meningococcemia form –Rarely, in adult population –Course: weeks~months –Intermitted high fever, tetter 皮疹、 purulent arthritis ， swelling of spleen –Diagnosis:once more bacteria culture

28. Clinical Manifestation  The mild form  Fever,arthralgia,URT infectious symptoms  Rare tetter  CSF normal  Frequently happen in younger and older population

29. Laboratory Findings  Blood pictures: WBC↑↑↑ ， NE↑↑PLT is decrease in DIC WBC↑↑↑ ， NE↑↑PLT is decrease in DIC  CSF (important)  suppurative ， WBC>1000X10 6 /L ， ANC 为主  Pr↑, Glu↓ Cl - ↓  Pressure ↑

30. Laboratory Findings  lumbar puncture 腰穿

31. Laboratory Findings  Bacteriology  Smear

32. Laboratory Findings  Bacteriology  Culture (gold standard)

33. Laboratory Findings Cerebrospinal fluid CSF: septic meningitis normal Viral meningitis purulent meningitis tuberculous meningitis appearancetransparent transparent or slightly cloudy cloudy Ground glass alike pressure(cm H 2 O) 5-12 may be elevated >20 pleocytosis /L 0~8 x 10 6 50~50 0×106/ L >1000 x 10 6 100-500 x 10 6 protein (g/L) 0.15~0.45 may be elevated mildly ~1 1~2 ou >2 glucose (mmol/L) 2.8~4.2normal↓↓ ( mmol/L ) ( mmol/L )120~130normal↓↓ smear--++

34. Laboratory Findings  Immunologic test antigen antigen antibody antibody  Other  CSF-β2M globin  LLT

35. E.C.M  Diagnosis and differential diagnosis –diagnosis  season ， suddenly high fever ， headache ， vomiting  petechia ， meningeal irritation  blood 、 CSF tests ， bacteria culture –differential diagnosis  Other purulent meningitis  TB meningitis,Epidemic encephalitis B,etc  Septicemia

36. Treatment  Common type –General treatment –Pathogenic treatment ： 1.penicillin G 2.Chloramycin: 3.Ceftriaxone,Cefotaxime –symptomatic therapy ： defervescense 退热， Decrease intracranial hypertension 降颅压

37. Treatment  Fulminant type –Shock form ： 1.pathogenic therapy 2.Anti-shock 3.Steroid, hydrocoticosterone, etc 4.Anti-DIC 5.Protect major organs

38. Treatment  Fulminant type Meningoencephalitis type - Meningoencephalitis type 1. Antibiotics 2. Decrease intracranial hypertension ， prevent 2. Decrease intracranial hypertension ， prevent brain hernia 3. Steroid 4. Anti-respiratory failure 5. Symptomatic treatment: management of fever,convulsion 惊厥

39. Prevention  Isolation source of infection  Cut the route of transmission  Protect susceptible population 1.Chemoprophylaxis: SMZ CO or Rifampicin 2. Vaccination