Otogenic spilt purulent meningitis.

Otogenic diffuse purulent meningitis (leptomeningitis) is an inflammation of the pia and arachnoid membranes of the brain with the formation of purulent exudate and increased intracranial pressure.

Based on the predominant localization of the process, otogenic purulent meningitis is classified as basal, that is, it is characterized by damage to the membranes of the base of the skull and brain with the involvement of the roots of the cranial nerves.

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Pathogenesis of otogenic diffuse purulent meningitis

In leptomeningitis, the inflammatory process spreads to the brain tissue, and encephalitis develops. In children, brain tissue suffers to a greater extent than in adults, so they are more often diagnosed with diffuse purulent meningoencephalitis.

Symptoms of otogenic diffuse purulent meningitis

Meningitis symptoms and the overall clinical picture of a typical form of meningitis consist of general cerebral and meningeal syndromes. In turn, meningeal syndrome consists of symptoms of irritation of the meninges and characteristic inflammatory changes in the cerebrospinal fluid.

Otogenic meningitis is characterized by the following symptoms of meningitis: acute onset, fever (up to 39-40 C), which is remittent or hectic in nature, tachycardia, and increasing weight loss of the patient. The general condition of the patient is severe. Psychomotor agitation or clouding of consciousness, delirium are observed. The patient lies on his back or on his side with his head thrown back. The position of lying on his side with his head thrown back and his legs bent is called the "gun trigger" or "pointer dog" pose. Extension of the head and flexion of the limbs are caused by irritation of the meninges.

The patient is bothered by severe headache, nausea and vomiting. These symptoms are related to symptoms of central genesis and are associated with increased intracranial pressure. The headache intensifies when exposed to light, sound or touching the patient.

Classification of otogenic diffuse purulent meningitis

For practical purposes, purulent meningitis can be divided into acute, chronic, and recurrent. Each of these types is associated with a specific type of microorganism and has its own clinical manifestations.

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Diagnosis of otogenic diffuse purulent meningitis

The diagnosis is confirmed by the presence of meningeal symptoms (stiff neck, Kernig's sign, upper and lower Brudzinski's sign) caused by irritation of the posterior roots of the spinal cord.

In meningitis, rigidity of the occipital muscles can manifest itself as either mild difficulty in tilting the head toward the chest, or complete lack of neck flexion and opisthotonus.

Kernig's symptom is the inability to passively extend the leg, previously bent at a right angle at the hip and knee joints.

The upper Brudzinski symptom is manifested by involuntary bending of the legs and pulling them towards the stomach when examining the rigidity of the occipital muscles.

Brudzinski's lower symptom consists of involuntary flexion of the leg at the hip and knee joints with passive flexion of the other leg at the same joints.

The development of encephalitis is diagnosed when reflexes appear that indicate damage to the pyramidal tract (Babinski, Rossolimo, Zhukovsky, Gordon, Oppenheim reflexes).

In severe cases of the disease, cranial nerves may be affected and, in this connection, focal neurological symptoms may appear. Most often, the function of the abducens nerve suffers (paralysis of the oculomotor muscles occurs). 1/3 of patients have changes in the fundus.

Atypical forms of meningitis are characterized by the absence or weak expression of meningeal symptoms. Meningitis symptoms in adults are atypical against the background of a severe condition and high pleocytosis of the cerebrospinal fluid. This form of the process ("meningitis without meningitis") is typical for weakened, exhausted patients and indicates an unfavorable prognosis.

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Laboratory research

In the blood - pronounced neutrophilic leukocytosis, reaching 10-15x10 ⁹ /l. shift of the formula to the left, sharp increase in ESR.

The basis of diagnosis is the study of cerebrospinal fluid. Important information can be obtained even with its external osmiagra. The presence of even a slight turbidity indicates pleocytosis - an increased content of cellular elements (more than 1000x10 ⁶ /l) in the cerebrospinal fluid (the norm is 3-6 cells / μl). The height of pleocytosis is used to judge the clinical form of meningitis. In serous meningitis, the cerebrospinal fluid contains up to 200-300 cells / μl, in serous-purulent meningitis their number reaches 400-600 cells / μl, with an increase in the number of leukocytes over 600x10 ⁶ /l, meningitis is considered purulent. The study of the leukocyte formula of the cerebrospinal fluid is also important. The predominance of neutrophilic leukocytes in the formula indicates the progression of the process, while an increase in the content of lymphocytes and eosinophils is a reliable sign of stabilization of the process and the predominance of sanation mechanisms.

In meningitis, there is an increase in the pressure of the cerebrospinal fluid (normally it is 150-200 mm H2O) and it flows out of the needle at a rate of 60 drops per minute. The protein content in it increases (normal 150-450 mg/l), the amount of sugar and chlorides decreases (normal sugar is 2.5-4.2 mmol and chlorides 118-132 mmol/l), the Pandy and Nonne-Eielt globulin reactions become positive. When sowing cerebrospinal fluid, growth of microorganisms is detected.

Instrumental research

The most informative methods for diagnosing subdural abscesses are cerebral angiography, CT and MRI.

In cerebral angiography, the main signs of a subdural abscess are the presence of an avascular zone, displacement of the anterior cerebral artery to the opposite side and displacement of the angiographic Sylvian point; the severity of dislocation changes in the vessels depends on the volume and localization of the subdural abscess.

Subdural abscesses in CT and MRI are characterized by the presence of foci of a convex-concave (crescent) shape, with an uneven internal surface, repeating the contours of the brain relief, displacement of the brain from the inner layer of the dura mater. In CT, the density of the subdural abscess is within +65... +75 HU.

Differential diagnostics

Otogenic meningitis, unlike epidemic cerebrospinal meningitis, develops slowly. Meningeal symptoms gradually appear and increase, the general condition may not correspond to the severity of the pathological process. Determining the nature and composition of the cerebrospinal fluid is one of the main methods of early diagnosis, assessing the severity of the disease and its dynamics.

In children, exposure of the meninges to toxins may result in serous meningitis in the absence of bacteria in the cerebrospinal fluid.

Increased cerebrospinal fluid pressure is accompanied by moderate pleocytosis and absent or weakly positive protein reaction.

In acute purulent otitis media in children, fulminant forms of meningitis are sometimes encountered. Differential diagnostics are carried out with epidemic cerebrospinal, serous viral and tuberculous meningitis. Epidemic cerebrospinal meningitis is characterized by a rapid onset and detection of meningococci in the cerebrospinal fluid. When diagnosing cerebrospinal and viral meningitis, the epidemic situation, the presence of catarrhal phenomena in the upper respiratory tract are assessed, and the normal otoscopic picture is also taken into account. Tuberculous serous meningitis is more common in children, is characterized by a sluggish course, and is combined with tuberculous lesions of other organs. Its characteristic sign is the precipitation of a delicate fibrin film after settling the cerebrospinal fluid for 24-48 hours. In tuberculous and serous viral meningitis, moderate (mainly lymphocytic) pleocytosis is observed. In tuberculous meningitis, the number of cells is up to 500-2000 cells / μl, which is slightly more than in viral (up to 200-300 cells / μl). Tuberculous meningitis is usually accompanied by a decrease in sugar in the cerebrospinal fluid, and in viral meningitis, the sugar content is often normal.

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