Otogenous diffuse purulent meningitis

Otogenny diffuse purulent meningitis (leptomeningitis) - inflammation of the soft and arachnoid shells of the brain with the formation of purulent exudate and increased intracranial pressure.

On the basis of the predominant localization of the process, otogenic purulent meningitis belongs to the basal, that is, it is characterized by the defeat of the skull and brain base shells involving the roots of the cranial nerves.

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Pathogenesis of otogenic disseminated purulent meningitis

With leptomeningitis, the inflammatory process spreads to the brain substance, encephalitis develops. In children, brain tissue suffers more than adults, so they are more often diagnosed with diffuse purulent meningoencephalitis.

Symptoms of otogenous diffuse purulent meningitis

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

For otogennogo meningitis are characterized by such symptoms of meningitis acute onset, fever (up to 39-40 C), having a remitting or hectic character, tachycardia, increasing weight loss patient. The general condition of the patient is severe. There is a psychomotor agitation or a clouding of consciousness, delirium. The patient lies on his back or on his side with his head thrown back. The position lying on the side with the head thrown back and the legs bent is called the pose of the "rifle trigger" or "the dog". Extension of the head and flexion of the limbs are due to irritation of the meninges.

The patient is disturbed by severe headache, nausea and vomiting. These symptoms refer to the symptoms of central genesis and are associated with increased intracranial pressure. Headache is aggravated by exposure to light, sound, or touch to the patient.

Classification of otogenous diffuse purulent meningitis

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

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Diagnosis of otogenic diffuse purulent meningitis

The diagnosis is confirmed in the presence of meningeal symptoms (rigidity of the occipital muscles, Kernig symptom, upper and lower symptom of Brudzinsky) due to irritation of the posterior roots of the spinal cord.

With meningitis, stiff neck may manifest as a slight difficulty in tilting the head to the chest, and a complete absence of neck flexion and opisthotonus.

The symptom of Kernig is the impossibility of passive extension of the leg, previously bent at right angles in the hip and knee joints.

The upper symptom of Brudzinsky is manifested involuntary bending of the legs and pulling them to the stomach while examining the rigidity of the occipital muscles.

The lower symptom of Brudzinsky consists in involuntary bending of the leg in the hip and knee joints with the passive bending of the other leg in the same joints.

The development of encephalitis is diagnosed with the appearance of reflexes indicative of the defeat of the pyramidal pathway (reflexes of Babinsky, Rossolimo, Zhukovsky, Gordon, Oppenheim).

In severe disease, damage to the cranial nerves and, in connection with this, the emergence of focal neurological symptoms. Most often, the function of the abducens nerve suffers (paralysis of the oculomotor muscles occurs). In 1/3 of patients there are changes on the fundus.

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

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Laboratory research

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

The basis of diagnosis is the study of cerebrospinal fluid. Important information can be obtained already with its external osmigra. The presence of even a slight turbidity testifies to pleocytosis - the increased content of cellular elements (more than 1000x10 ⁶ / l) in cerebrospinal fluid (norm of 3-6 cells / μl). The height of pleocytosis is judged on the clinical form of meningitis. Serous meningitis in the cerebrospinal fluid contains up to 200-300 cells / mm3, in serous-purulent cases their number reaches 400-600 cells / mm3, with an increase in the number of leukocytes in excess of 600x10 ⁶ / l, meningitis is considered purulent. It is also important to study the leukocyte formula of cerebrospinal fluid. The predominance of neutrophilic leukocytes in the formula indicates a progression of the process, while the increase in lymphocyte and eosinophil content is a reliable sign of stabilization of the process, the predominance of the mechanisms of sanitation.

With meningitis, there is an increase in the pressure of the cerebrospinal fluid (normally it is 150-200 mm of water). And it flows out of the needle at a rate of 60 drops per minute. It increases the protein content (norm 150-450 mg / l), reduces the amount of sugar and chlorides (sugar norm 2.5-4.2 mmol and chlorides 118-132 mmol / l), positive globulin reactions of Pandi and Nonne-Aielt . When sowing cerebrospinal fluid, microorganisms grow.

Instrumental research

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

In cerebral angiography, the main signs of the subdural abscess are the presence of the avascular zone, the displacement of the anterior cerebral artery and the opposite side and the displacement of the angiographic sylvia point, the severity of the dislocation changes of the vessels from the volume and localization of the subdural abscess.

Subdural abscesses with KT and MRI are characterized by the presence of foci of convex-concave (semilunar) shape, with an uneven internal surface that repeats the outlines of the brain relief, pushing the brain away from the inner layer of the dura mater. With KT, the density of the subdural abscess is in the range +65 ... + 75 HU.

Differential diagnostics

Otogenic meningitis, unlike epidemic cerebrospinal meningitis, develops slowly. Gradually appear and grow meningeal symptoms, the general condition may not correspond to the severity of the pathological process. Determination of the nature and composition of cerebrospinal fluid is one of the main methods of early diagnosis, assessment of the severity of the disease and its dynamics.

Children from exposure to toxins on the meninges can experience serous meningitis in the absence of bacteria in the cerebrospinal fluid.

An increase in the pressure of the cerebrospinal fluid is accompanied by a moderate and pleocytosis and the absence or weakly positive reaction to the protein.

In acute purulent otitis media, children sometimes have fulminant forms of meningitis. Differential diagnosis is carried out with epidemic cerebrospinal, serous viral and tuberculous meningitis. For epidemic cerebrospinal meningitis is characterized by a rapid onset and the 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, and the normal otoscopic picture are evaluated. Tuberculous serous meningitis is more common in children, differs sluggish course, combined with tuberculosis lesions of other organs. Its characteristic feature is precipitation of tender fibrin film after settling of cerebrospinal fluid for 24-48 hours. With tubercular and serous viral meningitis, moderate (predominantly lymphocytic) pleocytosis is observed. With tuberculous meningitis, the number of cells is up to 500-2000 cells / mm3, which is somewhat higher than in viral (up to 200 300 cells / μl). Tuberculosis meningitis is usually accompanied by a decrease in sugar and liquor, and with viral sugar content is usually normal.

[10], [11], [12], [13], [14],