1、TUBERCULOUS MENINGITIS,结核性脑膜炎,Longnan Hospital Chenjing,第一页，共六十八页。,Tuberculous meningitis is an infection of the membranes 膜covering the brain and spinal cord(meninges).Tuberculosis(TB)is caused by the bacterium Mycobacterium tuberculosis结核分枝杆菌 and is annually responsible for nearly two million deat
2、hs worldwide.A third of the worlds population is currently infected with the TB bacillus,and more than eight million new cases are diagnosed each year.,第二页，共六十八页。,Tuberculous meningitis must be considered in patients who present with a confusional state,especially if there is a history of pulmonary
3、tuberculosis,alcoholism,corticosteroid treatment,HIV infection,or other condition associated with impaired immune responses.,第三页，共六十八页。,It should also be considered in patients form areas(eg,Asia,Africa)or groups(eg,the homeless and inner-city drug users)with a high incidence of tuberculosis.,第四页，共六
4、十八页。,Causes,Risk factors include a history of:AIDS Excessive alcohol use Pulmonary tuberculosis Weakened immune system,第五页，共六十八页。,第六页，共六十八页。,第七页，共六十八页。,第八页，共六十八页。,Pathogenesis&Pathology发病机制&病理,Tuberculous meningitis usually results from reactivation of latent infection with mycobacterium tuberculosi
5、s.结核性脑膜炎多是由于潜伏的结核杆菌复发感染引起的。,第九页，共六十八页。,Primary infection,typically acquired by inhaling bacillus containing droplets,may be associated with metastatic dissemination of blood-borne bacilli from the lungs to the meninges and surface of the brain.Here the organisms remain in a dormant state in tubercle
6、s that can rupture into the subarachnoid space at a later time,resulting in tuberculous meningitis.,原发性感染，尤其是通过吸入含菌颗粒引起的感染，可能与血源性细菌从肺部到脑膜及大脑外表的播散有关。此处的致病菌在结核结节中处于休眠状态，后期可破入蛛网膜下腔，并导致结核菌性脑膜炎。,第十页，共六十八页。,主要发现是含有大量单核细胞的脑基底部脑膜分泌物。脑膜及脑外表可见结核结节。,The main finding is a basal meningeal exudate渗出物containing pr
7、imarily mononuclear cells.Tubercles may be seen on the meninges and surfaces of the brain.,第十一页，共六十八页。,The ventricle may be enlarged as a result of hydrocephalus,and their surfaces may show ependymal exudate or granular ependymitis.Arteritis can result in cerebral infarction,and basal inflammation a
8、nd fibrosis can compress cranial nerves.,脑积水可引起脑室扩大，并且脑室外表可有大量室管膜渗出物或颗粒状室管膜炎。动脉炎可导致脑堵塞，而颅底部炎症反响和纤维化可压迫神经。,第十二页，共六十八页。,Acute tuberculous meningitis with marked involvement of the vessel walls and occlusion of smaller vessels.The vascular involvement can result in infarction.,第十三页，共六十八页。,第十四页，共六十八页。,第
9、十五页，共六十八页。,Clinical Findings,A.SYMPTOMSSymptoms have usually been present for less than 4 weeks at the time of presentation and include fever,lethargy昏睡 or confusion,and headache.Weight loss,vomiting,neck stiffness,visual impairment,diplopia 复视,focal weakness,and seizures may also occur.A history of
10、 contact with known cases of tuberculosis is usually absent.,第十六页，共六十八页。,B.SIGNS,Fever,signs of meningeal irritation脑膜刺激征,and a confusional state are the most common findings on physical examination,but all may be absent.Papilledema视乳头水肿,ocular palsies眼肌麻痹,and hemiparesis轻偏瘫 are sometimes seen.,第十七页
11、，共六十八页。,Complications include spinal subarachnoid block脊髓蛛网膜下腔梗阻,hydrocephalus脑积水,brain edema脑水肿,cranial never palsies颅神经麻痹,and stroke caused by vasculitis or compression of blood vessels at the base of the brain因血管炎或颅底血管受压导致的卒中.,第十八页，共六十八页。,结核球,第十九页，共六十八页。,stroke,第二十页，共六十八页。,hydrocephalus,第二十一页，共六十
12、八页。,Laboratory Findings,Only one-half to two-third of patients show a positive skin test for tuberculosis or evidence of active or healed tubercular infection on chest x-ray.,第二十二页，共六十八页。,CSF,The diagnosis is established by CSF analysis.CSF pressure is usually increased,and the fluid is typically cl
13、ear and colorless but may form a clot upon standing.Lymphocytic and mononuclear cell pleocytosis of 50-500 cells/mL is most often seen,but polymorphonuclear 多形核细胞pleocytosis can occur early and may give an erroneous impression of bacterial meningitis.CSF protein is usually more than 100 mg/dL,partic
14、ularly in patients with spinal subarachnoid block.The glucose level is usually decreased and may be less than 20 mg/dL.,第二十三页，共六十八页。,Acid-fast smears抗酸染色涂片 of CSF should be performed in all cases of suspected tuberculous meningitis,but they are positive in only a minority of cases.,第二十四页，共六十八页。,Defi
15、nitive diagnosis is most often made by culturing M tuberculosis from the CSF,a process that usually takes several weeks and requires large quantities of spinal fluid for maximum yield.,第二十五页，共六十八页。,第二十六页，共六十八页。,第二十七页，共六十八页。,The polymerase chain reaction(PCR)聚合酶链反响 has also been used for diagnosis.,第
16、二十八页，共六十八页。,Finally,the CT scan may show contrast enhancement of the basal cisterns and cortical meninges,or hydrocephalus.,第二十九页，共六十八页。,MRI appearance of the typical pattern of central nervous system tuberculous meningitis,第三十页，共六十八页。,Differential Diagnosis,Many other conditions can a subacute confusional state with mononuclear cell单核细胞 pleocytosis 脑脊液细胞增多,including syphilitic 梅毒的,fungal,neoplastic 肿瘤的,and partially treated bacterial meningitis.These can be diagnosed by appropriate smears 涂片,cu