中枢神经感染.pptx

中樞神經感染奇美醫學中心神經外科郭進榮定義影響它的覆蓋物,叫做 腦膜炎 meningitis影響腦實質組織,叫做腦炎 encephalitis影響脊髓,叫做 脊髓炎 myelitis如果所有都受影響的,meningoencephalomyelitis在腦子或脊髓之內那裡也許是 膿瘍(abscess),並且在他們之外也許是硬膜外膿腫或subdural 蓄膿(empyema)腦膜炎(Menigitis)指軟細腦膜發炎,常侵犯蜘蛛膜軟腦及蜘蛛膜下腔感染途徑及病源體1.感染途徑 .臨近器官之直接侵入 .它處有感染經血行性散播2.常見菌種 .嬰兒期(Infant),1個月內 -E.coli .孩童(Children)-H.influenzae流行性噬血桿菌 .成人(Adult):S.pneumoiae肺炎鏈球菌S.pneumoniae (肺炎鏈球菌)成年人最常見的腦膜炎致病菌成對的葛蘭氏陽性菌鼻咽為此菌最常見的地方冬天常見死亡率21%Hemophilus-influenzae 流行性噬血桿菌小的革蘭氏陰性球菌(1-2micrometer diameter)由飛沫或呼吸道分泌物傳染病毒性腦膜炎Sign and symptoms Headache Fever Viral syndrome Meningismus最常見的腦膜炎最良性的腦膜炎較少有局部神經學症狀，且少留下併發症 Mycobacterium tuberculosis 結核菌CSF 內淋巴球多蛋白質增加糖分減少結核菌培養約六成陽性治療至少須半年至一年影像學檢查可發現meninges 顯影,水腦三合一結核菌治療腦膜炎臨床症狀1.脖子僵硬 (Neck stiffness)2.畏光3.Kernigs sign4.Brudzinskis neck sign5.發燒腰椎穿刺(Lumbar puncture)腰椎穿刺(Lumbar puncture)診斷腦膜炎最有價值檢查腰椎穿刺之解讀化膿性結核性病毒性外觀混濁半透明至混濁清澈有時混濁壓力(mmH20)極度上升（200-700)中度上升(200-450)中度上升(200-350)細胞(個/mm3)多型性白血球(1000-5000)單核球與多型性白血球混合單核球少見多型性白血球蛋白質(mg/dl)100-500,有時大於1000100-400100-500,很少超過500葡萄糖(mg/dl)40或 血糖之一半 50正常腰椎穿刺之禁忌症顱內有腫塊(腫瘤或血塊等)有出血傾向者有脊椎硬膜上膿瘍腰椎穿刺之可能併發症頭痛感染出血神經傷害Fungus meningitis黴菌腦膜炎隱球菌最常見(cryptococcus neoformans)高危險群AIDS器官移植糖尿病India Ink test postive for cryptococcus infection與鴿糞有關治療用Amphotericin B,Fluconazole水腦是最常見的併發症腦膿瘍(Brain abscess)1.可由臨近器直接擴散 2.可由遠方感染源經血液傳播 3.電腦斷層可見打藥後環形顯影影像 (ring enhancement)4.腰椎穿刺不一定可知感染源腦膿瘍(Brain abscess)診斷局部神經學症狀及癲癇表示腦部局部病灶高危險群先天性心臟病併右向左分流細菌性心內膜炎肺膿瘍及肺擴張不全鼻竇炎打藥的CT或MRI可顯現出環狀顯影的影像且周邊水腫立體定位切片確定診斷預後預後病毒性以降腦壓及支持療法為主，只有少數病毒有抗病毒藥物；細菌性需使用抗生素治療，二者皆需注意合併症。細菌性腦炎若感染嚴重極易造成神經系統損傷、聽力喪失，甚至危及生命。大部分單純的非細菌性腦膜炎經過支持性療法後，預後都相當不錯。隱形球菌(Cryptococcus)鴿子6.細菌性腦膜炎在嬰兒期(Infant)最常見菌種 1.E.coli 2.Pneumococcus 3.Meningococcus 4.Listeria monocytogens7.腦膜炎臨床症狀不包括 1.脖子僵硬(Neck stiffness)2.嗜光 3.Kernigs sign 4.發燒8.診斷腦膜炎最有價值檢查為 1.腰椎穿刺 2.電腦斷層 3.血管攝影 4.腦波 9.腦膜炎是指何層腦膜發炎 1.硬腦膜 2.蜘蛛膜 3.軟腦膜 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