tuberculous meningitis in the elderly
Introduction
Introduction to tuberculous meningitis in the elderly Tuberculous meningitis (tuberculous meningitis) is called non-suppurative inflammation caused by MTB invading the meninges. As part of the disseminated miliary tuberculosis, it can also be secondary to bacteremia caused by tuberculosis such as lung, lymph nodes, bones or urinary system. In addition, MTB can also directly break into the skull from tuberculosis lesions of the skull or spine. Or tuberculous meningitis in the spinal canal. Whether MTB invades the central nervous system after blood flow can affect the number of invasive MTB, and the virulence is closely related to the body's reactivity and resistance. According to the main pathological changes and invasion, the clinical pathology is divided into simple meningitis type, skull base adhesion meningitis type, meningoencephalitis type and spinal type. Tuberculous meningitis is more common in children, but currently more than half of the patients are adults. 3/4 of adult nodules have adult primary lesions. The mortality rate of encephalopathy is between 15% and 30%. basic knowledge The proportion of sickness: 0.01% Susceptible people: the elderly Mode of infection: respiratory transmission Complications: brain edema, cerebral embolism, hydrocephalus, cerebral palsy
Cause
The cause of tuberculous meningitis in the elderly
(1) Causes of the disease
Tuberculous meningitis is a non-suppurative meningitis caused by Mycobacterium tuberculosis, often associated with primary tuberculosis infections in other parts of the body, especially tuberculosis and acute miliary tuberculosis, others such as lymphatic tuberculosis, intestinal tuberculosis, Bone tuberculosis, kidney tuberculosis, etc. may also be associated.
(two) pathogenesis
Due to the recurrence of tuberculosis and the spread of cheese lesions near the meninges, tubercle bacilli can spread to the meninges with the blood in the miliary tuberculosis. The main pathological changes are the extensive chronic inflammation of the meninges, the subarachnoid space, especially the brain base. The pool is filled with viscous exudate, blocking the cerebrospinal fluid circulation pathway causing hydrocephalus and increased intracranial pressure, vascular inflammation and thrombosis leading to cerebral infarction.
Prevention
Elderly tuberculous meningitis prevention
Primary prevention
(1) Establish a prevention and control system: establish and improve the prevention and control institutions at all levels, be responsible for organizing and implementing the system of management, management, and overall management, and formulate prevention and treatment plans according to the epidemic and epidemiological characteristics of the region, and carry out education and training. Good living habits, training technicians in tuberculosis prevention and treatment, and promoting social participation and support for tuberculosis prevention planning and implementation.
(2) Early detection and thorough treatment of patients who have been discovered: Case finding mainly relies on symptomatic treatment, timely detection and diagnosis of tuberculosis patients to avoid missed diagnosis and misdiagnosis, must be "detected must cure, the rule must be thorough", must be thoroughly Treating patients, especially infectious patients, can greatly reduce the infection source density and effectively reduce the infection rate and reduce the incidence.
2. Secondary prevention Early detection of tuberculosis patients and timely treatment to prevent the bacteria and slow down.
(1) Early detection: Strengthen health promotion, popularize knowledge about tuberculosis prevention, and make the people do self-examination and mutual supervision. Once suspicious persons are found, they will go to the hospital immediately. This is beneficial to the patients themselves and the whole society. It is early An effective means of discovery and early treatment.
(2) Early treatment: The treatment of tuberculosis includes the following aspects: rational use of anti-tuberculosis drugs to kill and inhibit bacteria, so that the lesions heal; surgical removal of destructive lesions, prevention and treatment of disease dissemination or infection; symptomatic treatment .
3. Three levels of prevention
The prevention is based on secondary prevention. Timely treatment can reduce the incidence of complications. The complications of tuberculosis are:
1 large area of double tuberculosis function is extensively damaged, leading to bronchiectasis secondary to secondary lung infection, both of which can lead to further impairment of function and even respiratory failure.
2 Chronic fibrovascular tuberculosis caused by long-term recurrent episodes further affects pulmonary function.
3 large area of pleural adhesion is caused by improper treatment of tuberculous pleurisy, can cause restrictive ventilation dysfunction, and even pulmonary heart disease and respiratory failure. Therefore, the prevention of recurrence of tuberculosis is the key to tertiary prevention, which requires clinicians to treat Strictly follow the principles of early, regular, appropriate, combined, and full use of sensitive drugs, treat patients, and strengthen supervision, so that the tuberculosis patients' disease procedures are minimized, and the serious adverse consequences caused by recurrence are prevented. Due to the lack of timely or inappropriate diagnosis and treatment, the tuberculosis patients should be reduced in disease procedures as much as possible. On the basis of preventing further development of the lesions, the existing pulmonary heart function should be preserved, and the potential compensatory capacity should be fully utilized to enable the patients to reach Functional rehabilitation.
For those who are sick and disabled due to tuberculosis, the society should take care of and guide them. Firstly, they should properly isolate and supervise the use of drugs, and strive to control the bacteria in the intensive treatment process. On this basis, it is necessary to publicize to the society and the family. Enlisting social and family care and help, strengthening patient function training and nutritional support are long-term and complicated tasks, which require the participation of family members. Psychological rehabilitation is an easily overlooked problem for tuberculosis patients. Medical workers It is the responsibility to explain the pathogens, pathogenesis, transmission routes, treatment intended and current treatment effects of tuberculosis to patients in order to eliminate some unnecessary psychological concerns of patients, and to explain to them the purpose of appropriate isolation measures Limit, and explain that tuberculosis is a communicable disease that can be basically controlled, and build confidence in patients to overcome the disease, which is beneficial for patients to actively cooperate with early rehabilitation.
Complication
Elderly tuberculous meningitis complications Complications brain edema cerebral embolism hydrocephalus cerebral palsy
Concurrent cerebral edema, cerebral embolism, hydrocephalus, cerebral palsy and so on.
Symptom
Elderly tuberculous meningitis symptoms common symptoms fatigue disturbance disorder low heat meningeal irritation sign increased intracranial pressure loss of appetite meningitis coma tremor edema
The course of the disease is subacute and chronic, with early manifestations of hypothermia, headache, fatigue, loss of appetite, mental abnormalities, personality changes, development of consciousness disturbance after a few weeks, coma, meningeal irritation, cranial nerve palsy, optic disc edema, fashion Tremor and involuntary movement, increased intracranial pressure is more common, often accompanied by hydrocephalus.
Examine
Examination of tuberculous meningitis in the elderly
Blood picture
White blood cells can be moderately increased in the early stage, neutrophils increase, and erythrocyte sedimentation rate increases.
2. Tuberculin test
Intradermal injection of tuberculin (PPD) 1TU (0.02 g) or 5 TU (0.1 g) of pure protein derivative is positive in the early stage, and some cases may be negative due to low immunity or severe disease.
3. Cerebrospinal fluid examination
It is of great significance for the diagnosis of the brain.
(1) Increased pressure: often in 2.16 ~ 3.72kPa (220 ~ 380mmH2O), very few more than 4.9kPa (500mmH2O), late due to inflammatory adhesions, spinal canal obstruction and low pressure.
(2) Visual observation: early cerebrospinal fluid is colorless and transparent, with slight turbidity or ground glass in the middle and late stage. It is orange yellow or light yellow when there is bleeding or bleeding. A few can be bloody. The cerebrospinal fluid specimen is placed in the refrigerator for 24 hours, showing a typical funnel shape. Film formation.
(3) pH value: The pH value of cerebrospinal fluid is reduced and acidic.
(4) The number of cells is moderately increased: the number of cells is (100-500)×106/L, lymphocytes predominate, neutrophils are dominant in the acute phase or worsening phase, and a certain number of red blood cells exist in the total number of cells. Concurrent meninges, cerebral vascular tuberculous vasculitis (necessary exclusion of lumbar puncture trauma), a small number of brain caused by acute miliary tuberculosis, early cerebrospinal fluid is mild turbidity, white blood cell count up to 1000 × 106 / L, Mainly neutrophils.
(5) Increased total protein: total protein is 0.5-5g/L, most cases are 13g/L. Pandy qualitative test positive test indicates that globulin is increased. If the total amount of protein is significantly increased, it often indicates cerebrospinal fluid circulatory disorder. The presence of yellowing suggests a spinal canal obstruction.
(6) Progression period: glucose content <2.24mmol / L, while measuring blood sugar levels, cerebrospinal fluid / blood sugar content < 1: 2, gradually recover with the improvement of the condition, if the amount of sugar is still low, suggesting a poor prognosis.
(7) low chloride content: often <115mmol / L, progressive progressive reduction with the progress of the disease, cerebrospinal fluid sugar and chloride reduction is a typical performance of the brain, and the chloride content is more sensitive than the reduction of sugar, is also An important indication for the recurrence of the brain.
(8) Determination of adenosine deaminase (ADA): The upper limit of normal cerebrospinal fluid is 100.0~133.4 nmol/(L·s) (6-8 U/L), and the level of ADA in patients with brain formation is increased to >166.7 nmol/( L·s) (10U/L), the positive rate is about 90%, and the ADA value of other bacterial meningitis is not significantly increased.
(9) Tuberculosis test: It is the gold standard for the diagnosis of brain-binding test. It is decisive for the diagnosis. The positive rate of general smear is 15%~30%, the positive rate of culture is 30%~40%, and the cerebrospinal fluid is taken 5ml, 3000r. Centrifugation for 30 min/min, sediment smear examination, or thick smear from the cerebrospinal fluid film after standing to check the tuberculosis can increase the positive rate, culture, animal vaccination is used as the basis for the final diagnosis.
Recently, there are domestic reports on the use of polymerase chain reaction (PCR), dot enzyme immunofiltration (DIEFA) and rapid immunochromatographic test card (ICAT) to detect the diagnostic value of CSF for nodulation. The antigen of the bacteria, the latter two for the detection of tuberculosis antibodies, and the non-conjunctival patients with the control test, the tuberculosis CSF, the sensitivity is higher, the specificity is stronger, but the PCR affects more factors, and the DIEFA method and ICAT Rapid detection of brain CSF antibodies has important application value.
X-ray inspection:
4. Head CT CT can show the location, extent and certain properties of the brain lesions, which can help to judge the pathological type of the brain, the disease stage and the comorbidities, can guide the choice of treatment methods, evaluate the curative effect, and predict the prognosis. Valuable clinical examination methods.
(1) The performance of exudate: the brain pool and the lateral cerebral ventricle at the bottom of the brain lose transparency, and the density is dense. The obvious shadow is a special manifestation of the brain CT, and the enhanced scanning density is enhanced.
(2) The manifestation of cerebral edema: for the area where the density of the large piece is reduced, it can also be seen in the peripheral part of the lesion, or the hydrocephalus is around the ventricle, and the enhanced scan image is unchanged.
(3) Inflammatory lesions of the brain parenchyma: The miliary tuberculosis is a small isobaric or low-density nodule, and the enhanced scan image is enhanced.
(4) The performance of tuberculoma: high-density, equal-density or low-density lesions, single or multiple ring-shaped, disc-shaped shadows merge into irregular masses, enhanced scanning shows a bead-like ring density increase It is a characteristic change of tuberculoma, and its occupying volume can cause displacement of surrounding tissue structure.
(5) The manifestations of cerebral infarction: the plain lesion showed a low-density area, and the intensive scan was still a low-density area for cerebral infarction.
(6) hydrocephalus performance: different parts, varying degrees of ventricular dilatation with brain parenchyma compression.
5. Cerebral angiography
The diagnosis, location and scope of cerebral infarction have a positive significance.
6. Chest X-ray examination
Tuberculosis was found to help diagnose the brain.
Diagnosis
Diagnosis and diagnosis of tuberculous meningitis in the elderly
Diagnostic criteria
The diagnosis of tuberculous meningitis is difficult, and elderly patients are more difficult due to symptoms and atypical signs, but the following points can be used as a basis for diagnosis.
1. Close history of tuberculosis exposure, tuberculosis in the lungs and other areas.
2. Subacute meningitis and tuberculosis blood symptoms, prominent intracranial pressure, and other focal symptoms and signs.
3. Cerebrospinal fluid examination showed a change in tuberculous meningitis.
4. The most characteristic examination is the anti-acid staining smear of cerebrospinal fluid to find acid-fast bacilli, but the positive rate is low, and it can also be used for CSF tuberculosis PCR and anti-nuclear antibody examination.
5. CT scan can find obstructive hydrocephalus, the basal pool is cast-type strengthening, and some patients may have infarcts in the basal ganglia.
Differential diagnosis
Tuberculous meningitis often needs to be differentiated from other meningitis.
