Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
30.08.2026
Размер:
51 Мб
Скачать
☆
extratesticularcomplicationofmumps.
Infectious(Non-viral)Causes.Otherinfectiouscausesofasepticmeningitisincludespirochetal infections,fungalinfections,tuberculosis(TB),andparasiticinfections.Notethat,althoughspirochetes andtuberculosisarebacteria,routinebacterialcultureswillbenegativeandthustheseinfectionsare,in thissetting,consideredaseptic.
SpirochetalinfectionsincludeLymedisease,syphilis,andleptospirosis.
Borreliaburgdorferi,whichcausesLymedisease,producesalymphocyticmeningitisthatistypicallyseenseveralweeksafter theappearanceoftheinitialrashoferythemamigrans(seepage223formoreinformationabouttheneurologicmanifestationsof Lymedisease). Syphiliticmeningitis,causedby Treponemapallidum,tendstooccurin thesettingofsecondarysyphilis andisoftenassociated withadisseminatedrash(seepage220formoreinformationaboutsyphilis). Leptospirosis,causedbyLeptospiraspirochetesthatpreferwarmclimates,isacquiredthroughexposuretocontaminatedwater orsoil.Ittendstopresentwith theabrupt onsetoffever, myalgias,andheadache;meningitisisobservedinover50%ofthose infected.
https://t.me/med1917
Thecorkscrew-appearingBorreliaburgdorferi,asseenbydarkfieldmicroscopy.(ReprintedfromStrohl WA,RouseH,FisherBD.Lippincott’sIllustratedReviews:Microbiology.LippincottWilliams&Wilkins;
2001.)
Amongthefungi,themajorculpritsarecryptococcusandcoccidioides.
Cryptococcus,anencapsulatedbuddingyeast,isaleadingcauseofmeningitisamongpatientswithHIVandthosewhoarefor anyreasonseverelyimmunocompromised.Infectionpresentsindolently,evolvingoveraperiodofseveralweeks,oftenwithsigns andsymptomsofelevatedintracranialpressure(thefungal capsules cancloguptheventricularsystem,preventing normalCSF outflow).CSFanalysisisnotableforanelevatedopeningpressureandapositivecryptococcalantigen.Amildlymphocytosisand elevatedproteinarecommonbutnotalwayspresent;thebasicCSFprofilecanbenormal.Initialtreatmentiswithamphotericin andflucytosine.RepeatedlumbarpuncturesmaybenecessarytoremoveexcessCSFandtherebypreventelevatedintracranial pressure.Fluconazoleisusuallyusedforlong-termmaintenance.
https://t.me/med1917
Cryptococcusappearas buddingyeastsurroundedbymucoidcapsules.(ReprintedfromMcClatcheyKD.Clinical Lab oratoryMedicine.2nded.LippincottWilliam s&Wilkins;2002.)
Coccidioides is endemic in the southwestern United States as well as in Central and South America (although with climate change,casesarebeingseenfarthernorthaswell).Mostpatientswhohavebeenexposedeitherremainasymptomaticorhave only mild flu-like symptoms. Severe disease, when it occurs, most often manifests as pneumonia, but the organism can disseminate and cause osteomyelitis, septic arthritis, and meningitis. Unlike cryptococcus, coccidioides can affect both immunocompetentandimmunosuppressedpatients.Patientsatriskforseverediseaseincludepregnantwomen,diabeticpatients, cigarettesmokers,andtheelderly,as wellas patientswhoare immunosuppressed.Lifelongantifungaltreatment(typicallywith fluconazole)isnecessary;ifleftuntreated,coccidioidesmeningitisisuniversallyfatal.
Box8.3OtherFungiThatCanAttacktheCentralNervousSystem
Certainfungithatcanattackthecentralnervouss ystem dosowithoutactuallycausingmeningitis.However,it’sworthtakingabrieflook atthemherewithinthecontextofCNSfungaldis eas e.
Aspergillus can caus e both parenchymal dis ease (including abs cesses  and granulom as) and dis eas e due to vascular invasion (multifocal ischemic and/or hem orrhagic infarcts). Im m unos uppres s ed patients are at greatest ris k, particularly thos e that are neutropenicoronchronicglucocorticoidtherapy.Acombinationofpositivebloodcultures ,serum biom arkers(galactom annanandbeta­D-glucanas s ays ),bronchoalveolarlavage,andneuroimagingis oftenneces s aryfordiagnosis .Voriconazole,oftenincombinationwith caspofungin,isfirst-linetreatment.
Mucorm ycosis is  a m old that m os t often affects patients with diabetes (particularly thos e in diabetic ketoacidos is), hematologic malignancies,orother immunocompromis edstates(pos t trans plant,HIV/AIDS).Itisinhaled and attacks  the paranas alsinuses  and vasculature.Theinfectiontypicallypresents asanacutesinusitis ,withfever,purulentnas aldis charge,headache,andsinuspain.But this is  not your everydaysinus infection. It can s pread with devastating s peed to caus e pulmonary diseas e, orbital com plications (resulting in proptosis  and eventual blindness),and cerebral manifestations  (often due to s pread from  the sphenoid s inus  into the cavernous s inus ,caus ingm ultiplecranialneuropathies ).Sus pectmucormycosisinapatient,particularlyoneatrisk,whopres entswith fever,acutesinusitis,andas s ociatedneurologicsymptom s .Ablackes char,theresultoftissuenecros is ,maybevisiblewithinthenasal pas s ages  orels ewherein theoropharynxoraroundtheorbits. Diagnos is  isdifficultand us uallyrequires  bothnasal endoscopyand neuroim aging. Treatment includes  surgical debridem ent and antifungal therapy with amphotericin B. Des pite aggressive therapy, mortalityis high,ranginginsomestudiesabove60%.
Tuberculosis causesa subacute basilar meningitis (meaning itaffectsthe base of thebrain). The onset is usually gradual with headache, vomiting, and lethargy. Cranial nerve deficits result from inflammationthatisconcentratedinandaroundthebrainstem.Diagnosiscanbedifficult,becausethe CSFacid-fastbacillismearisoftennegativeandtheculturecantakeweekstogrow.CSFadenosine deaminasecanbeausefuladjunctivetest,butapositiveresultisnotspecifictoTBandcanbeseen
https://t.me/med1917
withotherbacterialinfections.Inmostcases,multiplelumbarpunctureswithrepeatedCSFsamples areneededtoconclusivelymakethediagnosis.Additionaltesting—positivefindingsonskintesting (purifiedproteinderivative[PPD]) or aninterferon-gamma releaseassayalongwith a chestx-ray consistent with tuberculosis—strongly support the diagnosis. Treatment should be started empiricallyonthebasisofclinicalsuspicionandnotbedelayedfordiagnosticconfirmation.Initial four-drug therapy (typically with rifampin, isoniazid, pyrazinamide, and ethambutol) is given for 2months;rifampinandisoniazidarethencontinuedforanadditional7to10months.
AFBstainforTB.(ReprintedfromShieldsJA,ShieldsCL.Eyelid,Conjunctival,andOrbitalTumors:An AtlasandTextbook.3rded.WoltersKluwer;2015.)
Box8.4OtherNeurologicComplicationsofTuberculosis
Atuberculomaisacollectionoftubercles(hardnodulesformedbyTB)thatclumptogether intoafirmmass.Tuberculomascanoccurinboththebrainandthespinalcordand,when symptomatic,presentlikeatumororothermasslesionwithheadache,seizure,and/orfocal deficits,dependingonthelocation.Theyappearasring-enhancinglesionsonMRI. Treatmentislargelythesameasfortuberculousmeningitis.
WhenTBaffectsthejointsandbones,itisreferredtoasskeletalTB.Osteomyelitisand
https://t.me/med1917
arthritiscanoccur;spondylitis(inflammationofthevertebrae,alsoknownasPottdisease)is anothermanifestation.Thethoracicandlumbarvertebraearemostoftenaffected,causing progressivebackpainandgaitinstability.Treatmentinvolvesantimicrobialtherapyand,in certainadvancedcases,surgicaldebridement,decompression,and/ordrainage.
Finally,anumberofparasites,mostnotoriouslyNaegleria,cancauseameningoencephalitisthatcan befatal.
NoninfectiousCauses.Leukemia,lymphoma,andmetastaticcarcinomacanallseedthemeninges, causingwhatisknownasleptomeningealcarcinomatosis.CSFanalysiswillshownoinfection,but cytologymaybepositiveformalignantcells(seeChapter16fordetails).Variousmedicationscanalso causeasepticmeningitis,includingnonsteroidalanti-inflammatorydrugs(NSAIDs),theantibiotic trimethoprim-sulfamethoxazole,andIVimmunoglobulin(IVIG).
CausesofAsepticMeningitis
Viralmeningitis Spirochetalinfections Fungalinfections Tuberculosis Malignancy Medication-induced
ChronicMeningitis
Yes,thereissuchathing.ItisdefinedasthepresenceofinflammationintheCSF(i.e.,aCSFpleocytosis, anotherwordforanincreasedwhitebloodcellcountinabodyfluid,inthiscasetheCSF)persistingfor atleast1monthwithoutresolution.Thetypicalpatientpresentswithseveralweeksofheadache,nausea, oneorseveralcranialneuropathiesandpolyradiculopathy.
Chronicmeningitiscanbecausedbyinfections(includingviral,bacterial,fungal,andparasitic infections),aswellasbyavarietyofnoninfectiousconditionsincludingmalignancy,autoimmune diseases(suchassystemiclupuserythematosusandsarcoid),vasculitis(Behcetsyndromeand granulomatosiswithpolyangiitis),andmedications(NSAIDs,intravenousimmunoglobulin[IVIG],and intrathecalagents).
Empiricantibiotictherapyisnotrecommended,becausethediagnosticpossibilitiesaresodiverseand difficulttosortout.Smallcasesstudieshaveshownthatsomepatientswithidiopathicchronicmeningitis mayrespondtoantituberculosistherapyandsometoglucocorticoids,butthesetherapies,particularlythe latter,arenotbenignandonlyshouldbeconsideredafterextensiveevaluationandconsultationwith specialistsfromallpertinentfields.
Theoverallprognosisforpatientswithchronicmeningitisisgoodifacausecanbediagnosedand treated.Forthosewithidiopathicdisease,mostpatientsalsodowell;theirsymptomseitherimproveor stabilizeoveraperiodof1toseveralyears.
Encephalitis
https://t.me/med1917
AnOverview
Almostallcasesofinfectious3encephalitisareviral.Mostvirusescancauseeithermeningitisor encephalitis,butthemajorityaremorelikelytocauseoneratherthantheother.HSV-1,forinstance,is mostlikelytocauseencephalitisbutcancausemeningitis;HSV-2,aspreviouslydiscussed,ismuchmore likelytocausemeningitisandislesslikelytocauseencephalitis.Inmostcases,however,thespecific causeofencephalitisisneverfound.Patientswithviralencephalitistendtohaveabenignandself­limitedcourse,butthereareexceptions(seebelow).
Hereisalistofsomeofthemorecommonvirusesthatcancauseencephalitis:
Herpesviruses(HSV-1>HSV-2,VZV,EBV,HHV-6) Arboviruses(WestNile,Japanese,St.Louis,EasternandWesternequine) Enteroviruses(echo,coxsackie,polio) HIV Rabies Measles Influenza
HSV-1,herpessimplexvirus1;HSV-2,herpessimplexvirus2;VZV,varicellazostervirus;EBV,epsteinbarrvirus;HHV-6,human herpesvirus6.
Encephalitispresentsmostcommonlywithfeverandalteredmentalstatus,rangingfromsubtle confusiontoobtundation.Signsofmeningealirritation,includingneckstiffnessandphotophobia,are usuallyabsent.Seizuresarecommon.Focalneurologicdeficits,suchashemiparesisoraphasia,can occur.Atypicalviralprodrome(fevers,chills,myalgias)usuallyprecedesthebraininvolvement.
Aswithmeningitis,CSFanalysisiscritical.Sincemostcasesareviralinorigin,anasepticprofile predominates(i.e.,lymphocyticpleocytosiswithanormaltomildlyelevatedproteinandanormal glucose).PCRtestingisavailableformanyoftheviralcauses,includingherpesviruses,enteroviruses, andWestNilevirus.
HerpesEncephalitis
Thisistheoneyoudon’twanttomiss,becausetreatmentisavailableandearlyinterventioncanbe lifesaving.HSV-1causesmostcases,andencephalitiscanoccurwithprimaryinfectionorreactivation. Patientspresentwiththetypicalfeaturesofencephalitisdescribedabove;morethanhalfwillexperience seizures.TheCSFprofileisnotableforanelevatedprotein,alymphocyticpredominanceofcellsand, unlikemostviralencephalitides,althoughcertainlynotpathognomonic,anelevatedredbloodcellcount. CSFPCRtestingforHSV-1hasahighdiagnosticsensitivityandspecificity.MRIofthebrainwilloften revealedemaorhemorrhagewithinthetemporallobes,andanEEGwillclassicallyshowperiodic sharpwavesarisingfromoneorbothtemporallobes.TreatmentisIVacyclovir,4whichshouldbe givenempiricallyifthereisanyclinicalsuspicion.Mortalityusedtobeexceedinglyhigh(over70%),but earlytreatmenthasreducedthissubstantially.However,manypatientswillsufferresidualneurologic deficitsthatmayincludecognitivedeficits,memoryimpairment,andbehavioralabnormalities.
https://t.me/med1917
AnMRIofapatientwithHSV-1encephalitisshowingmarkededemaoftherighttemporallobe.(Reprinted fromLouisED,MayerSA,RowlandLP.Merritt’sNeurology.13thed.WoltersKluwer;2015.)
Arthropod-BorneEncephalitis
Insectscancarryanumberofpathogensthatcancauseencephalitis.Amongtheonesyou’veprobably
https://t.me/med1917
heardofareWestNilevirus,Japaneseencephalitis,St.Louisencephalitis,EasternandWesternequine encephalitis,denguefever,andLymedisease.Thepatient’sgeographiclocationandhistoryofpossible exposure(oftenviatravel)canbehelpful,butpatientsmustundergoCSFanalysistoruleoutother treatablecauses.Serologyandnucleicacidtestingcanaidinthediagnosis.Onlysupportivetreatmentis availablefortheviraletiologies.DoxycyclineistherecommendedtherapyforLymedisease.
WestNilevirus(WNV)isasingle-strandedRNAvirusthatfirstappearedintheUnitedStatesin1999. Althoughthemajorityofcasesareasymptomatic,neuroinvasivediseasecanoccurandisassociatedwith ahighmortality.Inadults,WNVencephalitisisoftenassociatedwithextrapyramidalsymptomssuchas tremor,parkinsonism,andmyoclonus.Inchildren,meningitisisthemorecommonpresentationandlooks justlikeotherviralmeningitides.WNVcanalsocauseanacutemyelitissimilartopoliomyelitis, characterizedbyanasymmetricflaccidparalysis,hyporeflexia,andautonomicdysfunction.Thediagnosis ofWNVinfectionismadebyserum(antibody)andCSF(antibodyandPCR)testing.Thereisnoknown treatment,althoughsomestudieshaveshownapotentialbenefitofIVIG,particularlyin immunocompromisedpatients.
WestNilevirusismostcommonlyspreadinthesummerbythebiteofaninfectedmosquito.(GathanyJ. PublicHealthImagesLibrary.CentersforDiseaseControlandPrevention;2014.http://phil.cdc.gov)
Nowthatyouarewellversedinbothmeningitisandencephalitis,weneedtospendsometimeon severalspecificinfections,manyofwhichwehavealreadybrieflydiscussed,thatcanhaveimportant neurologicconsequences.TheseincludeHIV,syphilis,Lymedisease,neurocysticercosis,leprosy, poliomyelitis,andCOVID-19.
https://t.me/med1917
HIVInfection:NeurologicComplications
Beforetheadventofmodernantiretroviraltherapy,CNSopportunisticinfectionswerecommoninHIV­positivepatients.Fortunately,theseinfectionsaresignificantlylesscommontoday.
HIVmeningitisistechnicallynotanopportunisticinfectionbutratheramanifestationofacuteHIV infection.Itpresents as a typicalaseptic meningitis thattendstoself-resolvewithin 2 to4 weeks. Guillain-BarresyndromecanalsooccurinassociationwithacuteHIVinfection,althoughitusually appearsseveralweekslater. Progressive multifocal leukoencephalopathy (PML), theresultofinfection with the JC virus,is muchlesscommontodayinpatientswithHIVthankstothewidespreaduseofantiretroviraltherapy. PML is a disease of the white matter (white matter, leuko, in the brain, encephalo, is damaged, pathy)thattypicallypresentswithsubacuteneurologicdeficits;thesymptomsdependonthelocation of the white matter lesions. Seizures, a manifestation of cortical disease, are also common, presumablyduetolesionsthatlieadjacenttothecortex.Variousmedications,includingnatalizumab andocrelizumab(usedtotreatmultiplesclerosis),canalsoincreasetheriskofPML(seepage246).  Toxoplasmosis, caused by the intracellular protozoan parasite Toxoplasma gondii, is the most common CNS infection in patients with untreated or inadequately treated HIV. Toxoplasmosis in immunocompetent patients is nearly always asymptomatic, but when CD4 counts fall below 100cells/µL,theparasitecanreactivateandcausebothCNSandsystemicdisease.Encephalitisis themostcommonneurologicmanifestation.Apresumptivediagnosisismadebybrainimaging(see below, and Box 8.5) and serologic testing in the appropriate clinical context; although often unnecessary,biopsyisrequiredfordefinitivediagnosis.Acutetreatmentiswithpyrimethamineand sulfadiazine.Leukovorinis given as well, topreventpyrimethamine-induced hematologic toxicity. Trimethoprim-sulfamethoxazole is used for prophylaxis in HIV-positive patients withCD4counts below100cells/µL.
https://t.me/med1917
(A)Fluid-attenuatedinversionrecovery(FLAIR)MRIofapatientwithPML,showingthecharacteristic nonenhancing,asymmetric,andconfluentwhitematterlesions.(B)PostcontrastT1-weightedMRIofa patientwithtoxoplasmosis,showingtheclassicring-enhancinglesion.Toxoplasmosiscanbe indistinguishablefromCNSlymphomaonimaging;clinicalcontextiskey,butbrainbiopsymayberequired todifferentiatethetwodiseases.(ReprintedfromAtlasSW.MagneticResonanceImagingoftheBrainand Spine.5thed.WoltersKluwer;2016.)
Other infectious complications include cytomegalovirus encephalitis and, as mentioned earlier, cryptococcalmeningitis. NoninfectiousneurologiccomplicationsofchronicHIVinfectioninclude: a distal symmetric polyneuropathy (either from the infection itself or as a side effect of antiretroviraltherapy) chronicinflammatorydemyelinatingpolyneuropathy(seepage287) immunereconstitutionsyndrome(IRIS).IRIScanoccurwhen patientswith lowCD4countsstart antiretroviraltherapy.Symptomsrangefromheadacheanddizzinesstodeliriumandcoma HIV-associated neurocognitive disorder, or HAND. This is a form of dementia that can present with varying types and degrees ofcognitive deficits. Itis the resultof ongoing inflammationthat persists despiteviral suppression.Although the prevalenceandseverity have decreased inrecent years, mild forms of cognitive dysfunction still develop in as many as 20% of HIV-positive individuals.
OnefinalneurologiccomplicationofHIVinfectionisprimaryCNSlymphoma,whichcanoccurin bothimmunocompetentandimmunocompromisedpatients,andisdiscussedindetailinChapter16.
Box8.5CerebralRing-EnhancingLesions
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности