caso clinico 1 diciembre 2010 · infecciones del snc meningitis encefalitis abscesos y empiemas ......

CASO CLINICO 1 DICIEMBRE 2010

SUSANA GARCIA ESCUDEROR3 MEDICINA INTERNACOMPLEJO ASISTENCIAL LEON

Servicio de Medicina Interna

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MOTIVO DE INGRESOVarón de 49 años que ingresa por CEFALEA, DOLOR LUMBAR y FIEBRE.

ANTECEDENTE PERSONALES‐No alergias medicamentosas conocidas‐Técnico de medio ambiente‐Vive en medio rural‐Soltero‐No hábitos tóxicos‐Meningitis aséptica secundaria a Rikettsiosis en 2006.‐Intervenido de peritonitis con perforación gástrica en 1989.‐No diabetes mellitus. No HTA. No dislipemia. No hiperuricemia.‐No cardiopatía ni broncopatía conocida.‐No antecedentes de TBC


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ENFERMEDAD ACTUALVarón de 49 años intervenido 2 dias antes del ingreso de hernia inguinal derecha con raquianestesia. En las 24 horas siguientes refiere dolor lumbar intenso y pocas horas después comienza con rigidez de nuca y espalda, vómitos y fiebre. No dolor faringeo ni ótico. No otra clínica acompañante

EXPLORACIÓN FÍSICATº al ingreso 36.2 y Tº posteriormente 39.1TA 90/40. Delgado. COC. Bien hidratado. Buena coloración piel y mucosas.Bien perfundido. PC normales. No focalidad neurológica.Rigidez de nuca+++ y signo de Kernig y Bruzinsky ++++.No adenopatías. No bocio. No aumento PVY.ACP: rítmico a 80 lxm. No soplos. Mcv.ABD: blando, depresible, no doloroso, no masas ni megalias.EEII: no edemas ni signos TVP. Pulsos normales. Cicatriz de intervención a nivel inguinal dcho.


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COAGULACIÓNTP‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐72%INR‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐1.24TTPA‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐26,1 sg

BIOQUIMICAGlucosa‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐122Urea‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NCreatinina‐‐‐‐‐‐‐‐‐‐‐‐‐NNa‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NK‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NCL‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NGOT‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NGPT‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NFA‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NGGT‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NColesterol‐‐‐‐‐‐‐‐‐‐‐‐‐NLDL‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NHDL‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NTag‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐NProteinas‐‐‐‐‐‐‐‐‐‐‐‐‐‐5.8Albumina‐‐‐‐‐‐‐‐‐‐‐‐‐3.37PCR‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐150.7

HEMOGRAMAHb‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐13.7Hto‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐40.8VCM‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐93.7Leucos‐‐‐‐‐‐‐‐‐‐‐‐‐‐14.800

83%N2%cayados7%L6%M

Plaquetas‐‐‐‐‐‐‐‐‐133.000VSG‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐30


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CASO CLINICO 1 DICIEMBRE 2010Servicio de Medicina Interna

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LIQUIDO de ASPECTO TURBIOLeucocitos‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐1300PMN‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐80%MN‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐20%Hematies‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐120Glucosa‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐47 (122)Proteinas‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐149


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ENTONCES TENEMOS…

VARON 49 AÑOS

MENINGITIS ASEPTICA

RAQUIANESTESIA

FIEBRE, CEFALEA y DOLOR LUMBAR

RIGIDEZ NUCA +++SIGNO KERNIG y BRUZINSKY +++

LEUCOCITOSIS con desviación izquierdaPCR 150.7

TAC CEREBRAL NORMAL

LCR TURBIO con PMN, glucosa y proteínas

MENINGITIS

MENINGITIS

INFECCIONES DEL SNC

MENINGITIS

ENCEFALITIS

ABSCESOS Y EMPIEMAS

PRIONES


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MENINGITIS•MENINGITIS AGUDA

Instauración brusca (horas)

•MENINGITIS SUBAGUDA

Desarrolla en 1‐7 días

•MENINGITIS CRONICA

Comienzo insidioso (semanas)

Síntomas comienzan 24h tras la intervención

BACTERIANAVIRICA

TBC

BRUCELLA

TREPONEMA PALLIDUM

BORRELIA

FUNGICASCryptococcus neoformans

Coccidiodes immitIs


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MENINGITIS

MENINGITIS VIRICA

LCR claro

Presión normal

Mononucleares

Proteínas altas

Glucosa normal

MENINGITIS BACTERIANA

LCR turbio

Presión No alta

PMN

Proteínas ++altas

Glucosa baja

MENINGITIS TUBERCULOSA

LCR claro

Presión normal

Mononucleares (lf)

Proteínas altas

Glucosa baja

ADA elevado

MENINGITIS FUNGICA

Inmunodeprimidos

Criptococo

Inhalado (tierra)

Mononucleares

Cuadro lento

LIQUIDO de ASPECTO TURBIOLeucocitos‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐1300PMN‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐80%MN‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐20%Hematies‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐120Glucosa‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐47 (122)Proteinas‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐149


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MENINGITIS BACTERIANA

RUTA PATOGENOS PREDOMINANTES

Directo S. aureus y enterobacterias

Craneotomía y fractura de cráneo

Diseminación desde seno adyacente

Defecto ectodérmico congénito

Suhnt quirúrgica S epidermidis

Neuronal (vía axones) Toxina tetánica, virus de la rabia, virus herpes simiae (raro)

Olfatorio Virus Herpes simplex

Hematógena H infuenzae, S pneumonieae, N meningitis, M tuberculosisHongos (Cryptococcus, Coccidiodes)RicketsiaeEnterovirus, parotidits, VIH, arbovirus, virus de la coriomeningitis linfocitariaParásitos: Plasmodium, Trypanosoma


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[Iatrogenic meningitis after diagnosis lumbar puncture: 3 cases reports in the paediatric Children's Hospital of Tunis.][Article in French]Smaoui H, Hariga D, Hajji N, Bouziri A, Ben Jaballah N, Barsaoui S, Bousnina S, Sammoud A, Kechrid A.Laboratoire de Microbiologie, Hôpital d'Enfants, Tunis‐Bab Saadoun, Tunisia.AbstractWe have collected cases of iatrogenic meningitis managed in the Children's Hospital of Tunis, between January 1998 and December 2006. Clinical information about each patient were collected, all bacterial samples were investigated in the microbiology laboratory of the hospital. Bacterial isolates were identified according to conventional criteria. In the interval under study, we recorded three cases of iatrogenic meningitis after lumbar puncture. Two cases occurred in newborn admitted for suspicion of neonatal infection and one in a 2‐month‐old infant admitted for exploration of hyperpyretic convulsion. In all patients, the initial cerebrospinal fluid was normal. All patients developed symptoms of acute meningitis within 72 hours after lumbar puncture; the second cerebrospinal fluid was, then, typical for purulent meningitis. The causal agents isolated in the three cases were Klebsiella pneumoniae, Enterobacter cloacae, and Serratia marcescens, all resistant to betalactams by extended spectrum beta‐lactamaseproduction. The use of quinolones was required in all cases. Different complications were recorded: hydrocephalus and brain abscess in one case, respiratory and hemodynamic failure managed in the intensive care unit in the second, and brain hygroma in the third case. This study shows high morbidity of iatrogenic meningitis. Simple aseptic precautions undertaken before the procedure of lumbar puncture can prevent such cases. The urgent need for increasing the awareness among medical personnel in hospitals of developing countries cannot be overemphasized.PMID: 21103965 [PubMed ‐ as supplied by publisher]

PUBMED…Servicio de Medicina Interna

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[Bacterial meningitis secondary to spinal analgesia and anaesthesia.][Article in Spanish]Laguna Del Estal P, Castañeda Pastor A, López‐Cano Gómez M, García Montero P.Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro‐Majadahonda, Majadahonda‐Madrid, España.AbstractINTRODUCTION: Although rare, infectious complications from spinal analgesia and anaesthesia (SA) can have serious morbidity and mortality. This study describes the clinical features and outcome of SA‐associated bacterial meningitis in adults seen in a hospital over a 25 yearperiod.METHODS: We reviewed the charts of all patients (aged ≥14 years) diagnosed with SA‐associated bacterial meningitis between 1982 and 2006.RESULTS: Eight cases of SA‐associated bacterial meningitis were diagnosed (3.3% bacterial meningitis), with a median age of 62 years (range, 35‐80). SA procedures were: morphine infusion pumps with epidural (3 cases) or intrathecal (3) catheters, spinal cord stimulation with epidural neuroelectrode (1), and epidural anesthesia (1). Site of spinal insertion was: cervical (2 cases), thoracic (3), and lumbar (3). The median time to onset of meningitis was 26 days (range, 7‐101) after AE. The most common clinical findings were fever (8 cases, 100%), headache (7 cases, 87.5%), and neck stiffness (4 cases, 50%). CSF abnormalities were pleocytosis (8 cases, 100%), elevated protein level (8 cases, 100%), and hypoglycorrhachia (5 cases, 62.5%). The causative organisms were Staphylococcus epidermidis (2 cases), Staphylococcus aureus (2), Enterococcus faecalis (1), Streptococcus milleri (1), and Pseudomonas fluorescens (1); one patient had a negative CSF culture. Treatment included antibiotics and to remove the analgesia device in all patients. There was one death (12.5%).CONCLUSIONS: SA is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting.Copyright ©2009 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.PMID: 21093704 [PubMed ‐ as supplied by publisher]

PUBMED…Servicio de Medicina Interna

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Neumomoco ( S. pneumonieae):Adulto 50-70% G +Origen: infecciones agudas o crónicas en vías respiratorias: neumonía, otitis; fracturas de base de cráneo, fístulas durales.F. predisponentes: alcoholismo, diabetes, esplenectomia e hipogamma-globulinemia

Meningococo (N,. Meningitidis): Niños y jóvenes 10-35% P. entrada: nasofaringeF. predisponentes: deficits en complemento

Bacilos entericos gram-negativos 1-10%Enfermedades crónicas: diabetes, alcoholismo, cirrosisNeurocirugía.

Lysteria monocitógenes:5%Inmuninodeficiencia (Inmunidad celular): HIV, trasplante de órganos, cancer, embarazo, enfermedades crónicas en ancianos.

S epidermidis y S aureus: Origen: shunts ventriculoperitoneales, punción lumbar, ttointratecal Endocarditis

Hemofilus (H. Influenciae):Antes 1ª causa en meningitis infantiles (casi erradicado por vacunas.) Actualmente agente causal en personas mayores

GERMENES POSIBLESServicio de Medicina Interna

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ACTITUD A SEGUIR…

ANTIBIOTERAPIA EMPIRICAVANCOMICINA CEFOTAXIMA GENTAMICINA

Bacilos entericos gram (‐)S.Aureus.S.Epidermidis


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ESTO ES TODO AMIGOS


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caso clinico 1 diciembre 2010 · infecciones del snc meningitis encefalitis abscesos y empiemas ......

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