–едакци€ портала
03 окт€бр€ 2013, 23:44 590 +1

ћенингит 

√руппа заболеваний: болезни нервной системы
—межные болезни: менингококкова€ инфекци€
¬рач в каталоге: невролог
ѕораженный орган: головной мозг
 

‘акторы риска

  • »ммунодефицитные состо€ни€;
  • „ерепно-мозгова€ травма;
  • ќперативные вмешательства на голове и шее.

ќписание

ћенингит (термин состоит из др.-греч. μῆνιγξ — «мозгова€ оболочка» и суффикса лат. -itis - обозначающий воспалительный процесс) — воспаление оболочек головного мозга и спинного мозга.

Ќаиболее часто встречающиес€ симптомы менингита — головна€ боль, ригидность шеи одновременно с лихорадкой, изменЄнным состо€нием сознани€ и чувствительностью к свету (фотофобией) или звуку. »ногда, особенно у детей, могут быть только неспецифические симптомы, такие как раздражительность и сонливость.

ƒл€ диагностики менингита используетс€ люмбальна€ пункци€. ќна заключаетс€ в заборе спинномозговой жидкости из позвоночного канала с помощью шприца и еЄ исследовани€ на наличие возбудител€ заболевани€. Ћечение менингита проводитс€ с помощью антибиотиков, противовирусных или противогрибковых средств. »ногда дл€ предотвращени€ осложнений от сильного воспалени€ используютс€ стероидные средства.

ћенингит, особенно при задержке с лечением, может вызывать серьЄзные осложнени€: глухоту, эпилепсию, гидроцефалию и проблемы с умственным развитием у детей. Ќекоторые формы менингита (вызываемые менингококками, гемофильной палочкой типа b, пневмококками или вирусом паротита) могут быть предотвращены прививками.

 лассификаци€

ћенингиты классифицируютс€ по нескольким критери€м.

–азличают следующие виды воспалени€ мозговых оболочек:

  • лептоменингит — воспаление м€гкой и паутинной мозговых оболочек;
  • пахименингит — воспаление твердой мозговой оболочки;
  • в клинической практике под термином «менингит» обычно подразумевают воспаление м€гкой мозговой оболочки. 

ѕо характеру возникновени€:

  • первичный менингит, возникает как самосто€тельное заболевание;
  • вторичный менингит, возникает как осложнение другого процесса.

ѕо причине:

  • бактериальный менингит (пневмококковый, туберкулезный, менингококковый и др.);
  • вирусный менингит (вызванный энтеровирусами  оксаки и ≈—Ќќ, острый лимфоцитарый хориоменингит и др.);
  • грибковый менингит (криптококкозный, кандидозный и др.);
  • протозойный менингит (при мал€рии, при токсоплазмозе и др.);
  • смешанный;
  • другой этиологии.
ѕо характеру воспалительного процесса:
  • гнойный менингит (в цереброспинальной жидкости преобладают нейтрофилы);
  • серозный менингит(в цереброспинальной жидкости преобладают лимфоциты).
ѕо распространенности процесса:
  • генерализированный менингит;
  • ограниченный менингит.
ѕо течению заболевани€:
  • молниеносный (фульминантный);
  • острый менингит;
  • подострый менингит;
  • хронический менингит.
ѕо степени т€жести:
  • легкой формы;
  • средней т€жести;
  • т€желой формы;
  • крайне т€желой формы.

ѕричины

ћенингит может передаватьс€ несколькими пут€ми инфицировани€:

  •  онтактным — возникновение менингита происходит в услови€х уже существующей гнойной инфекции. –азвитию синусогенного менингита способствует гнойна€ инфекци€ околоносовых пазух (синусит, в частности гайморит), отогенного — сосцевидного отростка или среднего уха (отит), одонтогенного — патологи€ зубов.
  • Ћимфогенным, гематогенным, чрезплацентарным, периневральным.
  • ¬ услови€х ликвореи при открытой черепно-мозговой травме или позвоночно-спинномозговой травмы, трещине или переломе основани€ черепа.

„аще всего менингит возникает в результате проникновени€ в м€гкие мозговые оболочки различных чужеродных микроорганизмов, начина€ от вирусов и заканчива€ простейшими. 

ћенингококковый менингит

≈динственным источником возбудител€ инфекции €вл€етс€ человек. ¬ большинстве случаев менингококк, попав на слизистую оболочку носоглотки, не вызывает еЄ местного воспалени€ или заметных нарушений состо€ни€ здоровь€. Ћишь в 10—15 % случаев попадание менингококка на слизистую оболочку носоглотки, а возможно, и бронхов приводит к развитию воспалени€.

Ѕактериеми€ сопровождаетс€ токсемией, играющей большую роль в патогенезе болезни. ¬ажное значение имеют предшествовавшие вирусные заболевани€, резка€ смена климатических условий, травмы и другие факторы.

¬ патогенезе менингококковой инфекции играет роль сочетание процессов септического и токсического характера с аллергическими реакци€ми. Ѕольшинство поражений, возникающих в начале болезни, обусловлено первично-септическим процессом. ¬ результате гибели менингококков выдел€ютс€ токсины, поражающие сосуды микроциркул€торного русла.

—ледствием этого €вл€етс€ т€жЄлое поражение жизненно важных органов, прежде всего головного мозга, почек, надпочечников, печени. ” больных менингококкемией недостаточность кровообращени€ св€зана также с падением сократительной способности миокарда и нарушением сосудистого тонуса. √еморрагические сыпи, кровоизли€ни€ и кровотечени€ при менингококковом менингите обусловлены развитием тромбогеморрагического синдрома и повреждением сосудов.

¬торичный гнойный менингит

√нойный менингит — гнойное воспаление мозговых оболочек. ќсновные возбудители у новорождЄнных и детей — стрептококки группы ¬ или D, кишечна€ палочка, Listeria monocytogenes, гемофильна€ палочка, у взрослых — пневмококки, стафилококки и другие возбудители. ћикроорганизмы могут проникать непосредственно в нервную систему через раневое или операционное отверстие (контактно).

ƒл€ возникновени€ поражени€ головного мозга в большинстве случаев необходимо наличие очага хронической инфекции, из которого различными пут€ми происходит диссеминаци€ возбудител€ в оболочки головного мозга. ¬ большинстве случаев входными воротами €вл€етс€ слизиста€ оболочка носоглотки. ¬о всех случа€х, подозрительных на менингит, дл€ микробиологического исследовани€ кроме ликвора берут из предполагаемого первичного очага инфекции: мазки из носоглотки, среднего уха, ран после нейрохирургических и других оперативных вмешательств, кровь.

—ерозный менингит

—ерозные менингиты вирусного происхождени€ вызываютс€ энтеровирусами —  оксаки и ECHO, вирусами полиомиелита, эпидемического паротита, а также некоторыми другими видами вирусов. »сточником инфекции €вл€етс€ больной человек и «здоровый» вирусоноситель. ¬ирус передаетс€ через воду, овощи, фрукты, пищевые продукты, гр€зные руки. ћожет передаватьс€ и воздушно-капельным путЄм при большом скоплении людей. «аражение чаще происходит при купании в водоЄмах и плавательных бассейнах.

Ќаиболее часто болеют серозным менингитом дети от 3 до 6 лет, дети школьного возраста болеют чуть реже, а взрослые заражаютс€ очень редко. Ќаиболее выражена летне-сезонна€ заболеваемость. “акже переносчиками вируса могут служить различные насекомые, например клещи, дл€ возбудител€ клещевого энцефалита.

“уберкулЄзный менингит

“уберкулЄзный менингит развиваетс€ при наличии в организме туберкулЄзного очага. »нфекци€ проникает в оболочки мозга гематогенным путЄм. ѕри этом виде менингита происходит обсеменение оболочек, главным образом основани€ мозга, туберкулЄзными узелками величиной от булавочной головки до прос€ного зерна. ¬ подпаутинном пространстве скапливаетс€ серовато-жЄлтый студенистый экссудат.  оличество ликвора увеличиваетс€. ѕри люмбальной пункции он вытекает струЄй, прозрачен. ѕри лабораторном исследовании всегда обнаруживаетс€ большое количество белка и форменных элементов, преимущественно лимфоцитов. ¬ спинномозговой жидкости часто отмечаетс€ повышение, но иногда может быть и снижение количества глюкозы — до 0,825—1,650 ммоль/л. »ногда отмечаетс€ лейкопени€ или незначительный лейкоцитоз с небольшим сдвигом влево и лимфопенией.

¬ирусный менингит

¬озбудитель — вирусы  оксаки и ≈—Ќќ относ€тс€ к семейству Picormaviridae, роду Enterovirus. Ёто –Ќ -содержащие вирусы небольшого размера. ¬се 6 типов вирусов  оксаки ¬ патогенны дл€ человека. »дентифицированы 34 серотипа вирусов ≈—Ќќ, 2/3 из которых патогенны дл€ человека.

¬ирусы устойчивы к замораживанию, действию эфира, 70% спирта, 5% лизола, сохран€ют активность при комнатной температуре в течение нескольких дней и инактивируютс€ под действием формалина, хлорсодержащих средств, при нагревании, высушивании, ультрафиолетовом облучении.

ѕротозойные менингиты

ќдним из возбудителей €вл€етс€ Toxoplasma gondii, котора€ относитс€ к типу Protozoa (внутриклеточный паразит). Ѕессимптомными носител€ми могут €вл€тьс€ кошки.

“акже данный микроорганизм может находитьс€ в м€се и м€сных продуктах, может сохран€ть жизнеспособность при температуре от 2 до 5° — до мес€ца. √ибнет при температуре до 20° —. ‘ормирование иммунитета приводит к исчезновению возбудител€ из крови, прекращаетс€ его размножение в клетках. ќбразуютс€ истинные тканевые цисты, которые могут длительно, дес€тилети€ми, в интактном состо€нии сохран€тьс€ в организме.

 ак развиваетс€ болезнь

¬ патогенезе имеет значение токсеми€, особенно выраженна€ при т€жЄлых септических формах заболевани€. ¬ этих случа€х развиваетс€ инфекционно-токсический шок, обусловленный токсемией в результате массивного распада большого количества менингококков. Ёндотоксин нарушает микроциркул€цию, вызывает внутрисосудистое свЄртывание крови, нарушение обмена веществ. –езультатом токсикоза может быть отЄк мозга с синдромом внутричерепного повышенного давлени€ и летальным исходом от паралича дыхательного центра в среднем мозге. ¬ результате перенесЄнной инфекции в крови выздоравливающих нарастает число специфических антител. ѕеренесЄнна€ инфекци€ приводит к развитию типоспецифического иммунитета.

—имптомы

—имптомокомплекс любой формы менингита включает в себ€:

  • ќбщеинфекционные симптомы (жар, озноб, повышение температуры тела);
  • ”чащение дыхани€ и нарушение его ритма, изменение „—— (в начале заболевани€ тахикарди€, по мере прогрессировани€ заболевани€ — брадикарди€).
  • ¬ состав менингеального синдрома вход€т общемозговые симптомы, про€вл€ющиес€ тоническим напр€жением мышц туловища и конечностей. 
  • Ќередко по€вл€ютс€ продормальные симптомы (насморк, боли в животе и др.). 
  • –вота при менингите не св€зана с приемом пищи, а по€вл€етс€ сразу после смены положени€ или при усилении головной боли. 
  • √оловные боли, как правило, распирающего характера очень мучительны дл€ пациента, могут локализоватьс€ в затылочной области и отдавать в шейный отдел позвоночника. 
  • ѕациенты болезненно реагируют на малейший шум, прикосновени€, свет, поэтому стараютс€ избегать разговоров и лежат с закрытыми глазами.

¬ детском возрасте возможно по€вление судорог. ƒл€ менингита характерна гиперестези€ кожи и болезненность черепа при перкуссии. ¬ начале заболевани€ отмечаетс€ повышение сухожильных рефлексов, но с развитием заболевани€ они снижаютс€ и нередко исчезают. ¬ случае вовлечени€ в воспалительный процесс вещества мозга развиваютс€ параличи, патологические рефлексы и парезы. “€желое течение менингита обычно сопровождаетс€ расширением зрачков, диплопией, косоглазием, нарушение контрол€ над тазовыми органами (в случае развити€ психических расстройств).

—имптомы менингита в старческом возрасте атипичны: слабое про€вление головных болей или полное их отсутствие, тремор головы и конечностей, сонливость, психические расстройства (апати€ или, наоборот, психомоторное возбуждение).

ћенингококковый менингит

ћенингококковый менингит чаще начинаетс€ внезапно, с резкого подъЄма температуры, многократной рвоты, не принос€щей облегчени€ (рвота центрального происхождени€), головна€ боль в результате повышени€ внутричерепного давлени€. Ѕольной находитс€ в характерной позе: затылочные мышцы напр€жены, голова запрокинута назад, спина выгнута, живот вт€нут, ноги согнуты и приведены к животу.

” р€да больных в первый день заболевани€ на коже по€вл€етс€ полиморфна€ эритематозна€ или кореподобна€ сыпь, исчезающа€ в течение 1-2 ч. Ќередко отмечаетс€ гипереми€ задней стенки глотки с гиперплазией фолликулов. ” некоторых пациентов за несколько дней до заболевани€ диагностируетс€ острое респираторное заболевание. ” грудных детей заболевание может развиватьс€ постепенно; постепенное начало болезни у детей более старшего возраста наблюдаетс€ очень редко.

¬ зависимости от т€жести заболевани€ у больного могут наблюдатьс€ затемнение сознани€, бессознательное состо€ние, бред, судороги в мышцах конечностей и туловища. ѕри неблагопри€тном течении болезни в конце первой недели наступает коматозное состо€ние, на первый план выступают параличи глазных мышц, лицевого нерва, моно- или гемиплегии; приступы судорог учащаютс€, и во врем€ одного из них наступает смерть. ¬ тех случа€х, когда течение болезни принимает благопри€тный характер, температура снижаетс€, у больного по€вл€етс€ аппетит, и он вступает в стадию выздоровлени€.

ƒлительность менингококкового менингита в среднем 2-6 недель. ќднако известны случаи молниеносного течени€, когда больной погибает в течение нескольких часов от начала заболевани€, и случаи зат€жные, когда у больного после периода улучшени€ оп€ть повышаетс€ температура и устанавливаетс€ надолго. Ёта зат€жна€ форма представл€ет собой или гидроцефалическую стадию, или ту стадию, когда у больного наступает менингококковый сепсис с проникновением менингококка в кровь (менингококкцеми€). ≈Є характерной особенностью €вл€етс€ возникновение на коже геморрагической сыпи. ѕовышаетс€ температура, развиваетс€ тахикарди€, снижаетс€ артериальное давление, возникает одышка.

Ќаиболее т€жЄлым про€влением менингококкового менингита €вл€етс€ возникновение бактериального шока. «аболевание развиваетс€ остро. ¬незапно повышаетс€ температура, возникает сыпь. ѕульс становитс€ частым, слабого наполнени€. ƒыхание неравномерное. ¬озможны судороги. Ѕольной впадает в коматозное состо€ние. ќчень часто больной погибает, не приход€ в сознание.

Ќекрозы кожи. ѕри т€жЄлой менингококковой инфекции в сосудах кожи могут развитьс€ воспаление и тромбоз. Ёто ведет к ишемии, обширным кровоизли€ни€м и некрозам кожи (особенно в участках, подверженных сдавлению). «атем некротизированна€ кожа и подкожна€ клетчатка отторгаютс€, оставл€€ глубокие €звы. «аживление €зв обычно протекает медленно, может потребоватьс€ пересадка кожи. Ќередко образуютс€ келоидные рубцы.

 осоглазие. ¬ острой стадии менингита иногда поражаютс€ черепные нервы. Ќаиболее у€звим отвод€щий нерв, поскольку значительна€ его часть проходит по основанию головного мозга; поражение этого нерва ведет к параличу латеральных пр€мых мышц глаза. ќбычно через несколько недель косоглазие исчезает. –аспространение инфекции на внутреннее ухо может привести к частичной или полной глухоте.

”веит.  онъюнктивит при менингите встречаетс€ часто, однако на фоне лечени€ он быстро проходит. ”веит — более серьЄзное осложнение, он может привести к панофтальмиту и к слепоте. Ѕлагодар€ антимикробной терапии столь т€жЄлые последстви€ сейчас почти не встречаютс€.

¬торичный гнойный менингит

«аболевание начинаетс€ с резкого ухудшени€ общего состо€ни€, повышени€ температуры, чувства озноба. ѕри т€желых формах могут быть потер€ сознани€, бред, судороги, многократна€ рвота. –езко выражены менингеальные симптомы: ригидность затылочных мышц, симптомы  ернига и Ѕрудзинского. –азвиваетс€ тахикарди€, брадикарди€. Ћиквор мутный, вытекает под большим давлением. –езко повышен нейтрофильный цитоз, достигающий несколько тыс€ч, повышено содержание белка..

“ечение менингита острое. Ќо возможны случаи как молниеносного, так и хронического течени€ заболевани€. ¬ некоторых случа€х типична€ клиническа€ картина менингита маскируетс€ выраженными €влени€ми общего септического состо€ни€.

—ерозный менингит

—ерозный менингит чаще всего поражает детей в возрасте 2-7 лет. —ерозный менингит начинаетс€ постепенно, после выраженного продромального периода, который может длитьс€ 2-3 недели. ѕродромальные €влени€ выражаютс€ общим недомоганием, потерей аппетита, по€вл€етс€ субфебрильна€ температура. ѕосле периода предвестников наступают признаки менингита — по€вл€етс€ рвота, головна€ боль, запор, повышаетс€ температура, отмечаетс€ напр€жение затылка, симптомы  ернига и Ѕрудзинского. ¬ выраженных случа€х типично положение больного: голова запрокинута назад, ноги согнуты в коленных суставах, живот вт€нут.

“уберкулЄзный менингит

“уберкулЄзный менингит начинаетс€ постепенно, может длитьс€ 2-3 недели. ¬ыражен общим недомоганием, потерей аппетита. –ебенок становитс€ скучным, тер€ет интерес к играм, жалуетс€ на непосто€нную умеренную головную боль. ѕо€вл€етс€ субфебрильна€ температура. Ѕолезненные €влени€ постепенно нарастают. √оловна€ боль усиливаетс€, становитс€ посто€нной. ѕро€вл€етс€ рвота на фоне нарастающих менингеальных симптомов. ¬озникают признаки поражени€ черепных нервов, чаще III, IV и VI пар. “емпература тела достигает 38°-39 °C. ѕри т€жЄлом течении заболевани€ постепенно нарушаетс€ сознание, по€вл€ютс€ периодические судороги. —пинномозгова€ жидкость вытекает под повышенным давлением, прозрачна€ или слегка опалесцирующа€. ѕри микроскопическом исследовании обнаруживаетс€ лимфоцитарный плеоцитоз. ’арактерно понижение в спинномозговой жидкости количества глюкозы, что отличает туберкулЄзный менингит от менингитов другой этиологии. ¬ крови никаких изменений, специфических дл€ туберкулЄзного менингита, не по€вл€етс€. ќбнаруживаетс€ повышение —ќЁ до 15-20 мм/ч и умеренный лейкоцитоз (10-ё9 — 13-ё9 в 1 л).

¬ирусный менингит

¬ирусный менингит начинаетс€ остро, с высокой лихорадки и общей интоксации. Ќа 1-2-й день болезни по€вл€етс€ отчетливо выраженный менингеальный синдром — сильна€ упорна€ головна€ боль, повторна€ рвота, нередко отмечаетс€ в€лость и сонливость, иногда возбуждение и беспокойство.

¬озможны жалобы на кашель, насморк, боли в горле и боли в животе. „асто у больных по€вл€етс€ кожна€ гиперестези€, повышенна€ чувствительность к раздражител€м. ѕри осмотре вы€вл€ютс€ положительные симптомы  ернига, Ѕрудзинского, ригидность затылочных мышц, признаки выраженного гипертензионного синдрома. ѕри спинномозговой пункции прозрачна€ бесцветна€ цереброспинальна€ жидкость вытекает под давлением. ÷итоз повышен, преобладают лимфоциты, содержание белка, глюкозы и хлоридов нормальное. “емпература тела нормализируетс€ через 3-5 дней, иногда по€вл€етс€ втора€ волна лихорадки. »нкубационный период длитс€ обычно 2-4 дн€.

ѕротозойный менингит

ѕротекает как общее заболевание с мышечной и суставной болью, п€тнисто-папулезной сыпью, увеличением лимфатических желез, непосто€нной лихорадкой. ѕо€вл€етс€ головна€ боль, рвота, менингеальный синдром. ¬ спинномозговой жидкости невысокий лимфоцитарный плеоцитоз, в осадке иногда обнаруживаютс€ токсоплазмы.

 лещевой энцефалит

ћенингеальна€ форма клещевого энцефалита про€вл€етс€ в виде острого серозного менингита с выраженными общемозговыми и менингеальными симптомами. ¬ цереброспинальной жидкости отмечаютс€ характерное повышение давлени€ (до 500 мм вод.ст.), смешанный лимфоцитарно-нейтрофильный плеоцитоз (до 300 клеток в 1 мкл). Ѕольные жалуютс€ на сильную головную боль, усиливающуюс€ при малейшем движении головы, головокружение, тошноту, однократную или многократную рвоту, боли в глазах, светобо€знь. Ѕольные в€лы и заторможены. ќпредел€етс€ ригидность мышц затылка, симптомы  ернига и Ѕрудзинского. ћенингеальные симптомы держатс€ на прот€жении всего лихорадочного периода. ƒлительность лихорадки 7-14 дней. ѕрогноз благопри€тный.

ƒиагностика

ѕервичный или этиологически недифференцированный диагноз менингита устанавливаетс€ на основании сочетани€ триады синдромов:

  • ќболочечного (менингеального) симптомокомплекса;
  • —индрома интоксикации;
  • —индрома воспалительных изменений цереброспинальной жидкости.

ќсмотр врача

Ќа консультативном приеме врач проведет осмотр пациента и проведет р€д тестов дл€ оценки состо€ни€ больного:

  • —имптом  ернига. —остоит в невозможности разогнуть ногу больного в коленном суставе, когда она согнута в тазобедренном. ћешает разгибанию не боль, а напр€жение задней группы мышц бедра (тонический оболочный рефлекс). явл€етс€ одним из наиболее частых и посто€нных симптомов менингита.
  • ¬ерхний симптом Ѕрудзинского — при пассивном приведении головы больного к грудине, в положении лежа на спине, ноги его сгибаютс€ в коленных и тазобедренных суставах.
  • —редний симптом Ѕрудзинского — такое же сгибание ног при надавливании на лонное сочленение.
  • Ќижний симптом Ѕрудзинского — при пассивном сгибании одной ноги больного в коленном и тазобедренном суставах друга€ нога сгибаетс€ аналогичным образом.
  • ѕодскуловый (щЄчный) симптом Ѕрудзинского — при надавливании на щеки больного непосредственно под скулами происходит рефлекторное подн€тие плеч и сгибание предплечий (вследствие своеобразной позы этот симптом называют ещЄ симптомом «креста»).
  • —имптом √ийена — сдавливание четырех мышц бедра больного с одной стороны вызывает непроизвольное сгибание в тазобедренном и коленном суставах противоположной ноги.
  • —имптом √ермана — (симптом «ше€ — большой палец стопы») — при пассивном сгибании шеи у больного наблюдаетс€ экстензи€ больших пальцев стоп; симптом описан польским невропатологом ≈вфимиусом √ерманом при туберкулЄзном менингоэнцефалите.
  • —имптом «подвешивани€» Ћессажа. ЌоворождЄнного ребЄнка берут за подмышечные впадины обеими руками, придержива€ указательными пальцами голову со стороны спины, и приподнимают, что ведЄт к непроизвольному подт€гиванию ножек к животу за счЄт сгибани€ их в тазобедренном и коленном суставах и длительной их фиксации в таком согнутом положении. ” здорового ребЄнка при пробе Ћессажа ножки свободно двигаютс€ (сгибаютс€ и разгибаютс€).
  • —имптом ћондонези — надавливание на глазные €блоки через закрытые веки болезненно.
  • √лавные ориентиры невролога в дифференциации менингитов — исследование цереброспинальной жидкости, а именно определение соотношени€ клеток, уровн€ сахара и белка.

Ћабораторна€ диагностика

ќсновным методом диагностировани€ (или исключени€) менингита €вл€етс€ люмбальна€ пункци€ с последующим исследованием цереброспинальной жидкости. ¬ пользу данного метода говор€т его безопасность и простота, поэтому проведение люмбальной пункции показано во всех случа€х подозрени€ на менингит. ƒл€ всех форм менингита характерно вытекание жидкости под высоким давлением (иногда струей). ѕри серозном менингите цереброспинальна€ жидкость прозрачна€ (иногда слегка опалесцирующа€), при гнойном менингите — мутна€, желто-зеленого цвета. — помощью лабораторных исследований цереброспинальной жидкости определ€ют плеоцитоз (нейтрофилы при гнойных менингитах, лимфоциты при серозных менингитах), изменение соотношени€ количества клеток и повышенное содержание белка.

ƒл€ подтверждени€ диагноза менингита используют бактериологическое исследование слизи из носоглотки и спинномозговую жидкость.

“ехника забора и транспортировки материала. Ќосоглоточную слизь берут натощак стерильным тампоном до начала антибактериальной терапии. ¬з€тый материал должен хранитьс€ и транспортироватьс€ при температуре 37 — не более 1 часа, так как возбудитель крайне неустойчив во внешней среде. ¬ св€зи с этим посевы следует производить у постели больного, а забор материала на носительство лучше всего осуществл€ть в лаборатории. —терильный тампон, укреплЄнный на изогнутой проволоке, направл€етс€ концом вверх и подводитс€ под м€гкое нЄбо в носоглотку. ќб€зательно следует надавливать штапелем на корень €зыка. ѕри извлечении тампона он не должен касатьс€ зубов, щЄк и €зыка. ќтрицательные результаты бактериологического и бактериоскопического исследований не исключают менингококковую этиологию заболевани€.

  • Ѕактериоскопический метод: окраска мазков по √раму или метиленовым синим. ƒл€ исключени€ грибкового (криптококкового) менингита необходимо окрашивать препарат со спинномозговой жидкостью тушью. ќднако следует учитывать, что согласно отдельным отчетам внешний вид криптококков при микроскопии может существенно отличатьс€ от классического.
  • Ѕактериологический метод: выделение чистой культуры на средах с добавлением нормальной лошадиной сыворотки или сыворотки крупного рогатого скота и еЄ идентификаци€ по биохимической активности, антигенной структуре.
  • ћетод культивировани€. ѕри вирусных менингитах в препаратах, приготовленных с окрашиванием по √раму и тушью, невозможно идентифицировать возбудитель болезни.  ультивирование бактерий и грибов дает отрицательные результаты. ѕри культивировании клеточного материала или мозговой ткани со стандартными лабораторными клеточными лини€ми можно выделить возбудитель, серологически идентичный вирусу кори и обладающий свойствами вируса кори. “акже с помощью метода кокультивировани€ можно выделить вирус краснухи.
  • —еродиагностика менингита. “итр антител можно определ€ть в спинномозговой жидкости. »з-за длительности периода сероконверсии серологические данные используют в основном дл€ ретроспективного уточнени€ этиологии болезни. ѕри большинстве вирусных инфекций ÷Ќ— антитела к вирусу вырабатываютс€ в спинномозговой жидкости, и поэтому увеличиваетс€ индекс соотношени€ специфических антител в —ћ∆ и сыворотке.

Ћечение

ќсновной целью этиотропной терапии €вл€етс€ устранение причины заболевани€, в данном случае возбудител€ вызвавшего менингит.

¬ случае подозрени€ на менингит госпитализаци€ пациента об€зательна. ѕри т€желом течении догоспитального этапа (угнетение сознани€, лихорадка) пациенту ввод€т 50 мг преднизолона и 3 млн. ≈ƒ бензилпенициллина. ѕроведение люмбальной пункции на догоспитальном этапе противопоказано!

ќснова лечени€ гнойного менингита — раннее назначение сульфаниламидов (этазол, норсульфазол) в средней суточной дозе 5-6 г или антибиотиков (пенициллина) в средней суточной дозе 12-24 млн. ≈ƒ. ƒопускает введение бензилпенициллина интралюмбально (в крайне т€желом случае). ≈сли подобное лечение менингита в течение первых 3 дней оказываетс€ неэффективным, следует продолжить терапию полусинтетическими антибиотиками (ампиокс, карбенициллин) в сочетании с мономицином, гентамицином, нитрофуранами. ƒоказана эффективность такого сочетани€ антибиотиков до выделени€ патогенного организма и вы€влени€ его чувствительности к антибиотикам. ћаксимальный срок такой комбинационной терапии — 2 недели, после чего необходимо перейти на монотерапию.  ритери€ми дл€ отмены также служат снижение температуры тела, нормализаци€ цитоза (до 100 клеток), регресс общемозговых и менингеальных симптомов.

ќснову комплексного лечени€ туберкулезного менингита состоит в непрерывном введении бактериостатических доз двух-трех антибиотиков (тубазид 0,6 г/сутки + стрептомицин 1г/сутки). ѕри по€влении возможных побочных эффектов (вестибул€рные расстройства, нарушение слуха, тошнота) отмена данного лечени€ не требуетс€, показано уменьшение дозы антибиотиков и временное добавление к лечению десенсибилизирующих препаратов (димедрол, пипольфен), а также других противотуберкулезных препаратов (рифампицин, ѕј— , фтивазид). ѕоказани€ к выписке пациента: отсутствие симптомов туберкулезного менингита, санаци€ цереброспинальной жидкости (спуст€ 6 мес€цев от начала заболевани€) и улучшение общего состо€ние пациента.

Ћечение вирусного менингита может ограничитьс€ применением симптоматических и общеукрепл€ющих средств (глюкоза, анальгин, витамины, метилурацил). ¬ т€желых случа€х (выраженные общемозговые симптомы) назначают кортикостероиды и диуретики, реже — повторную спинномозговую пункцию. ¬ случае наслоени€ бактериальной инфекции возможно назначение антибиотиков.

ѕрофилактика

¬акцинаци€ предотвращает многие заболевани€, которые привод€т к менингиту. ќбычно прививки против менингита делают дет€м в раннем возрасте.

  • ¬акцина против бактерий Haemophilus influenzae типа B. Ќаиболее эффективным считаетс€ введение трЄх доз конъюгированных вакцин — в 3 мес€ца, 4,5 и 6 мес€цев с ревакцинацией в 12 мес€цев. ¬се существующие вакцины взаимозамен€емы. —ейчас бактерии Haemophilus influenzae типа ¬ считаютс€ одним из самых распространЄнных возбудителей бактериального менингита (по оценкам, около 3 миллионов т€желых заболеваний и 386 000 случаев смерти в год, главным образом, от менингита и пневмонии).
  • ћенингококкова€ вакцина защищает от N. meningitidis некоторых серогрупп — ј+— или ACWY. ¬акцинаци€ проводитс€ начина€ с 2-хлетнего возраста. Ёту прививку также рекомендуют первокурсникам, живущим в общежитии, солдатам-новобранцам, больным определЄнными заболевани€ми иммунной системы, а также туристам, путешествующим в страны, где периодически возникают эпидемии менингита, например, в некоторые страны јфрики.
  • ѕневмококкова€ вакцина также защищает от бактерий-возбудителей менингита. —уществует два типа пневмококковой вакцины. ѕневмококковую конъюгационную вакцину обычно ввод€т дет€м младше двух лет. ѕневмококкова€ полисахаридна€ вакцина рекомендована взрослым старше 65 лет. ѕолисахаридную вакцину ввод€т взрослым среднего возраста с ослабленным иммунитетом и определЄнными хроническими заболевани€ми.
  • “ривакцину против кори, эпидемического паротита и коревой краснухи обычно ввод€т дет€м. ќна защищает от менингита, который может возникнуть в результате кори, эпидемического паротита и коревой краснухи.
  • ¬акцина против ветр€ной оспы, поскольку инфекци€ ветр€ной оспы может потенциально привести к заболеванию вирусным менингитом.

¬ случае, если кто-то заболел.

  • Ќеобходимо воздерживатьс€ от контакта с больными менингитом, так как менингит передаЄтс€ воздушно-капельным путЄм. »ли использовать фильтрующие средства защиты, такие как, марлевые пов€зки, респираторы и т.п.
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