Method for predicting serous meningitis outcomes in children

FIELD: medicine.

SUBSTANCE: method involves making lumbar puncture and measuring liquor pressure, taking pleocytosis into account, making ultrasonic transcranial Doppler flowmetric examination of brain, determining linear blood circulation speed on interior carotid artery and posterior cerebral artery, detecting intracranial venous discharge disorders through orbital and vertebral veins. Regression coefficient is calculated from a formula

where X1 is patient age (in years); X2 is the pleocytosis in the first lumbar sample (in cells number per 1 mcl of liquor); X3 is the meningitis symptoms duration (in days); X4 is the focal symptoms availability (1- yes, 0- no); X5 is the general cerebral symptoms duration (in days); X6 is the liquor pressure when taking the first lumbar puncture (in mm of mercury column); X7 is the linear blood circulation speed in interior carotid artery (in Hz/s); X8 is the linear blood circulation speed in posterior cerebral artery (in Hz/s); X9 is the intracranial venous discharge disorders based on ultrasonic transcranial Doppler flowmetric examination data; retrograde discharge through orbital veins, increased one through vertebral veins and others (1- yes, 0- no). Value of y≤0.5, unfavorable outcome is to be predicted with cerebroasthenic, asthenoneurotic and hypertension syndromes being formed. If y>0.5, favorable infectious process outcome is to be predicted.

EFFECT: high accuracy of diagnosis.

4 tbl

 

The invention relates to medicine, namely to diagnosis. Determination of the nature of the disease and early prediction of outcome of serous meningitis allows you to optimize therapy to reduce the severity of neurological disorders at all stages of the infection process.

Serous meningitis are common lesions of the Central nervous system, the frequency of which in the structure of the CNS reaches 25-30%. Children and adolescents constitute elm), 65-78% among patients with serous meningitis. In the age structure of serous meningitis in children predominantly (55-75%) are over the age of 8 years, compared with children up to 3 years (5-10%). Currently, there is an increase in patients under the age of 3 years (8-10%) compared with previous years (3-5%). In recent years there has been an increase in the incidence of serous meningitis, in the etiology of which are not only viruses: enteroviruses, herpes viruses, West Nile virus, HIV, and others, but also bacteria, such as tuberculosis coli, Leptospira, Borrelia burgdorferi, Ehrlichia. Healthy after suffering serous meningitis remain 30-62% of patients. The outcome of the disease is described mainly zerebrasteniceski (39-45%), neurasthenic (12-30%) and hypertensive (8,6-12%) syndromes. Zerebrasteniceski and asthenoneurotic the ical syndromes occur in the early period of convalescence, 2-3 week of illness. The symptoms disappear for 8-12 month after suffering meningitis. Possible transformation Serebryanicheskaya syndrome in hypertensive syndrome after 1-3 months in 5-16% of patients, focal brain damage 3-7%, epilepsy 1-3%. Hypertensive syndrome occurs in 15-35% in residual period of serous meningitis, in 2/3 of the cases occurs a month after the illness, in 1/3 of cases 3 months, mostly diagnosed in older children. Long liquidynamics violations have a damaging effect on the optic nerve, causing venous congestion or atrophy of the optic nerve papilla on the inner ear, forming a sensorineural hearing loss. Diencephalic syndrome after suffering serous meningitis develops after 3 months after suffering serous meningitis, lasts for years 2-4,5% recovered. In 1-5% recover focal CNS and epileptiform seizures occur 6 months after suffering serous meningitis.

In this regard, there is no doubt the need for accurate prediction of the outcomes of serous meningitis in children in the early stages of the disease to improve outcomes through the application of differential treatment.

Known conventional schemes predicted what I outcomes of serous meningitis (Gadimova M.A., Protosevich P.M. Acute serous meningitis and encephalitis in children. - Leningrad. - 1974. - p.55-58; Fomin V.V. and other Enterovirus neuroinfections in children. - Yekaterinburg. - 1991. - p.92-96) is that the possibility of residual increases in severe disease, increasing of the period of restoration of the liquor, is determined by the state of cellular immunity. This method of forecasting outcomes of serous meningitis is lengthy and expensive. When serous meningitis important early diagnosis outcomes, as early and adequate therapy reduces the risk of residual effects.

There are predictions of outcomes of neuroinfections by examining EEG and transcranial dopplerography (rosin Y.A. Dissertation on competition of a scientific degree of the doctor of medical Sciences. Bioelectric activity and hemodynamics of the brain in acute CNS in children: diagnostic criteria and prognosis of neurological complications. - Saint-Petersburg. - 1999. - p.153-171), comprising predicting the outcomes of meningitis and viral encephalitis in children using EEG and transcranial ultrasound dopplerography. The author using Doppler and electroencephalographic parameters assessed the outcomes of meningitis and viral encepha itov. When serous meningitis this method is not possible with sufficient accuracy to predict such residual violations zerebrasteniceski and neurasthenic syndromes, most commonly occurring in the outcome of serous meningitis.

In connection with the above, the technical result of the present invention is to improve the prediction accuracy, provided early diagnosis. This is achieved by using clinical assessment and ultrasound transcranial Doppler study of the cerebral vessels, the authors propose according to the method comprehensively to perform a lumbar puncture to measure CSF pressure, given pleocytosis, ultrasonic transcranial dopplerography of the brain, determine the linear speed of blood flow in the internal carotid and posterior cerebral arteries detect a violation of intracranial venous outflow by orbital and pozvonocnik veins, then calculate the formula of the mathematical model and whenpredicted a favorable outcome, and when- an unfavorable outcome. The model obtained by the method of logistic regression analysis statistically significant (p<0.0001)and reliable information (72%).

Using this model, the calculations can is to be made by the physician on the PC or on a programmable calculator in 3-5 days from the receipt of the patient to the hospital.

A significant contrast to the known methods for predicting outcome of serous meningitis is the fact that to determine the prognosis of disease outcome uses a combination of clinical and Doppler signs in the acute period of the disease, each of the signs receive a score on the basis of the obtained formula calculates the regression coefficient, which significantly improves the forecasting accuracy. The present method put we established the fact that none of the previously used signs, including signs, based on the assessment of clinical symptoms, data, research tools, in itself, is not sufficient to reliably predict the outcome of serous meningitis. Only their combined assessment gives an accurate prediction of outcome in the early stages of the disease. 32 we analyzed the characteristics most important for determining the outcome of the disease was 9 characteristics, the correlation coefficient was (r)>2,5 (p<0,05). For the convenience of mathematical processing all the children were divided into 2 groups: 1 - the favorable outcome (n=48), 0 - negative (n=76). The correlation coefficient was calculated using equation coefficient using the SPT EXEL and the most important among them were:

Table 1
The characteristics included in the model.
Designation in the modelSigns
X1The patient's age (years)
X2Placitas at the first lumbar puncture (CL/1 µl CSF)
X3The duration of meningeal symptoms (in days)
X4The presence of focal symptoms (1 -, 0 - no)
X5Duration cerebral symptoms (in days)
X6Spinal fluid pressure at the first lumbar puncture (mm Hg)
X7The linear speed of blood flow in the internal carotid artery (in Hz/sec)
X8The linear speed of blood flow in the posterior cerebral artery (in Hz/sec)
X9Violations of intracranial venous outflow USTDV brain: retrograde blood flow through the ophthalmic veins, increased blood flow in the veins of a vertebrate, etc. (1 - available, 0 - no)

Table 2
The correlation coefficient (r) (p<0,05)
X1X2X3X4X5X6X7X8X9
Exodus0,250,30,250,250,40,260,25-0,40,25

As can be seen from table 2, the outcome will have a direct influence of the age of the patient, Placitas, duration cerebral meningeal symptoms, the presence of focal symptoms, spinal fluid pressure. Diplomaticheskii indicators: linear speed of blood flow in the internal carotid artery, the violation of intracranial venous outflow, at the same time, the linear speed of blood flow in the posterior cerebral artery has an inverse dependence on the outcome of the disease.

Using the formula logistic regression in the SPT NCSS 2000 mathematical model of the outcome of serous meningitis:

X2
Table 3
The equation coefficients obtained using logistic regression analysis and their significance levels for the model
SignThe model coefficientsThe level of significance, p
X1- 0,160,000000
- 0,0020,000000
X30,070,006
X4- 18,740,000000
X5- 0,30,001
X6- 0,030,000000
X7- 3,050,000000
X81,750,000000
X9- 0,850,1
Constant6,18

The offered method is as follows. At the time of hospitalization of the patient is performed lumbar puncture in the supine position on the right side, at the level of L4-L5on line Jacobi, under local anesthesia and aseptic conditions. With a measurement of spinal fluid pressure (in mm Hg), mm water column was transferred to mm Hg, as follows: 1 mm VODL=9,81 PA, 1 mm Hg=133 PA. Calculate pleocytosis in the cerebrospinal fluid normal Svetovid the microscope, the cells in 1 μl of CSF. Before lumbar puncture performed ultrasound transcranial Doppler study of the internal carotid and posterior cerebral artery using a pulse sensor at 2 M Hz at a depth of 60-80 mm, modified by the I angle sensor and the depth of the control volume are seeking the location of the maximum flow velocity and determine its value. Define impaired venous outflow brain by identifying the retrograde blood flow in the ophthalmic and vertebrate veins show increased blood flow in pozvonocnik veins (1 - available, 0 - no). Take into account the patient's age (years), duration of meningeal and cerebral symptoms in days.

The outcome of the patient is calculated by substituting the obtained data in the following formula:

When- a favorable outcome;- an unfavorable outcome.

The following examples perform a method of determining the outcome of serous meningitis in children.

EXAMPLE 1

Daniel U., 5 years, no history of the disease 3417, received 7.08.02 issued 26.08.02. Ds: Serous meningitis moderate form of enteroviral etiology (entero 70 of liquor from 8.08.02). Concomitant diagnosis: Herpes lobialis.

History of disease: ill 7.08.02 with severe headache, vomiting 2% amid severe headache, photophobia. The history of life: Growing and developing according to age, immunizations according to age, VCI in the hospital, the specialists were not observed, childhood infections was not sick, injury denies. Heredity and risk factors is not burdened. Complaints received at a severe headache, photophobia. When receiving SOS is the right moderate due to the symptoms of intoxication and severity of VCG. Meningeal symptoms positive, stiff neck+, symptom of Cernica+, the upper and lower symptoms Brudzinskogo+. Performed lumbar puncture 8/08: transparent liquor, liquor pressure of 9 mm Hg, lymphocytosis 18 cells in 1 μl of CSF protein has 0.168, lymphocytes 92%, neutrophils 8%, sugar 2.9 mmol/l, chlorides 115 mmol/L. the ultrasound transcranial Doppler cerebral blood vessels: blood flow in the carotid system normokinetic symmetric, signs of venous discirculatory no. (The linear speed of blood flow in the internal carotid artery 2 Hz/sec, the linear speed of blood flow in the posterior cerebral artery - 1,9 Hz/sec).

In the dynamics of observations obstipation syndrome was arrested on the 2nd day of hospitalization, meningeal and cerebral symptoms cropped the next day hospitalization. When re PL on the 17th day of hospitalization 23/08: lymphocytosis - 3 cells/ml, at the expense of mononuclear cells, protein - 0.06 g/l

The calculation was made of the likely outcome of the patient on the 3rd day of hospitalization:

- expected favorable outcome of the disease.

Issued on the 19th day of hospitalization with recovery during the follow-up monitoring within 1 year of the complaints, the child does not impose, neurological symptoms are not present. EEG age norm. The outcome of RA is valuable as a complete recovery.

Example 2

Marina F., case history No. 2541, 14 years old, was admitted 30.04.2002, issued 2.06.02. The diagnosis of Mumps is a viral infection: serous meningitis+submaxima, severe; and concomitant diagnosis: vaccination against mumps from 12.04.2002 g (series 0860, 0.5 dose). Anamnesis morbi: pain in acute 29.04.2002, (on the 17th day after revaccination against the disease. mumps), with increasing temperature 39,1, vomiting up to 6 times. Diagnosed with SARS, meningitis? focused on admission to the Department of neuroinfection NEEDY. Complaints received at a severe headache, vomiting and fever. Objectively at entry: moderately grave condition due to symptoms of intoxication. Meningeal symptoms at admission questionable: the rigidity of the muscles of the nape+/-, other meningeal symptoms are not present. On day 2 of hospitalization (2.05.2002 g) meningeal symptoms clear: the rigidity of the muscles of the neck+, symptom of Cernica+. Increased muscle tone along the pyramidal type symmetrically, increased tendon reflexes symmetrical, coordinatorsee violations within 4 days. To exclude meningitis performed lumbar puncture: CSF transparent, spinal fluid pressure of 15 mm Hg, lymphocytosis 866 cells in 1 μl of CSF, mononuclear cells 65%, segmented 45%, protein 3.88 g/l, sugar 2.8 mmol/l, chloride 106 mmol/l Of liquor selected antigen of the virus of epidemic pairs is Titus. Found in the blood of antibodies of class Ig M and Ig G in saliva selected antigen mumps. Conducted transcranial Doppler cerebral vessels 2.05.02: blood flow in the carotid system normokinetic symmetric, retrograde blood flow through the ophthalmic veins, increased blood flow in the veins of a vertebrate. (The linear speed of blood flow in the internal carotid and posterior cerebral arteries - 2 Hz/s, the index of the circulatory resistance supraclavicular and anterior cerebral arteries - of 0.54 and 0.59 respectively, disorders of intracranial venous outflow - 1).

In the Department of child fever continues to subfebrile figures within 6 days. Meningeal symptoms were observed up to 5.05.2002, (6 days). On the 13th day of hospitalization, the 14th day of the disease (12.05.2002, appears submaxima more to the right, in connection with which the child transferred to the isolation ward. With repeated lumbar puncture on the 24 day 25 day of hospitalization diseases (23.05.2002,): lymphocytosis 62/3 by mononuclear 61/3, neutrophile 1/3 protein 0,265 g/L. In General, the analysis of blood for admission: stab shift 12%, neutrophiles 63%, erythrocyte sedimentation rate, white blood cells, red blood without features; currently the General analysis of blood within the age limit.

The calculation was made of the likely outcome of the patient on the 6th day of hospitalization:

- predicted poor outcome.

Issued on the 30 day of hospitalization in a satisfactory condition. During the follow-up observation of the child within 3 months were found to have symptoms of intracranial hypertension and asthenoneurotic syndrome, 6 months after discharge on EEG during hyperventilation paroxysmal activity of the cerebral cortex generalized character.

Example 3

Yang B., 13 years old, no history of the disease 4386, received 2.10.02., discharged 16.10.02. The diagnosis of Serous meningitis enteroviral etiology (ECHO 6 of liquor from 3.10.), the intermediate form.

Complaints received at a severe headache, photophobia.

History of disease: ill 1.10 with severe headache, vomiting 5 times, photophobia.

The history of life: Growing and developing according to age, immunizations according to age, VCI in the hospital, the specialists were not observed, childhood infections chickenpox chickenpox, the concussion in 6 years. Heredity and risk factors is not burdened.

When entering a state of moderate severity due to the symptoms of intoxication and severity of intracranial hypertension. Meningeal symptoms slabopolozhitelnym, stiff neck±a symptom of Cernica+, the upper and lower symptoms Brudzinski is -.

Performed lumbar puncture 3.10: the liquor flowed transparent, under normal pressure of 7 mm Hg, lymphocytosis 67 cells in 1 μl of CSF due to mononuclear 60%, protein 0.3 g/l sugar in the liquor 3 mmol/l, chloride in the liquor 109 mmol/L.

Conducted transcranial Doppler ultrasound 3.10: the blood flow in the carotid system normokinetic, symmetric, signs of venous discirculatory no. (The linear speed of blood flow in the internal carotid artery and posterior cerebral artery: 2 Hz/sec).

Conducted EEG 7.10: moderate diffuse disorders of bioelectric activity with irritating of the cerebral cortex.

In the dynamics of observations obstipation and cerebral symptoms cropped on day 2 of hospitalization, meningeal symptoms cropped on the 3rd day of hospitalization.

Calculation of the likely outcome of the patient on the 4th day of hospitalization:

- predicted a favorable outcome.

Discharged on the 14th day of hospitalization with recovery. On follow up had no complaints, neurological status without features. EEG 6 months after discharge: age norm Exodus regarded as complete recovery.

Example 4

Roman Century, 9 years old, no history of the disease 3806, received 1.09.02 issued 19.09.02. The diagnosis of Serous m is ningit, the intermediate form, enteroviral etiology (ECHO 15 of liquor from 2.09).

Complaints received at a severe headache, vomiting.

History of disease: Ill 28.08 with headache and fever up to 39.5°C. 29.08 temperature and feeling normal. 31.08 again raising the temperature up to 37.5°With headache. 1.09 severe headache, vomiting, body temperature 36,6°C.

The life history: life History: Grew and developed according to the age, immunizations according to age, VCI in the hospital, the specialists were not observed, childhood infections chickenpox - chickenpox, measles, rubella, infectious mononucleosis. Trauma and surgery denies. Heredity and risk factors is not burdened.

When entering a state of moderate severity due to the symptoms of intoxication and severity of intracranial hypertension. Meningeal symptoms slabopolozhitelnym, stiff neck±a symptom of Cernica+, the upper and lower symptoms Brudzinskogo-.

Performed lumbar puncture 2.09: the liquor flowed transparent, under high pressure of 16 mm Hg, lymphocytosis 108 cells in 1 μl of CSF due to mononuclear 77%, protein 0,165 g/l, sugar in the liquor 2.5 mmol/l, chloride in the liquor 106 mmol/L.

Conducted transcranial Doppler ultrasound 3.10: the blood flow in the carotid system is e normokinetic, symmetric, signs of venous discirculatory no. (The linear speed of blood flow in the internal carotid artery and posterior cerebral artery: 2 Hz/sec).

In the dynamics of monitoring cerebral symptoms cropped on day 1 of hospitalization, meningeal symptoms cropped on the 5th day of hospitalization. With repeated lumbar puncture: 16.09: liquor flowed transparent with normal pressure of 7 mm Hg, lymphocytosis - 6 by mononuclear 90%protein - a 0.1

Calculation of the likely outcome of the patient on the 4th day of hospitalization:

- predicted a favorable outcome

Issued on the 19th day of hospitalization with recovery.

On follow up had no complaints, neurological status without features. EEG 6 months after discharge: age norm. The outcome is regarded as complete recovery.

Table 4
The test of the proposed method compared with the real.
The group of patientsThe prototype (people)Real outcomes (people)
Patients with residual phenomena6276
Patients without residual effects 3648

In the group of patients with unfavorable outcome (n=76) investigated the model provides the coincidence of the predicted results with the actual in 81,6% of cases (62 of 76 cases). In the group with a favorable outcome (n=48); in the group of patients with a favorable outcome match the predicted outcomes and the actual was 75% (36 out of 48 cases). Statistical significance of the model is (p<0,0001), information accuracy of 72%.

This method allows after the relief of cerebral and meningeal symptoms to predict the possible outcome of the patient, which is an important factor in reducing the frequency of residual neurological effects after suffering serous meningitis by adequate therapy in the acute period, and at the stage of follow up.

A method for predicting outcomes of serous meningitis in children, including the assessment of the clinical and research vessels of the brain by ultrasound, transcranial Doppler, characterized in that to determine the patient's age in years (X1), Placitas at the first lumbar puncture in CL/1 µl of CSF (x2), duration meningeal symptoms in days (X3), presence of focal symptoms: 1 -, 0 - no (X4), duration cerebral symptoms in days (X5), measure the CSF pressure at the first l is malnoy puncture in mm Hg (X6), the linear speed of blood flow in the internal carotid artery in Hz/sec (X7), the linear speed of blood flow in the posterior cerebral artery in Hz/sec (8x), detect the presence of disorders of intracranial venous outflow vertebrate eye and veins: 1 - available 0 - no (X9), then calculates the regression coefficientaccording to the formula:

and whenpredict adverse outcome with the formation Serebryanicheskaya, asthenoneurotic and hypertensive syndromes, and whena favorable outcome of infection.



 

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