What symptoms are observed with syphilitic meningitis. What is neurosyphilis, its diagnosis and treatment? Pelvic organ dysfunction

The content of the article

Damage to the nervous system syphilis It is customary to subdivide into early and late forms (early and late neurosyphilis). In early neurosyphilis, the membranes and vessels of the brain are affected, the mesenchymal reaction predominates, parenchymal elements can sometimes be involved in the process, but secondary. It is believed that early forms of neurosyphilis occur up to 5 years from the moment of infection (mainly in the first 2-3 years). With late neurosyphilis, nerve cells, nerve fibers and glia are affected, the changes are inflammatory-dystrophic in nature, while the mesenchymal reaction recedes into the background. It is believed that late forms of neurosyphilis can occur only many years (not earlier than 7-8) after infection with syphilis. Early neurosyphilis is called mesenchymal, and late neurosyphilis is called parenchymal neurosyphilis.
Lesions of blood vessels or membranes of the brain are often referred to as syphilis of the brain (lues cerebri), and in the presence of symptoms of damage to the brain and spinal cord, the disease is regarded as cerebrospinal syphilis.

Early neurosyphilis

Early syphilitic meningitis. Lesions of the meninges in the first few years from the moment of infection can be of varying degrees of severity: from hidden (latent) forms to acute generalized meningitis.
In most patients with latent meningitis, clinical symptoms are not detected. Some patients complain of headaches (“heavy head”), tinnitus, hearing loss and dizziness. Occasionally, hyperemia of the optic nerve head and papillitis are detected. The diagnosis is made on the basis of pathological changes in the cerebrospinal fluid, in which, in early latent meningitis, the inflammatory (protein, cytosis) components often predominate rather than the degenerative (Wassermann, Lange reactions) components.
Syphilis- practically the only infection that can cause changes in the cerebrospinal fluid in the absence of clinical symptoms of meningitis, therefore in this case the specific (i.e. syphilitic) etiology of such meningitis is indicated, calling this form latent (latent) syphilitic meningitis.
When treating early latent syphilitic meningitis, which accompanies early active forms of syphilis, use the instructions approved by the USSR Ministry of Health in 1976 (according to the form of syphilis present in the patient), with the only difference that 20% of the antibiotic is added to each course of therapy and more often use nonspecific agents, in particular pyrogenic drugs (pyrogenal, prodigiosan, etc.).
Acute generalized (manifest) syphilitic meningitis is currently extremely rare. It develops over 1-l.5 weeks (all membranes of the brain are involved in the process) and is accompanied by increasing headache, dizziness, tinnitus, vomiting not associated with food intake, a stream that occurs, without the urge to nausea. The temperature rises. Objectively, rigidity of the neck muscles, positive Kernig's signs, and lower Brudzinski's sign are noted. The appearance of pathological reflexes (Babinsky, Oppenheim, Rossolimo) and possible anisoreflexia indicate involvement in the process, in addition to the membranes, of the brain substance, i.e., meningoencephalitis.
An ophthalmological examination in some cases reveals hyperemia of the optic nerve head and papillitis. At the height of the disease, deafness and vascular disorders (strokes, paresis) may occur.
Acute generalized syphilitic meningitis occurs more often during the period of relapse of syphilis (5-8 months from the moment of infection), it may be the only manifestation of relapse of syphilis (i.e., without rashes on the skin and mucous membranes). The cerebrospinal fluid is dramatically changed: the protein content is increased, the cytosis of 200-400-1000 cells (mainly lymphocytes) in 1 μl (or they completely cover the entire field of view), the Lange reaction is often expressed as paralytic (6655432100) or meninthitis (0012345420 ) curve.
The described changes can be observed in acute meningitis of any etiology and only a sharply positive Wasserman reaction in the cerebrospinal fluid (more than 50-70% of patients), positive serological blood reactions, as well as positive reactions of immobilization of pallidum treponema (RIBT), immunofluorescence (RIF) and medical history indicates a syphilitic etiology of acute meningitis. Previously, this form of early neurosyphilis was often fatal, especially in cases of acute meningoencephalitis.
Treatment of early neurosyphilis In order to prevent the development of late forms of neurosyphilis, preventing the formation of penicillin-resistant forms of Treponema pallidum, it is necessary to saturate the body with penicillin around the clock (200,000-500,000 units every 3-4 hours) in a total dose per course of at least 18,000,000-24,000,000 units .
Subacute syphilitic meningitis It primarily affects the base of the brain and is therefore often called basal meningitis. It is much more common than acute generalized syphilitic meningitis. The clinical picture of this lesion summarizes the symptoms of meningitis and neuritis of the cranial nerves. In addition to headache and dizziness, nausea and vomiting occasionally occur. Kernig's and Brudzinski's symptoms and pathological reflexes are usually absent. Mild ptosis, facial asymmetry, smoothness of the nasolabial fold, deviation of the tongue to the side, and drooping of the soft palate are more often observed.
Syphilitic neuritis of the optic nerve with basal meningitis, as a rule, is bilateral and entails early impairment of visual functions. In this case, first of all, central vision decreases from slight blurring to almost complete blindness, for which patients usually turn to an ophthalmologist. These disorders are not accompanied by pain in the eye area. There is a partial change in the visual fields or a concentric narrowing of the boundaries of the visual fields. Sometimes the boundaries of the visual fields narrow to red and green colors, but change relatively little to white. Ophthalmoscopically, hyperemia of the optic disc, blurring of its boundaries, slight swelling of the disc tissue, expansion and tortuosity of the veins (the arteries change little) are detected. Hemorrhages on the disc and in its circumference are often observed, the retina around the disc becomes cloudy, hemorrhages and sometimes white degenerative lesions are also found in it. A favorable outcome of syphilitic optic neuritis is possible only if vigorous antisyphilitic treatment is started in a timely manner. In severe (advanced) cases, the disease can result in complete blindness.
Sometimes with basal meningitis, the VIII pair of cranial nerves is involved in the process. At the same time, most authors attach decisive diagnostic importance to the occurrence of bone-air dissociation (a sharp decrease or disappearance of bone conduction while maintaining air conduction), detected with a C128 tuning fork or audiography.
Basal meningitis occurs in 10-20% of all cases of early neurosyphilis. With it, the pathology in the cerebrospinal fluid is less pronounced than with acute syphilitic meningitis: protein up to 0.6-0.7 g/l, cytosis - 20-40 cells in 1 μl, the Wasserman reaction is positive, the Lange reaction curve has the appearance of a syphilitic wave or type of minimal pathology (three twos or one three).
Much less often, the membranes of the convex surface of the brain are involved in the process. In these cases, the clinical picture resembles cerebral vascular syphilis (Jacksonian seizures, aphasia, apraxnia, etc.) or progressive paralysis (intellectual impairment, behavioral abnormalities).
When carrying out differential diagnosis, it is taken into account that with vascular syphilis of the brain, pathology is often not detected in the cerebrospinal fluid, and with progressive paralysis, the Lange reaction always gives a paralytic type of curve.

Syphilitic meningomyelitis

Syphilitic meningomyelitis can occur in untreated or insufficiently treated patients with early syphilis, and its frequency among all forms of early neurosyphilis in recent decades does not reach 0.5% of cases [Milich M.V., 1980]. It must be differentiated from myelitis of another etiology, spinal cord tumor and metastatic tumors, thrombosis of the spinal cord vessels and the spinal form of multiple sclerosis.

Syphilitic myelitis clinic

Sometimes syphilitic meningomyelitis occurs suddenly, has a rather acute course and leads to paralysis (paraplegia) of the lower extremities with deep trophic disorders (formation of bedsores), reduction or loss of various types of sensitivity, and disruption of the sphincters. When the membranes of the spinal cord are damaged at the level of the lumbosacral segments, a picture of meningoradiculitis (“spinal sciatica”) arises, which has recently progressed relatively favorably. When the process is predominantly localized along the posterior surface of the spinal cord, the clinical picture of myelitis may resemble the clinical picture of tabes dorsalis (pseudotabes syphilitica) - decreased tendon reflexes in the legs, staggering in the Romberg position, dysfunction of the pelvic organs, superficial sensitivity in the legs, etc. In contrast to true tabes These disorders arise early (1-3 years after infection), occur against the background of hypertension of the muscles of the legs and thighs (with tabesa - hypotension) and are relatively quickly suppressed as a result of specific treatment.

Diagnosis of syphilitic myelitis

The diagnosis of syphilitic myelitis is confirmed by positive serological blood tests, positive RIBT, RIF and pathological indicators of cerebrospinal fluid (the Wasserman reaction is always positive). Ex juvantibus therapy is of limited value, since, unlike other forms of early neurosyphilis, syphilitic meningomyelitis (except in some cases of meningoradiculitis) is very often resistant to antisyphilitic treatment.

Late diffuse meningovascular syphilis

The meninges are moderately involved in the process, so the symptoms of meningitis in this form are not pronounced (persistent but mild headache, sometimes dizziness).
Symptoms of the disease are determined mainly by vascular damage and often clinically resemble a cerebral stroke. Vaacular origin of damage to the cranial nerves, sensitivity disorders, paresthesia, reflex disorders, hemiparesis, epileptiform seizures, alternating paralysis, speech and memory disorders, asthenia, etc. may occur.
Hemiplegia is most often caused by specific arteritis of one of the branches of the carotid or vertebrobasilar artery system.

Syphilis of the cerebral vessels (vascular syphilis)

With this form of late neurosyphilis, the membranes and substance of the brain are not involved in the process, so the cerebrospinal fluid is always normal. The disease is more common in people aged 30-50 years and is characterized by the deposition of a specific infiltrate in the vessels of the brain, which leads to the development of thrombosis and stroke.
The difficulty of diagnosis lies in the fact that in 60-70% of cases the standard complex of seroreactions (RV, Kahn, Sachs-Vitebsky reactions) turns out to be negative.
Late vascular syphilis of the brain can be combined with other forms of neurosyphilis, in particular with tabes dorsalis, and visceral syphilis. You should also remember about the possible combination of atherosclerosis and syphilis of the cerebral vessels, and this pathology is observed more often the older the patient is. Sometimes only a trial treatment finally resolves this issue.

Tabes dorsalis

Tabes dorsalis mainly affects the dorsal roots, dorsal columns and membranes of the spinal cord. In rare cases, only the cervical region ("upper tabes") is affected, more often the lumbar region ("lower tabes"), or both sections at the same time. In these parts of the spinal cord, processes of proliferation and destruction occur in parallel. Some symptoms associated with proliferative processes may undergo regression if treatment is started in a timely manner. The changes resulting from destruction are irreversible.
Characteristic are shooting (“dagger”) pains, drilling pains and pains of a tearing nature. Sometimes they resemble pain during gastric or cardiac crises (simulating angina), renal or hepatic colic, cystic or rectal crises. Such pain during tabes can appear and disappear suddenly, and can last from a few seconds to several days.
Paresthesia in the form of a feeling of encirclement, compression, compression in certain areas of the body, they currently occur in only 3-5% of patients with tabes dorsalis. This segmentation of the lesion is associated with the localization of the process at certain levels of the spinal cord. With paresthesia, there may be sensations of numbness, “crawling goosebumps,” and tingling in the legs, especially in the soles.
Disorders of urination, defecation, impotence. At first, there are difficulties when urinating, which are then replaced by urinary incontinence. Sometimes persistent constipation appears, less often - fecal incontinence. Impotence that occurs in the presence of other symptoms of tabes can be regarded as tabetic.
Cranial nerve dysfunction occurs in the form of paresis of the oculomotor nerves - ptosis, strabismus. Pupillary disorders are typical: the shape and size of the pupils and the Argyll Robertson symptom change (lack of pupillary reaction to light while maintaining close gaze). In the absence of Argyle Roberts's symptom, some patients with tabes dorsalis may experience sluggish photoreactions or absolute reflex immobility of the pupils. Primary tabetic atrophy of the optic nerves has two forms: progressive, which leads the patient to blindness over several months, and stationary, in which vision is reduced to a certain limit and no further decline occurs. Bilateral damage is typical.
Primary tabetic optic atrophy may be the only manifestation of tabetic optic atrophy and should be differentiated from other primary atrophies. The progressive form is always accompanied by an exacerbation of syphilitic meningitis with pronounced pathology in the cerebrospinal fluid.
Ophthalmoscopically, at first, only some pallor of the optic nerve head is detected (visual disturbance is still absent at this time). The color of the disc then becomes greyish, greyish-white or greyish-blue. Dark dots appear at the bottom of the eye - holes in the cribriform plate through which the disappeared nerve fibers passed. The boundaries of the disc are sharply defined, the surrounding retina is not changed. The vessels are also preserved. Changes in the disc usually appear much earlier than the loss of vision begins (in this regard, the importance of ophthalmoscopic examination of patients with syphilis becomes clear). Currently, primary optic atrophy occurs in 6-8% of tabes cases. Inner ear disease may be the earliest symptom of tabes dorsalis. In the later stages of tabes, the patient develops a characteristic ataxic gait: he first stands on his heels, then on the entire foot (“stamps with his heels”); staggers while walking, especially in the dark or with closed eyes. Impaired coordination is caused by damage to the posterior columns and, as a result, a disorder of the muscular-articular sense. In the earlier stages of the disease, instability in the Romberg position is detected, as well as disorders of deep muscle-articular feeling.
Tendon reflexes in the lower extremities are affected more often during tabes than in the upper extremities, since the lumbosacral spinal cord is affected more often than the cervical cord. At the beginning of the disease, the knee and Achilles reflexes increase (sometimes with an expansion of the reflexogenic zone), and then fade and completely disappear.
Surface sensitivity disorders are polymorphic, they often appear dissociated. Tactile sensitivity suffers most often, then pain sensitivity. Zones of impaired sensitivity look like belts (on the body) and spots (on the neck and face). Both hyperesthesia and hypoesthesia are noted. Some authors attach particular importance to the appearance of cold hyperesthesia (especially on the back, at the level of the shoulder blades), which is sometimes the first and only symptom of the onset of tabes dorsalis.
Tabetic arthropathy (Charcot's joint) leads to changes in the size, shape and configuration of joints in 1% of patients with tabes. Usually the process involves one, sometimes two joints. Most often the knees are affected, less often the hip joints and spine. The phenomena of osteoporosis develop in the bones, as a result of which fractures easily occur; they are noted in 2-8% of cases of tabetic arthropathy. A feature of tabetic arthropathy is its painlessness; in very rare cases, there is pain that gets worse at night.
Trophic disorders manifest themselves as painless foot ulcers (mal perforans pedis), as well as painless tooth loss, impaired nail growth, hair loss, osteopathy, and decreased sweating.
Serological reactions and cerebrospinal fluid. According to most authors, in 25-50% of patients, tabes dorsalis occurs with negative standard serological tests of blood and normal cerebrospinal fluid. RIBT is positive in more than 95% of cases and therefore its staging significantly helps in diagnosing tabes. The positivity rate for the RIF is also high.
In recent decades, the clinical picture of tabes described above either does not occur at all or is extremely rare: there are no tabetic pains, crises, paresthesias, dysfunction of the pelvic organs (i.e., subjective disorders), tabetic gait, etc. Currently, the disease is mild , smoothed. Consequently, the concept of pathomorphosis of tabes dorsalis is quite applicable here. In this regard, it seems that the concept of “low-symptomatic” and, in some cases, “rudimentary” tabes will be more consistent with the true state of affairs. Among the symptoms of classical tabes, with low-symptomatic (rudimentary) tabes, pupillary disorders (miosis, aisocoria), symptom Argyll Robertson, bone-air dissociation, mild ataxia (rocking in the Romberg position), impaired tendon reflexes and rarely primary tabetic atrophy of the optic nerves, arthropathy. In the absence of damage to vision and joints, patients with tabes now rarely seek medical help on their own (there are no subjective disorders), but are actively identified among people who have been insufficiently treated for early forms of syphilis, or by chance during a medical examination while in the hospital for another reason.
To diagnose low-symptomatic tabes, the presence of cardiovascular syphilis in the patient, which is observed in 12-15% of patients with tabes, sometimes helps. However, lesions of the aorta most often in these cases are asymptomatic.

Gumma brain

Gumma of the brain or spinal cord is now very rare. The first, as a rule, develops in the pia mater, but can later spread to the area of ​​the dura mater. It is possible that single large gummas of the brain or many small gummas may appear, which, merging, resemble a brain tumor in their course. The most common localization of gumma is the area at the base of the brain; less often, gumma is located in the substance of the brain.
Gumma of the brain entails a mild increase in intracranial pressure. Clinically, it resembles a brain tumor and is accompanied by various neurological symptoms, which are determined by its location. The patient's medical history (syphilis, insufficient treatment), positive RVs in the blood and cerebrospinal fluid, the “syphilitic wave” of the Lange reaction curve, positive results of RIBT and RIF allow one to suspect gumma.
The spinal cord gumma is often solitary. Symptoms depend on its location and size. Developing from the meninges, gumma causes the appearance of increasing radicular pain and paresthesia. Then disturbances of the motor and sensory spheres and the functions of the pelvic organs occur. Symptoms of a complete transverse spinal cord lesion may develop within a few months.

Treatment of late forms of syphilis

Treatment of patients with late forms of syphilis of the nervous system begins with the administration of drugs containing iodine and bismuth, according to the current instructions of 1976. Potassium iodide or sodium iodide is prescribed orally in the form of a 3% solution, 1 tablespoon 3 times a day after meals, washed down with milk. If well tolerated, switch to a 4-5% solution of iodides. Following the 2-week indicated therapy, bioquinol is prescribed 1 ml intramuscularly every other day. After three injections (if well tolerated), switch to a single dose of 2 ml intramuscularly every other day. Having introduced 10-12 ml of bioquinol, treatment with this drug is interrupted and penicillin therapy is started at 200,000 units every 3 hours around the clock, for a course of 40,000,000 units, after which injections of bioquinol are resumed to a total dose of 40-50 ml (including bioquinol received before penicillin ). After a 2-3 month break, a similar course of penicillin therapy is prescribed, followed by a course of treatment with bismoverol (1.5 ml 2 times a week intramuscularly).
After a second 2-3 month break, another 1-2 courses of treatment with heavy metal salts are carried out, depending on the indications of serological blood reactions, and at this point the treatment of this group of patients is considered complete.
If gumma of the brain or spinal cord is detected in a patient, after 3-4 weeks of preparation with drugs containing iodine, 2-3 courses of treatment with heavy metal salts are carried out, then one massive course of penicillin therapy, as indicated above. Treatment of these patients ends with one or two courses of treatment with salts of heavy metals.
The criterion for the saturation of anti-syphilitic treatment is mainly the data of clinical and liquorological examination (indicators of serological reactions play a lesser role in assessing the quality of therapy).

Syphilitic meningitis can be observed in all stages of syphilis, but more often in secondary and tertiary stages.

Early neurosyphilis lasts on average 2 to 3 years. Meningitis that develops during this period of the disease is classified as early, and meningitis that develops in the later period of neurosyphilis is classified as late syphilitic meningitis. Syphilitic lesions of the soft meninges can occur acutely, subacutely and chronically.

Unlike meningitis of other etiologies, syphilitic meningitis is often clinically asymptomatic, which served as the basis for identifying a special form of early neurosyphilis - latent syphilitic meningitis. With it, neither objective nor subjective symptoms of damage to the nervous system are detected, but there are changes in the cerebrospinal fluid:

pleocytosis (from single to 300 or more predominantly lymphocytic cells in 1 μl) with a normal or slight increase in protein content (up to 0.45-0.6‰)

globulin and colloid reactions are weakly positive or negative,

specific serological reactions in most patients are positive;

Cerebrospinal fluid pressure is usually elevated.

These changes are noted:

up to 6 months after infection in 8.1% of cases,

up to 1 year - in 33%,

up to 2 years - in 25.8%,

up to 3 years - in 22.8% of cases.

Treatment with specific antisyphilitic drugs has a great influence on changes in the cerebrospinal fluid.

In a number of patients with latent meningitis, examination can reveal erased symptoms of damage to the central nervous system: headache, dizziness, pain in the extremities, decreased pain sensitivity in the legs, limited trigeminal neuralgia, erased focal lesions. Meningitis that occurs in the first year and a half of the disease, 1-1.5 months after the end of a course of specific treatment, is defined as a neurorelapse and indicates inadequate treatment. Latent meningitis can develop in patients with late latent syphilis.

Manifest meningitis (acute febrile syphilitic cerebral) is characterized by an acute or subacute onset, an increase in temperature (usually to subfebrile levels), severe meningeal syndrome, and a variety of focal lesions of the nervous system. Headache, vomiting, general hyperesthesia are noted, and epileptic seizures are possible. A number of patients experience mental disorders - depression or emotional disinhibition, psychomotor agitation. Paresis of the III, IV, VII pairs of cranial nerves and congestion in the fundus are relatively common. In the cerebrospinal fluid, pleocytosis reaches 1000-2000 cells per 1 μl, lymphocytes predominate, but there are also neutrophil granulocytes, the amount of protein is increased; Fibrin film loss may occur. Serological reactions in the cerebrospinal fluid are positive in most cases; sometimes treponema pallidum is found.

The following forms of manifest meningitis are distinguished:

acute syphilitic hydrocephalus due to occlusion at the level of the posterior cranial fossa with congestion in the fundus, headaches and vomiting;

convexital acute meningitis, occurring with epileptic seizures and mental disorders;

basal meningitis with damage to cranial nerves;

spinal meningitis, in which the soft meninges are affected either diffusely or more often in the thoracic region with simultaneous damage to the roots and substance of the spinal cord (meningomyelitis, meningoradiculitis).

The course of manifest syphilitic meningitis is highly variable: in some cases it is rapid, in others it is slow, sometimes recurrent. It largely depends on the treatment. In patients with contagious forms of syphilis, meningitis before treatment is characterized by slowly, over several months, progressive meningeal symptoms, and after treatment - by the absence or mild severity of cerebral and meningeal symptoms.

In children, meningitis is a fairly common manifestation of congenital syphilis. Meningeal syndrome is not pronounced; moderate lymphocytic pleocytosis (100-150 cells per 1 μl), increased protein content, and positive serological reactions are observed in the cerebrospinal fluid. Sometimes the fluid is hemorrhagic. In the fundus there is atrophy of the optic nerves. Individual cranial nerves are affected. The transition of the inflammatory process to the brain substance causes the clinical picture of meningoencephalitis, in which focal symptoms and convulsions occur.

Diagnostics

The diagnosis of syphilitic meningitis is based on clinical and laboratory data.

Syphilitic meningitis

Syphilitic meningitis most often develops in the second stage of syphilis and occurs in the form of latent or acute meningitis, which is characterized by high fever with pronounced meningeal symptoms. It differs from cerebrospinal meningitis in the nature of changes in the cerebrospinal fluid and positive serological reactions. In later cases of syphilis, gummous syphilitic meningitis may occur, characterized by a sluggish course, with exacerbations, damage to the cranial nerves. mild meningeal syndrome, but with positive serological reactions of the cerebrospinal fluid. Treatment of syphilitic meningitis is specific (see Brain. Syphilis of the brain).

Syphilitic meningitis is observed in all stages of syphilis, starting from its first manifestations, but most often in the secondary and tertiary stages. The initial period of neurosyphilis lasts on average from 2 to 3 years, and meningitis developing during this period of syphilis should be considered early. But according to G.V. Robustov, in the first year of syphilis, asymptomatic meningitis occurs, with secondary recurrent syphilis, acute syphilitic meningitis develops, and between these two forms there are transitional forms with erased symptoms. Syphilitic lesions of the soft meninges can develop acutely, subacutely and chronically. Acute syphilitic meningitis occurs in the initial period and with neurorelapses; subacute and chronic are possible in all stages of syphilis.

Pathological anatomy. The main form of damage to the soft meninges in early neurosyphilis is a serous inflammatory process. According to the histological picture, these serous meningitis are similar to meningitis of another etiology, and only the detection of spirochetes in exudate-impregnated membranes finally establishes the syphilitic etiology of these serous meningitis. Macroscopically, with syphilitic meningitis, thickening and clouding of the soft meninges is detected, most often at the base of the brain in the area of ​​the optic chiasm and on the convex surface of the frontal and occipital lobes. Microscopically, lymphocytes predominate in the exudate. The walls of the vessels of the meninges undergo a number of changes, up to the formation of obliterating endarteritis. In the membranes of the spinal cord, lymphoid infiltration and new formation of granulation tissue with transition to scarring are also observed, as a result of which adhesions occur with narrowing and obliteration of the subdural and subarachnoid spaces and impaired circulation and outflow of cerebrospinal fluid. As a rule, with syphilitic meningitis, the process spreads to the substance of the brain and spinal cord, to the roots of the spinal and cranial nerves. In the later stages of early neurosyphilis, productive changes begin to predominate with the formation of granulation tissue and granulomas (gummy meningitis).

Clinical picture and course. Early syphilitic meningitis can manifest itself in various clinical forms. 1. The most common form is latent, or asymptomatic, syphilitic meningitis, in which there are no signs of damage to the nervous system. With this form of meningitis, there are mainly only changes in the cerebrospinal fluid in the form of pleocytosis (20-50-100 cells per 1 mm3) with a normal or slight increase in the amount of total protein (up to 0.45‰); the Wasserman reaction in liquid is positive in most patients, the Wasserman reaction in the blood can be negative (D. A. Shamburov).

Asymptomatic syphilitic meningitis is observed in 9.5% of all patients with fresh syphilis and is more common in the first year after infection, and then its frequency decreases (M. S. Margulis).

2. A number of patients with minor changes in the cerebrospinal fluid have complaints of headache, dizziness, tinnitus, and pain in the extremities. Headache may depend on increased cerebrospinal fluid pressure and irritation of membrane receptors. This irritation spreads to the spinal roots and cranial nerves, which is clinically expressed by trigeminal and occipital neuralgia, radicular pain and paralysis of individual nerves. The phenomena of irritation and loss from the cranial nerves and spinal roots, as well as more or less pronounced changes in the cerebrospinal fluid in the initial stages of early neurosyphilis are the link between them and the so-called neurorelapses.

Acute syphilitic meningitis, occurring in the first year and a half of the disease after 1-1.5 months. after the end of the course of treatment, it is called neurorelapse (see). Among patients with clinical and serological relapses after insufficient specific treatment of early forms of syphilis, meningitis is observed in more than 40% of cases (P. E. Maslov, G. V. Robustov and N. M. Turanov). G.V. Robustov believes that neurorelapses represent an acute, very early activation of the syphilitic process in the central nervous system and are an important indicator of inadequate treatment. Neurorelapses are expressed in damage to the facial and auditory nerves and the phenomena of acute meningitis; Sometimes acute hydrocephalus with congestive nipples and Meniere's symptom complex are observed. There is also damage to the optic nerves on both sides in the form of papillitis, retrobulbar neuritis and optic neuritis. Damage to the oculomotor nerves results in mild paresis or paralysis of the eye muscles. Facial nerve paralysis is often unilateral, peripheral; Cerebrospinal fluid in neurorelapses gives pronounced pleocytosis with a slight increase in the amount of protein.

3. Acute febrile syphilitic cerebrospinal meningitis is characterized by an acute onset, fever, and rapid development of the clinical picture. The temperature is often low-grade, severe headaches, vomiting, and often epileptiform seizures. Kernig's and Brudzinski's symptoms and neck stiffness are evident; a number of patients experience mental disorders in the form of agitation or depression; paralysis of the oculomotor nerves (strabismus, diplopia, ptosis), as well as peripheral paresis of the facial nerve, are common. In the cerebrospinal fluid, changes are expressed much more sharply than in the two previous forms, especially pleocytosis, which reaches 2000 cells per 1 mm 3; the cells are mainly lymphocytes with a small admixture of neutrophils; the amount of protein is increased to 0.66‰, and sometimes to 1.2‰, the Wassermann reaction in the cerebrospinal fluid is always positive, which distinguishes this type of meningitis from other serous meningitis. The liquid is clear, sometimes cloudy; when standing, a fibrinous clot may form, as in tuberculous meningitis. Spirochetes are sometimes found in the liquid.

The course of acute febrile syphilitic meningitis is variable - in some cases fast, in others slow, and sometimes recurrent. Fatalities are rare; Properly administered therapy results in improvement and even recovery.

In children, meningitis develops due to congenital syphilis, the meningeal syndrome is mildly expressed, and individual cranial nerves are involved: when the process passes to the substance of the brain, convulsions and focal symptoms sometimes appear (D. S. Futer).

Late syphilitic meningitis Pathomorphologically they are characterized by gummous infiltration of the meninges and vessel walls, as well as the formation of solitary gummas. In cerebral localization, the base of the brain is most often affected. The development and course of the disease process is chronic, less often subacute.

Compared to early syphilitic meningitis, late syphilitic meningitis is characterized by the absence or mild severity of meningeal symptoms; temperature is usually normal; Patients often complain of headaches, worse at night, and dizziness. With intracranial hypertension, hydrocephalus develops due to occlusion. Headaches and dizziness, often paroxysmal, are accompanied by vomiting.

Mental disorders in the form of confusion, delusions and hallucinations are common.

In basal syphilitic meningitis, the oculomotor nerve is most often affected, then the trochlear, abducens, optic and hypoglossal nerves. In almost a third of cases, complete or partial paralysis of the oculomotor nerve occurs (see Ophthalmoplegia). Along with ptosis and ophthalmoplegia, Argyll Robertson syndrome (see Argyll Robertson syndrome), which occurs with late syphilitic meningitis in 10% of cases, may also occur. Damage to the abducens nerve on one side occurs together with damage to other nerves of the base. The trigeminal nerve is affected relatively rarely, the facial nerve is usually affected together with the oculomotor nerve. Damage to the auditory nerve is expressed by nystagmus, dizziness and decreased hearing; localization of the gummous process in the area of ​​the cerebellopontine angle produces a syndrome characteristic of a tumor of this localization. The vagus and hypoglossal nerves are rarely affected, only in combination with damage to other nerves.

The optic nerves can be affected simultaneously with other nerves, sometimes independently and even primarily without the involvement of the soft meninges [Nonne (M. Nonne)]. Optic neuritis manifests itself as central scotoma and bitemporal hemianopia. Congestion at the bottom of the eye is observed in 10% of cases; A congestive nipple with basal meningitis is characterized by its rapid disappearance after treatment. Primary simple atrophy of the optic nerve, more typical of late neurosyphilis, is rarely observed. Secondary atrophies are much more common and provide a better prognosis for vision preservation than primary simple atrophies. With basal gummous meningitis, along with the cranial nerves, the pituitary gland and hypothalamus are affected with the development of adipose-genital dystrophy, various hypothalamic syndromes, and in some cases acromegalic syndrome (A. O. Dolin).

Late syphilitic meningitis of the convex surface of the cerebral hemispheres is much less common than basal meningitis. Symptomatology depends on the localization of the process: epileptic seizures, often focal symptoms in the form of hemiplegia, aphasia, apraxia, etc. It is often necessary to differentiate between a tumor and gumma of the cerebral hemispheres, and only a positive Wasserman reaction and characteristic changes in the cerebrospinal fluid resolve the issue in favor of the gummous process hemispheres.

With spinal localization of gummous meningitis, the soft membranes are affected either diffusely throughout, or, more often, in the thoracic region; the membranes are rarely affected in isolation, in most cases simultaneously with the roots or substance of the spinal cord, which is clinically expressed in the form of syphilitic meningoradiculitis and meningomyelitis (M. S. Margulis). In the meningoradicular form of meningitis, radicular pain predominates, sometimes muscle atrophy, and in the meningomyelitic form, spastic paraparesis with conductive sensitivity disorders and pelvic function disorders is in the foreground.

In the cerebrospinal fluid in late syphilitic meningitis, pleocytosis is always detected. In basal forms of meningitis, pleocytosis reaches 100-500 cells per 1 mm3. It is highest in spinal and cerebrospinal forms (D. A. Shamburov). The cells are predominantly lymphocytes. The amount of protein is increased from 0.6 to 3‰; the largest amount of protein is observed in spinal forms of meningitis, and xanthochromia is sometimes observed in them. Colloidal reactions are always positive. The Wasserman reaction in the cerebrospinal fluid in acute and subacute cases is always positive.

The course of late syphilitic meningitis is variable, remissions are frequent. The basal form is characterized by lability of cerebral and focal symptoms and remission. The same occurs with spinal forms, in which the process often takes a chronic course; the prognosis for them is less favorable than for cerebral forms.

Treatment Syphilitic meningitis is currently carried out according to certain schemes (N. S. Smelov), according to guidelines for the treatment of syphilis of the nervous system (see Syphilis, treatment). Penicillin, bismuth, iodide preparations, mercury, novarsenol are used in a certain sequence, depending on the form of meningitis and the nature of the previous treatment for syphilis. Particular attention should be paid to the treatment of patients with neuritis and atrophy of the optic nerves with decreased vision and neuritis of the VIII pair with hearing damage; in these cases, when prescribing specific therapy, it is necessary to take into account the special sensitivity of these nerves to certain drugs (mercury, arsenic). Specific therapy can be carried out in combination with pyrotherapy, vitamins (B1, C), strychnine, physiotherapy and balneotherapy (hydrogen sulfide baths, electrophoresis with iodine, etc.).

Meningitis: types, causes, symptoms, treatment

Meningitis video

Meningitis is a bacterial infection of the membranes lining the brain and spinal cord, in which the brain cells themselves are not damaged, since the inflammatory process develops outside the meninges. Meningitis is divided into viral (serous) and bacterial.

Viral meningitis is more common than bacterial meningitis and is milder. Outbreaks of viral meningitis typically occur in late summer and early fall. It most often affects children and adults under 30 years of age.

The following types of meningitis are distinguished:

— Aseptic meningitis

— Cryptococcal meningitis

- Infections occurring near the brain, such as in the ears or nose

— Complications of brain, head or neck surgery

— Shunting for hydrocephalus

— Diabetes

— Sickle cell anemia

— Taking medications that suppress the immune system

— Living in unfavorable living conditions (barracks, barracks, cramped quarters)

- Boils on the neck or face

Many types of viruses can cause meningitis:

— Enteroviruses. Most viral meningitis is associated with enteroviruses that cause intestinal diseases, such as Escherichia coli, Salmonella, Pseudomonas aeruginosa.

- Staphylococcus. The development of staphylococcal meningitis is promoted by chronic pneumonia, abscesses, osteomyelitis of the bones of the skull and spine, and sepsis.

- Herpes. Viral meningitis can be caused by the herpes virus, the same virus that can cause cold sores and genital herpes. However, people with herpes or genital herpes themselves are not at greater risk of developing meningitis from this type of virus.

- Tuberculosis. The primary site of infection, tuberculosis, develops in the lungs or intrathoracic lymph nodes.

— Mumps and HIV. Viruses that cause mumps and HIV can cause aseptic meningitis.

— West Nile virus. Recently, West Nile virus, spread through mosquito bites, has become a cause of viral meningitis.

— Fungal infections and candidiasis.

Symptoms of meningitis in children and adults

Common symptoms of meningitis usually appear very quickly and may include:

- Fever and chills, especially in children and newborns;

— Mental disorders, changes in consciousness, hallucinations;

- Nausea and vomiting;

- Sensitivity to light (photophobia), patients usually lie with their heads turned to the wall and covered with a blanket;

“Severe, intense, bursting headache that gets worse when moving or walking, from loud noises and bright lights.”

- Rigid neck muscles (meningismus) - limitation or impossibility of flexing the head;

- Kernig's symptom - the inability to extend a leg that is previously bent at the knee and hip joints;

— Brudzinski's symptoms:

when, when passively bringing the head to the chest with the patient lying on his back, involuntary flexion of the legs occurs in the knee and hip joints; when pressing on the area of ​​the pubic symphysis, involuntary flexion of the legs occurs in the knee and hip joints; when checking Kernig's symptom, involuntary flexion of the other leg occurs in the same joints .

- Pale skin and blueness of the nasolabial triangle;

- Protrusion and pulsation of the fontanel in infants;

- Decreased attention;

- Sucking disorders or irritability in infants, they are restless, often cry out and are sharply excited by any touch

- Decreased appetite, but without refusal of liquids;

- Rapid breathing and shortness of breath;

- Frequent pulse;

— Reduced blood pressure;

— Unusual poses in children, such as the “cop dog” pose, when the head is thrown back and the legs are bent at the knees and pulled up to the stomach;

— Lesage’s “suspension” symptom, when, when holding the child in the armpits, he pulls his legs towards his stomach and holds them in this position;

— Increased tactile sensitivity, when even a light touch to the patient causes increased pain;

- Appearance of a rash;

- Convulsions in young children.

Diagnosis of meningitis

Typically, meningitis can be recognized after a physical examination of the patient, when the following are detected:

- Increased heart rate

Pathomorphology.

Macroscopic examination reveals thickening and clouding of the membranes. In cases of gummous meningitis, gray-red tubercles the size of a millet grain are visible, scattered in the pia mater. Changes in the membranes are more pronounced on the lower surface of the brain. Histologically, infiltrates consisting of lymphocytes and plasma cells are found in the membranes of the brain. Exudate appears on the lower surface of the brain in the area of ​​the chiasm, then spreads through the cisterns to the entire lower surface and lateral sulcus. Along with diffuse inflammation of the membranes, miliary gummas (accumulations of lymphoid, plasma and giant cells) located on the lower surface of the brain and along large vessels can be observed. The inflammatory process in the membranes often spreads to the roots of the cranial nerves and spinal cord.

Clinic. Syphilitic meningitis can occur latently, in the form of an acute and chronic disease.

The latent form of meningitis occurs without clinical manifestations or with mild symptoms. Patients may complain of headache, dizziness, mild visual and hearing impairment. Objectively, there are no signs of focal damage to the nervous system; only moderately expressed autonomic disorders can be detected. Damage to the membranes is indicated by changes in the cerebrospinal fluid, in which a slight increase in the number of lymphocytes and protein, positive globulin reactions, and a change in the Lange reaction are detected. Latent, or asymptomatic, syphilitic meningitis develops in the primary and secondary periods of syphilis and occurs especially often in patients who have not been treated or have not completed the course of treatment, a year and a half after infection. However, at a later date, after 5 years or more, examination of the cerebrospinal fluid can reveal the presence of latent meningitis. This form of damage to the meninges is easily treatable with the use of antisyphilitic therapy.

The acute form of syphilitic meningitis usually occurs in the secondary period, when treponemes enter in large quantities into the subarachnoid space of the brain and spinal cord. The disease begins acutely, body temperature rises to 38 °C, headache, dizziness, tinnitus, photophobia, nausea, and vomiting appear. In the fundus, hyperemia or swelling of the optic disc is sometimes detected. Meningeal symptoms are mildly expressed. When the inflammatory process is localized on the lower surface of the brain, the functions of the cranial nerves, most often the oculomotor nerves, are disrupted, which is accompanied by ptosis and double vision. Anisocoria and sluggish pupillary reactions are often observed.

In the cerebrospinal fluid flowing under high pressure, the number of cells increases to 200-106 per liter or more, the amount of protein increases to 6000-12000 mg/l, globulin reactions, as well as Wasserman and Lange reactions, are positive. Under the influence of specific treatment, the symptoms of the disease disappear quickly, and changes in the cerebrospinal fluid persist longer.

Chronic form of syphilitic meningitis develops in the tertiary period of syphilis, 3-5 years after the initial infection. Its main symptom is headache of various localizations, worsening at night. Sometimes the headache is combined with dizziness and vomiting. Meningeal symptoms are usually mild. Damage to the cranial nerves is typical. The oculomotor nerve is most often affected, which is accompanied by double vision, ptosis, strabismus, impaired eye mobility, and mydriasis. Argyll Robertson's sign may also be found (p. 114). When the abducens nerve is damaged, double vision and convergent strabismus occur. The optic nerve is very often affected. In the fundus there is a picture of neuritis, or congestive disc, visual acuity decreases, and the field of vision narrows. If the optic pathway is damaged, hemianopia may occur. Often the facial and vestibulocochlear nerves are involved in the process.

The defeat of the latter can sometimes be the only symptom of the disease. In this case, noise in the ear occurs, accompanied by hearing loss, up to complete deafness. Damage to the vestibule nerve is accompanied by dizziness. The involvement of the trigeminal nerve in the process can be very painful for patients. Its defeat causes neuralgia with attacks of intense facial pain, sensitivity disorders in the face, decreased corneal reflex and, in some cases, trophic neurokeratitis. When the membranes on the upper lateral surface of the brain are damaged, focal neurological syndromes may occur, and generalized and Jacksonian epileptic seizures are not uncommon. In the cerebrospinal fluid, lymphocytic pleocytosis is found up to 300-106 in 1 l and an increase in the amount of protein up to 6000-10000 mg/l, positive globulin reactions, Wasserman reaction.

The prognosis is generally favorable with the use of specific treatment that causes resorption of gummous formations.

LECTURE No. 10. Meningitis and encephalitis. Neurosyphilis

1. Meningitis

Meningitis is an inflammation of the meninges. There are serous and purulent meningitis. According to pathogenesis, meningitis is divided into primary and secondary. According to localization, meningitis is divided into generalized and limited, as well as basal and convexital (on a convex surface). According to the course, fulminant, acute, subacute and chronic meningitis are distinguished. According to the severity, meningitis is divided into mild, moderate, severe and extremely severe forms. According to etiology, bacterial, viral, fungal and protozoal meningitis are distinguished.

There are three mechanisms for the development of meningitis: as a result of an open craniocerebral or spinal injury, lymphogenous or perineural spread of the pathogen, hematogenous spread of the pathogen.

Pathogenesis includes inflammation and swelling of the meninges, impaired circulation in the cerebral vessels, delayed resorption of cerebrospinal fluid, the development of cerebral hydrops, increased intracranial pressure, overstretching of the meninges, nerve roots and the effects of intoxication.

Meningitis is characterized by three syndromes: general infectious, meningeal, and syndrome of inflammatory changes in the cerebrospinal fluid.

To clarify the diagnosis, cerebrospinal fluid is examined using bacteriological or other methods. The general infectious syndrome includes fever, chills, leukocytosis, increased ESR, increased heart rate and respiratory rate.

Meningeal syndrome includes headache, vomiting, meningeal posture, Kernig and Brudzinski signs, and neck stiffness. The disease begins with the appearance of a headache as a result of irritation of the receptors of the meninges by the inflammatory process and toxins. Vomiting occurs with a headache and is not associated with food intake. Rigidity of the cervical muscles is determined when attempting to passively flex the head in a supine position and consists of a sensation of resistance that causes pain in the patient.

Kernig's symptom is the appearance of pain in the lower back and leg when trying to passively extend it in the knee joint. The leg is bent at the hip joint at a right angle. There is also an increase in sensitivity to loud sounds and various smells. Pain occurs when the eyeballs move. Characteristic is the zygomatic ankylosing spondylitis symptom - local pain when tapping along the zygomatic arch. A mandatory research method is lumbar puncture.

Meningitis is characterized by an increase in cerebrospinal fluid pressure, a change in the color of the cerebrospinal fluid, pleocytosis, depending on whether the meningitis is serous or purulent, the number of leukocytes or lymphocytes increases. The amount of protein also increases. The most clinically pronounced is meningitis of bacterial origin.

Epidemic cerebrospinal meningitis is caused by Weichselbaum's meningococcus and is transmitted by droplets and contact. The incubation period is 1–5 days. It is characterized by an acute onset: the temperature rises to 40 °C, severe headaches, vomiting appear, and consciousness is impaired. The meningeal syndrome appears by the third day of illness. The cerebrospinal fluid is cloudy, the cerebrospinal fluid pressure is increased, neutrophilic pleocytosis is noted, the amount of protein is 1-16 g/l. In the blood, the number of leukocytes is up to 30 X 10/l, ESR is increased. Complications of the disease may include cerebral edema and acute adrenal insufficiency.

Secondary purulent meningitis can occur through contact, perineural, hematogenous or lymphogenous infection. Characteristic symptoms are weakness, fever up to 40 °C, headache, and occasional vomiting. A day later, membrane symptoms and mental disorders appear. Cranial nerves are often affected.

Treatment of purulent meningitis includes analgesics, anticonvulsants, antibiotics, and sulfonamides. The choice of antibiotic depends on the etiology. If hypovolemia develops, an intravenous infusion of saline is administered. When acidosis develops, a 4–5% solution of sodium bicarbonate (up to 800 ml) is administered. Hemodez is used for detoxification.

Tuberculous and viral meningitis refers to serous meningitis.

Tuberculous meningitis is a secondary disease. The route of spread is hematogenous. The disease is preceded by a prodromal period, manifested by weakness, headaches, mental disorders, anorexia, and low-grade fever.

After 2–3 weeks, the meningeal syndrome appears. During the examination, an increase in liquor pressure is noted. Pleocytosis is observed in the cerebrospinal fluid (600–800 X 10 /l), the amount of protein is 2–3 g/l. Precipitation in the form of a fibrin mesh is characteristic.

Tuberculosis pathogens are found in the cerebrospinal fluid. In the blood - leukocytosis and increased ESR. Treatment includes anti-tuberculosis drugs and corticosteroids.

2. Encephalitis

Encephalitis is inflammation of the brain. Classification.

Symptoms and signs of syphilis (first, main, initial, external)

The first symptoms of syphilis appear 3-5 weeks after infection. Until this moment, the disease proceeds without any external manifestations. The disease occurs with periods of remission and exacerbation, and each new period will have its own symptoms, which determine the stage of the disease at the moment.

The first symptoms of syphilis occur at the site of infection in the body and appear as a small red spot called chancre. which turns into a papule, and from it ulcers are obtained, usually round in shape, up to 2 cm in diameter. Such ulcers rarely merge with each other and are not prone to bleeding. When examining the chancre, you can clearly determine its boundaries, and during palpation you can feel the compaction formed by the infiltrate. The first symptoms of syphilis, photos of which are so widely distributed on the Internet, in addition to hard chancre at the entrance gate of the disease, you can see extra genital chancre in the mammary glands, on the fingers, tongue, lips and in the anal area. Following the ulcers, syphilitic symptoms such as regional inflammation of the lymph nodes can be observed. During inflammation, pain does not appear, but upon palpation, the tightly elastic consistency of the inflamed node is felt.

The initial symptoms of syphilis can be atypical and manifest as:

• Unilateral enlargement of the tonsil without the appearance of skin ulcers;
• The formation of a painful compaction on the finger, which turns into an equally painful ulcer or erosion.
• Redness of the tissue in the scrotum, penis, labia, foreskin, cervix or clitoris, usually called indurative edema. The redness has a bluish tint and does not form a pit when pressed.

Many symptoms of syphilis in pictures look like other diseases and, in fact, are not only manifestations of the disease, but also the causes of other STDs and other complications. The most common diseases caused by treponema include:

Many of the listed lesions can lead to irreversible consequences for the body, therefore it is very important that the doctor knows the main symptoms of syphilis and, when examining patients with one of the listed diseases, at the slightest suspicion about the causes of these diseases, refers the patients for serological analysis. Otherwise, the treatment will become ineffective, which will simply be a waste of time, and the diseases will disappear not as a result of successful treatment, but will serve as a signal that the main infection has passed into a latent form, followed by a secondary form, the internal and external symptoms of syphilis in which will be significantly differ from earlier manifestations.

Symptoms of syphilis at the secondary stage of development mainly manifest themselves in the form of generalized rashes on the mucous membranes and skin. This symptom of syphilis is observed 2-3 months after infection. Usually, by this time, the primary symptoms of syphilis infection disappear from the surface of the membranes, but often, after the initial signs of infection with Treponema pallidum, scar changes remain on the skin and mucous membranes. Signs and symptoms of stage 2 syphilis are associated with vascular changes in the deep layers of the dermis, and are mostly localized on the soles, palms, limbs and face. In some cases, skin rashes are accompanied by a sore throat, mild malaise and a slight increase in temperature.

Syphilis symptoms, photos of rashes

Rashes as symptoms of syphilis disease are varied in nature and manifestations, which can be seen in the photos of patients with the second stage of the disease. If you look closely at different photos, you can see that the rash in patients with syphilis can be blistering, spotty or pustular with a dark red color. If you look at photos of the same patients after a certain period of time, you will notice how the color of the initially dark red rash has faded. To the symptoms of syphilis characteristic of women. include syphilitic leukoderma or, as this sign of the disease is sometimes called, “Necklace of Venus.” The necklace of Venus appears six months after infection and is located on the lateral and posterior parts of the neck and has characteristic signs that indicate to an experienced specialist an infection with Treponema pallidum. These signs include the specificity of hypopigmented rashes, the size of the nail on the little finger, around which there are hyperpigmented areas. Since these rashes do not itch, do not flake, and do not rise above healthy skin, women who are not particularly attentive to themselves may miss these syphilitic symptoms as manifestations of the second stage of the disease.

The next external manifestation is papules, which can appear both on previously untouched areas of the skin and in areas previously affected by the rash. Papules differ in size from each other according to the following classification:

• Up to 5 mm - miliary
• From 5 to 20 mm - lenticular
• From 20 to 25 mm - nummular.

However, these are not all the options for how syphilis manifests itself, the symptoms of which in the second stage of the disease are manifested by condyloma. Condylomas most often form in the inguinal-femoral folds, intergluteal or anal area, under the influence of irritation and maceration processes. Condylomas lata, caused by Treponema pallidum, should be distinguished from condylomata acuminata, the causative agent of which is the human papillomavirus.

Those who are faced with this disease for the first time sometimes try to find information on the Internet by entering “syphilis symptoms: video, photos, consequences” in the search bar, where they hope to see all the manifestations of the disease and find out what awaits them in the future.

During the secondary stage of the disease, papules form on the palms, soles and scalp under the hair. Less commonly, they appear on the lips, palate, tonsils or tongue. Signs that are not visible externally, but are noticeable to the patient, include hoarseness, and in some cases reaching aphonia. The cause of vocal changes is the same papules that affect the vocal cords.

Less commonly, the patient may exhibit signs of the disease such as pustular syphilides or pustular elements. Typically, such manifestations are combined with low immunity and concomitant diseases - gonorrhea, mycoplasma, ureaplasma, chlamydia, hepatitis or HIV.

Another characteristic sign of the second stage of the disease is alopecia. This is the common name for baldness, which affects not only the hair on the head, but also on the pubic area, armpits, as well as eyebrows and eyelashes.

After some time, the disease becomes latent, but the absence of symptoms of syphilis has nothing to do with improving the health of the patient, who remains extremely contagious to others, and the infection continues to spread throughout the body and affect organs and tissues.

The latent period ends with the tertiary stage of the disease, which usually occurs 4-5 years after infection in patients who needlessly refused treatment.

What are the symptoms of syphilis at this stage? The main signs of the onset of the last stage of the disease are:

• Gummy syphilide - gummas form on the tongue, soft palate, hard palate, in the nasal mucosa, sometimes in the heart, and then ulcers and scars form in place of the gummas.
• Tuberous syphilide - dark red tubercles form on the skin, ranging in size from a small grain to a large pea, which, as in the previous case, turn into ulcers and then scar.
• Tertiary erythema - ring-shaped pale pink spots form on the skin, with a diameter of 50 to 150 mm, which are not itchy and do not cause significant discomfort, but will result in the development of atrophy.

At the third stage of the disease, there is a close relationship between syphilis symptoms and treatment, since by this period the body is severely depleted, both by the destructive effect of the infection and by the various medications used in therapy, which leads to damage to a number of internal organs:

• The liver is destroyed - symptoms of hepatitis appear;
• The stomach suffers - frequent gastritis;
• Cardiovascular diseases - myocarditis, aneurysm, tachycardia, shortness of breath, heart pain, general weakness;
• Lungs - granulomas appear;
• Kidneys - filtration worsens, protein is detected in the urine.

Signs of damage to the nervous system due to Treponema pallidum infection are as follows:

• Progressive paralysis with the development of syphilitic psychosis and dementia;
• Tabes dorsalis with the development of blindness, defecation and urination disorders;
• Syphilitic meningomyelitis;
• Meningovascular form of the disease;
• Syphilitic hydrocephalus;
• Basal meningitis;
• Generalized meningitis;
• Asymptomatic meningitis is the complete absence of the main external manifestations of the disease, but at the same time positive reactions in the analysis of cerebrospinal fluid and serological testing.

As it becomes clear from the above, the danger of infection with spirochetes lies not only in the high chance of infection, but also in a variety of symptoms, which only get worse in the absence of proper treatment for the first manifestations of the disease.

Meningitis

Causes and symptoms of meningitis

What is meningitis?

Meningitis is a dangerous disease; it is an inflammation of the membranes of the brain and spinal cord. The disease can occur either independently or as a complication of another process.

There are several classifications of meningitis. According to the etiology, meningitis can be bacterial, viral, fungal; by the nature of the inflammatory process - purulent and serous (rapid damage to the membranes of the brain, which is characterized by a serous inflammatory process). According to the course, acute, subacute and chronic meningitis are distinguished; by origin - primary and secondary (arising against the background of another disease).

The most common symptoms of meningitis are headache. numbness of the neck, high temperature, disturbances of consciousness, fear of light and increased sensitivity to sounds. Nonspecific symptoms include irritability and drowsiness.

Causes of meningitis

The most common causes of meningitis are bacteria or viruses that affect the soft membranes of the brain and cerebrospinal fluid.

In children, meningitis is caused mainly by enteroviruses that enter the body through food, water, and dirty objects.

In adults, bacterial meningitis predominates, caused by the bacteria Streptococcus pneumoniae and Neisseria meningitidis. These bacteria do not cause meningitis when they are in the throat and nose, but when they enter the blood, cerebrospinal fluid and soft tissues of the brain, they provoke inflammation.

Sometimes meningitis is caused by other types of bacteria. Group B streptococcus often causes illness in newborns infected during or after birth. Listeria monocytogenes also primarily affects infants and older adults.

Meningitis often develops as a complication of various diseases and head injuries.

The disease can be transmitted during childbirth, by airborne droplets, through mucous membranes, dirty water, food, rodent and insect bites.

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Symptoms of meningitis

The most common symptoms of meningitis are headache, numbness (stiffness) of the neck muscles, fever, disturbances of consciousness (including coma), and increased sensitivity to light and sound. The patient experiences nausea and vomiting, general weakness, heart rhythm disturbances, and muscle pain. Meningeal syndrome is expressed by Kernig and Brudzinski symptoms: the patient cannot bend the neck or straighten the leg at the knee joint. Hyperesthesia manifests itself in hypersensitivity: a person cannot tolerate bright light, loud sounds, or touches.

An upper respiratory tract infection is often a precursor to meningitis, but taking antibiotics can smooth out the overall picture of the disease. With a weakened immune system, meningitis can occur either as a mild infection with a slight fever and headache, or quickly develop into a coma.

Meningitis is diagnosed by examining the cerebrospinal fluid after taking a lumbar puncture.

Bacterial meningitis usually begins acutely, and meningeal symptoms are pronounced. Serous tuberculous meningitis has a gradual course.

A variety of chronic diseases often lead to lesions of the meninges: tuberculosis, syphilis, sarcoidosis, toxoplasmosis, brucellosis.

Types of meningitis

Bacterial meningitis usually occurs due to the penetration of pneumococcus, meningococcus, and Haemophilus influenzae bacteria into the central nervous system.

1. Haemophilus influenzae provokes the disease mainly in children under 6 years of age, less often in adults. It occurs against the background of diseases such as pneumonia, otitis media, diabetes mellitus. alcoholism, traumatic brain injury, sinusitis.

2. Meningococcal meningitis is usually quite severe; A hemorrhagic rash may appear in the form of spots (stars) of different sizes. The spots are localized on the legs, thighs and buttocks, mucous membranes and conjunctiva. The patient is worried about chills and high fever, intoxication is possible.

3. Pneumococcal meningitis occurs quite often and occurs with the occurrence of pneumonia in approximately half of patients. The disease is most severely experienced by people with diabetes, alcoholism, and cirrhosis of the liver. Symptoms include damage to consciousness and cranial nerves, gaze paresis, and epileptic seizures. Pneumococcal meningitis can recur and often leads to death.

Bacterial meningitis can lead to complications such as shock, endocarditis, purulent arthritis, bleeding disorders, pneumonia, and electrolyte disorders.

Viral meningitis begins with symptoms of the infectious disease that caused it. Such meningitis occurs with moderate fever, severe headache and weakness. In this case, patients have mild meningeal symptoms. The disease most often occurs without disturbances of consciousness.

Tuberculous meningitis is now often one of the first clinical symptoms of tuberculosis. Previously, this form of the disease was always fatal, but now, with adequate treatment, the mortality rate is 15–25% of all cases of the disease. Tuberculous meningitis begins with an increase in temperature. headache, vomiting. Meningeal symptoms appear and cranial nerves are affected.

Treatment of meningitis

Treatment of meningitis should always be comprehensive and carried out in a hospital. The patient is prescribed strict bed rest, antibiotics and antiviral drugs. Sometimes severe illnesses require resuscitation procedures. With proper and timely treatment, meningitis is completely curable.

To prevent some types of meningitis, a vaccination is given that is valid for about four years, but it is impossible to protect against the disease 100%. The main thing is to diagnose it in a timely manner and begin treatment immediately.

Pneumococcus
Pneumococci can remain on the mucous membrane of the oral cavity and upper respiratory tract for a long time and not cause any symptoms. However, when the body’s defenses decrease, the infection becomes more active and spreads through the blood. The difference between pneumococcus is its high tropism ( preference) to brain tissue. Therefore, already on the second or third day after the disease, symptoms of damage to the central nervous system develop.

Pneumococcal meningitis can also develop as a complication of pneumococcal pneumonia. In this case, pneumococcus from the lungs reaches the meninges through the lymph flow. Meningitis has a high mortality rate.

Haemophilus influenzae
Haemophilus influenzae has a special capsule that protects it from the body's immune forces. A healthy body becomes infected through airborne droplets ( when sneezing or coughing), and sometimes contact ( in case of non-compliance with hygiene rules). Once on the mucous membrane of the upper respiratory tract, Haemophilus influenzae reaches the meningeal membranes through the blood or lymph flow. Next, it is fixed in the soft and arachnoid membrane and begins to multiply intensively. Haemophilus influenzae blocks the villi of the arachnoid membrane, thereby preventing the outflow of cerebral fluid. In this case, fluid is produced, but does not drain away, and the syndrome of increased intracranial pressure develops.

In terms of frequency of occurrence, meningitis caused by Haemophilus influenzae is in third place after meningococcal and pneumococcal meningitis.

This route of infection is characteristic of all primary meningitis. Secondary meningitis is characterized by dissemination of the pathogen from the primary chronic source of infection.

The primary site of infection may be:

• inner ear with otitis;
• paranasal sinuses with sinusitis;
• lungs with tuberculosis;
• bones with osteomyelitis;
• injuries and wounds due to fractures;
• jaw and teeth during inflammatory processes in the jaw apparatus.

Otitis media
Otitis media is an inflammation of the middle ear, that is, the cavity located between the eardrum and the inner ear. Most often, the causative agent of otitis media is staphylococcus or streptococcus. Therefore, otogenic meningitis is most often staphylococcal or streptococcal. An infection from the middle ear can reach the meningeal membranes both in the acute and chronic periods of the disease.

Routes of infection from the middle ear to the brain :

• with blood flow;
• through the inner ear, namely through its labyrinth;
• by contact in case of destruction in the bone.

Sinusitis
Inflammation of one or more paranasal sinuses is called sinusitis. The sinuses are a kind of air corridor that connects the cranial cavity with the nasal cavity.

Types of paranasal sinuses and their inflammatory processes :

• maxillary sinus– its inflammation is called sinusitis;
• frontal sinus– its inflammation is called frontal sinusitis;
• lattice labyrinth- its inflammation is called ethmoiditis;
• sphenoid sinus- its inflammation is called sphenoiditis.

Due to the proximity of the paranasal sinuses and the cranial cavity, the infection very quickly spreads to the meningeal membranes.

Pathways for infection to spread from the sinuses to the meningeal membranes :

• with blood flow;
• with lymph flow;
• by contact ( with bone destruction).

In 90 to 95 percent of cases, sinusitis is caused by a virus. However, viral sinusitis can rarely cause meningitis. As a rule, it is complicated by the addition of a bacterial infection ( with the development of bacterial sinusitis), which can subsequently spread and reach the brain.

The most common causes of bacterial sinusitis are:

• Pneumococcus;
• hemophilus influenzae;
• Moraxella catharalis;
• Staphylococcus aureus;
• Streptococcus pyogenes.

Pulmonary tuberculosis
Pulmonary tuberculosis is the main cause of secondary tuberculous meningitis. The causative agent of tuberculosis is Mycobacterium tuberculosis. Pulmonary tuberculosis is characterized by a primary tuberculosis complex, in which not only lung tissue is affected, but also nearby vessels.

Components of the primary tuberculosis complex:

• lung tissue ( as tuberculous pneumonia develops);
• lymphatic vessel ( tuberculous lymphangitis develops);
• lymph node ( tuberculous lymphadenitis develops).

Therefore, most often mycobacteria reach the meninges with lymph flow, but they can also hematogenously ( with blood flow). Having reached the meninges, mycobacteria affect not only them, but also the blood vessels of the brain, and often the cranial nerves.

Osteomyelitis
Osteomyelitis is a purulent disease that affects the bone and surrounding soft tissue. The main causative agents of osteomyelitis are staphylococci and streptococci, which enter the bone due to injury or through the bloodstream from other foci ( teeth, boils, middle ear).

Most often, the source of infection reaches the meninges through the bloodstream, but with osteomyelitis of the jaw or temporal bone, it penetrates the brain by contact, due to bone destruction.

Inflammatory processes in the jaw apparatus
Inflammatory processes in the jaw apparatus affect both bone structures ( bone, periosteum), and soft tissues ( The lymph nodes). Due to the proximity of the bone structures of the jaw apparatus to the brain, the infection quickly spreads to the meninges.

Inflammatory processes of the jaw apparatus include:

• osteitis– damage to the bone base of the jaw;
• periostitis– damage to the periosteum;
• osteomyelitis– damage to both bone and bone marrow;
• abscesses and phlegmons in the jaw apparatus– limited accumulation of pus in the soft tissues of the jaw apparatus ( for example, at the bottom of the mouth);
• purulent odontogenic lymphadenitis– damage to the lymph node of the jaw apparatus.

Inflammatory processes in the jaw apparatus are characterized by contact dissemination of the pathogen. In this case, the pathogen reaches the meningeal membranes due to bone destruction or abscess rupture. But lymphogenous spread of infection is also characteristic.

The causative agents of infection of the jaw apparatus are:

• viridans streptococcus;
• white and golden staphylococcus;
• peptococcus;
• peptostreptococcus;
• actinomycetes.

A special form of meningitis is rheumatic meningoencephalitis, which is characterized by damage to both the meninges and the brain itself. This form of meningitis is the result of rheumatic fever ( attack) and is mainly characteristic of childhood and adolescence. Sometimes it can be accompanied by a large hemorrhagic rash and is therefore also called rheumatic hemorrhagic meningoencephalitis. Unlike other forms of meningitis, where the patient's movements are limited, rheumatic meningitis is accompanied by severe psychomotor agitation.

Some forms of meningitis are a consequence of generalization of the initial infection. Thus, borreliosis meningitis is a manifestation of the second stage of tick-borne borreliosis ( or Lyme disease). It is characterized by the development of meningoencephalitis ( when both the membranes of the brain and the brain itself are damaged) in combination with neuritis and radiculitis. Syphilitic meningitis develops in the second or third stage of syphilis when treponema pallidum reaches the nervous system.

Meningitis can also be a consequence of various surgical procedures. For example, postoperative wounds, venous catheters and other invasive medical equipment can be the gateway to infection.
Candidal meningitis develops against a background of sharply reduced immunity or against the background of long-term antibacterial treatment. Most often, people with HIV infection are susceptible to the development of candidal meningitis.

Signs of meningitis

The main signs of meningitis are:

• chills and fever;
• headache;
• stiff neck;
• photophobia and hyperacusis;
• drowsiness, lethargy, sometimes loss of consciousness;

Some forms of meningitis may cause:

• rash on the skin, mucous membranes;
• anxiety and psychomotor agitation;
• mental disorders.

Chills and fever

Fever is the dominant symptom of meningitis. It occurs in 96–98 percent of cases and is one of the very first symptoms of meningitis. The rise in temperature is due to the release of pyrogenic ( fever-causing) substances by bacteria and viruses when they enter the blood. In addition, the body itself produces pyrogenic substances. The most active is leukocyte pyrogen, which is produced by leukocytes at the site of inflammation. Thus, the increase in temperature occurs due to increased heat production both by the body itself and by the pyrogenic substances of the pathogenic microorganism. In this case, a reflex spasm of skin vessels occurs. Vasospasm entails a decrease in blood flow in the skin and, as a result, a drop in skin temperature. The patient feels the difference between internal warmth and cold skin as chills. Severe chills are accompanied by trembling throughout the body. Muscle tremors are nothing more than the body’s attempt to warm up. Stunning chills and a rise in temperature to 39 - 40 degrees are often the first sign of illness.

Headache

Severe, diffuse, progressive headache, often accompanied by vomiting, is also an early sign of the disease. Initially, the headache is diffuse and is caused by the phenomenon of general intoxication and elevated temperature. In the stage of damage to the meninges, the headache increases and is caused by cerebral edema.

The cause of cerebral edema is:

• increased secretion of cerebrospinal fluid due to irritation of the meninges;
• disruption of the outflow of cerebrospinal fluid up to blockade;
• direct cytotoxic effect of toxins on brain cells, with their further swelling and destruction;
• increased vascular permeability and, as a result, penetration of fluid into the brain tissue.

As intracranial pressure increases, the headache becomes bursting. At the same time, the sensitivity of the scalp is sharply increased and the slightest touch to the head causes severe pain. At the peak of the headache, vomiting occurs, which does not bring relief. Vomiting may be repeated and does not respond to antiemetic medications. Headaches are triggered by light, sounds, turning the head and pressing on the eyeballs.

In infants, there is bulging and tension of the large fontanelle, a pronounced venous network on the head, and in severe cases, divergence of the sutures of the skull. This symptomatology, on the one hand, is caused by the syndrome of increased intracranial pressure ( due to cerebral edema and increased secretion of cerebrospinal fluid), and on the other hand, the elasticity of the skull bones in children. At the same time, young children experience monotonous “brain” crying.

Stiff neck

Neck stiffness occurs in more than 80 percent of meningitis cases. The absence of this symptom can be observed in children. The patient's posture, characteristic of meningitis, is associated with muscle rigidity: the patient lies on his side with his head thrown back and his knees brought to the stomach. At the same time, it is difficult for him to bend or turn his head. Stiff neck is one of the early symptoms of meningitis and, along with headache and fever, forms the basis of meningeal syndrome, which is caused by irritation of the meninges.

Photophobia and hyperacusis

Painful sensitivity to light ( photophobia) and to sound ( hyperacusis) are also common symptoms of meningitis. Like hypersensitivity, these symptoms are caused by irritation of receptors and nerve endings in the meninges. They are most pronounced in children and adolescents.

However, sometimes the opposite symptoms may occur. Thus, if the auditory nerve is damaged, with the development of neuritis, hearing loss may occur. In addition to the auditory nerve, the optic nerve can also be affected, which, however, is extremely rare.

Drowsiness, lethargy, sometimes loss of consciousness

Drowsiness, lethargy and loss of consciousness are observed in 70 percent of cases and are later symptoms of meningitis. However, in fulminant forms they develop on days 2–3. Lethargy and apathy are caused by both general intoxication of the body and the development of cerebral edema. For bacterial meningitis ( pneumococcal, meningococcal) there is a sharp depression of consciousness up to coma. Newborn babies refuse to eat or often spit up.

As brain swelling increases, the degree of confusion worsens. The patient is confused, disoriented in time and space. Massive cerebral edema can lead to compression of the brain stem and inhibition of vital centers, such as the respiratory and vascular. At the same time, against the background of lethargy and confusion, pressure drops, shortness of breath appears, which is replaced by noisy shallow breathing. Children are often drowsy and lethargic.

Vomit

With meningitis, one-time vomiting is rarely observed. As a rule, vomiting is often repeated, repeated and not accompanied by a feeling of nausea. The difference between vomiting during meningitis is that it is not associated with eating. Therefore, vomiting does not bring relief. Vomiting can be at the height of a headache, or it can be provoked by exposure to irritating factors - light, sound, touch.

This symptomatology is caused by the syndrome of increased intracranial pressure, which is the main symptom of meningitis. However, sometimes the disease may be accompanied by low intracranial pressure syndrome ( cerebral hypotension). This is especially common in young children. Their intracranial pressure is sharply reduced, to the point of collapse. The disease occurs with symptoms of dehydration: facial features become sharper, muscle tone is reduced, reflexes fade. Symptoms of muscle stiffness may then disappear.

Rash on the skin, mucous membranes

A hemorrhagic rash on the skin and mucous membranes is not a mandatory symptom of meningitis. According to various sources, it is observed in a quarter of all cases of bacterial meningitis. Most often it is observed with meningococcal meningitis, since meningococcus damages the inner wall of blood vessels. Skin rashes occur 15–20 hours after the onset of the disease. The rash is polymorphic - roseola, papular, rash in the form of petechiae or nodules are observed. The rashes are always irregular in shape, sometimes protruding above the skin level. The rash tends to coalesce and form massive hemorrhages that appear as purplish-blue spots.

Hemorrhages are observed on the conjunctiva, oral mucosa and internal organs. Hemorrhage with further necrosis in the kidneys leads to the development of acute renal failure.

Convulsions

Seizures occur in one fifth of cases of meningitis in adults. In children, tonic-clonic convulsions are often the onset of the disease. The younger the child, the higher the likelihood of developing seizures.

They can occur like epileptic convulsions, or tremor of individual parts of the body or individual muscles may be observed. Most often, young children experience tremor of the hands, which later turns into a generalized seizure.

These cramps both generalized and local) are a consequence of irritation of the cortex and subcortical structures of the brain.

Anxiety and psychomotor agitation

As a rule, the patient's agitation is observed in a later stage of meningitis. But in some forms, for example, with rheumatic meningoencephalitis, this is a sign of the onset of the disease. Patients are restless, agitated, disoriented.
With bacterial forms of meningitis, excitement appears on the 4th – 5th day. Often psychomotor agitation is replaced by loss of consciousness or transition to a coma.
Meningitis in infants begins with anxiety and unmotivated crying. The child does not fall asleep, cries, and gets excited at the slightest touch.

Mental disorders

Mental disorders during meningitis belong to the so-called symptomatic psychoses. They can be observed both at the beginning of the disease and in a later period.

Mental disorders are characterized by:

• excitement or, on the contrary, inhibition;
• rave;
• hallucinations ( visual and auditory);

Most often, mental disorders in the form of delusions and hallucinations are observed with lymphocytic choriomeningitis and meningitis caused by the tick-borne encephalitis virus. Encephalitis Economo ( or lethargic encephalitis) are characterized by visual colorful hallucinations. Hallucinations can occur at high temperatures.
In children, mental disorders are more often observed with tuberculous meningitis. They experience an anxious mood, fears, and vivid hallucinations. Tuberculous meningitis is also characterized by auditory hallucinations and disturbances of consciousness of the oneiric type ( the patient experiences fantastic episodes), as well as a disorder of self-perception.

Features of the onset of the disease in children

In children, the clinical picture of meningitis comes first:

• fever;
• convulsions;
• vomiting like a fountain;
• frequent regurgitation.

Infants are characterized by a sharp increase in intracranial pressure with bulging of the large fontanel. A hydrocephalic cry is characteristic - a child, against a background of confused consciousness or even unconsciousness, suddenly screams. The function of the oculomotor nerve is impaired, which is expressed in strabismus or drooping of the upper eyelid ( ptosis). Frequent damage to the cranial nerves in children is explained by damage to both the brain and meninges ( that is, the development of meningoencephalitis). Children are much more likely than adults to develop meningoencephalitis because their blood-brain barrier is more permeable to toxins and bacteria.

In infants, you need to pay attention to the skin. They may be pale, cyanotic ( blue) or pale grayish. A clear venous network is visible on the head, the fontanel is pulsating. The child may constantly cry, scream and tremble. However, with meningitis with hypotensive syndrome, the child is lethargic, apathetic, and constantly sleeps.

Symptoms of meningitis

The symptoms that appear with meningitis can be grouped into three main syndromes:

• intoxication syndrome;
• cranial syndrome;
• meningeal syndrome.

Intoxication syndrome

Intoxication syndrome is caused by septic damage to the body due to the spread and multiplication of infection in the blood. Patients complain of general weakness, fatigue, weakness. Body temperature rises to 37 - 38 degrees Celsius. A headache of aching nature appears periodically. Sometimes signs of ARVI come to the fore ( acute respiratory viral infection): nasal congestion, cough, sore throat, aching joints. The skin becomes pale and cold. Appetite decreases. Due to the presence of foreign particles in the body, the immune system is activated and tries to destroy the infection. In the first days, a rash may appear on the skin in the form of small red dots, which are sometimes accompanied by itching. The rash disappears on its own within a couple of hours.

In severe cases, when the body is unable to fight the infection, it attacks the blood vessels of the skin. The walls of the blood vessels become inflamed and clogged. This leads to ischemia of skin tissue, minor hemorrhages and skin necrosis. Compressed areas of the skin are especially vulnerable ( back and buttocks of a patient lying on his back).

Craniocerebral syndrome

Craniocerebral syndrome develops due to intoxication of the body with endotoxins. Infectious agents ( most often, meningococcus) spread throughout the body and enter the blood. Here they are susceptible to attack by blood cells. With increased destruction of infectious agents, their toxins enter the blood, which negatively affect its circulation through the vessels. Toxins cause intravascular coagulation and blood clots. The brain matter is especially affected. Blockage of brain vessels leads to metabolic disorders and accumulation of fluid in the intercellular space in brain tissue. As a result, hydrocephalus appears ( cerebral edema) with increased intracranial pressure. This causes sharp headaches in the temporal and frontal region, intense and painful. The pain is so unbearable that patients moan or scream. In medicine, this is called hydrocephalic cry. The headache is aggravated by any external irritant: sound, noise, bright light, touch.

Due to swelling and increased pressure, various parts of the brain that are responsible for the functioning of organs and systems suffer. The thermoregulation center is affected, which leads to a sharp increase in body temperature to 38 - 40 degrees Celsius. This temperature cannot be lowered by any antipyretics. The same explains the profuse vomiting ( vomiting fountain), which does not stop for a long time. It appears when the headache gets worse. Unlike vomiting during poisoning, it is not associated with food intake and does not bring relief, but only worsens the patient’s condition. In severe cases, the respiratory center is affected, leading to respiratory failure and death.
Hydrocephalus and impaired circulation of cerebral fluid causes convulsive attacks in various parts of the body. Most often they are generalized in nature - the muscles of the limbs and torso contract.

Progressive cerebral edema and increasing intracranial pressure can lead to damage to the cerebral cortex with impaired consciousness. The patient cannot concentrate, is unable to perform tasks given to him, and sometimes hallucinations and delusions appear. Psychomotor agitation is often observed. The patient moves his arms and legs chaotically, his whole body twitches. Periods of excitement are followed by periods of calm with lethargy and drowsiness.

Sometimes the cranial nerves are affected by swelling of the brain. The oculomotor nerves that innervate the eye muscles are more vulnerable. With prolonged squeezing, strabismus and ptosis appear. When the facial nerve is damaged, the innervation of the facial muscles is disrupted. The patient cannot close his eyes and mouth tightly. Sometimes sagging of the cheek on the side of the affected nerve is visible. However, these disturbances are temporary and disappear after recovery.

Meningeal syndrome

The main characteristic syndrome of meningitis is meningeal syndrome. It is caused by impaired circulation of cerebrospinal fluid against the background of increased intracranial pressure and cerebral edema. The accumulated fluid and edematous brain tissue irritate the sensitive receptors of the vessels of the meninges and spinal nerve roots. Various pathological muscle contractions, abnormal movements and the inability to bend limbs appear.

Symptoms of meningeal syndrome are:

• characteristic “cocked hammer” pose;
• stiff neck;
• Kernig's sign;
• Brudzinski's symptoms;
• Gillen's sign;
• reactive pain symptoms ( Bekhterev's symptom, palpation of nerve points, pressure on the ear canal);
• Lessage's sign ( for children).

Characteristic pose
Irritation of the sensitive receptors of the meninges causes involuntary muscle contraction. When exposed to external stimuli ( noise, light), the patient takes a characteristic position, similar to a cocked gun. The occipital muscles contract and the head falls back. The stomach is pulled in and the back is arched. The legs are bent at the knees towards the stomach and the arms towards the chest.

Stiff neck
Due to the increased tone of the neck extensors, stiffness of the neck muscles appears. When trying to turn the head or bend it towards the chest, pain appears, which forces the patient to throw his head back.
Any movements of the limbs that cause tension and irritation of the spinal membrane cause pain. All meningeal symptoms are considered positive if the patient is unable to perform a certain movement because it causes acute pain.

Kernig's sign
With Kernig's symptom, in a supine position, you need to bend the leg at the hip and knee joint. Then try to straighten your knee. Due to the sharp resistance of the flexor muscles of the leg and severe pain, this is almost impossible.

Brudzinski's symptoms
Brudzinski's symptoms are aimed at trying to provoke the characteristic meningeal posture. If you ask the patient to bring the head to the chest, this will cause pain. He will reflexively bend his knees, thereby easing the tension on the spinal membrane and the pain will ease. If you press on the pubic area, the patient will involuntarily bend his legs at the hip and knee joints. When studying the Kernig sign on one leg, during an attempt to straighten the leg at the knee, the other leg involuntarily bends at the hip and knee joint.

Gillen's sign
If you squeeze the quadriceps muscle on one leg, you may see the same muscle on the other leg involuntarily contract and flex the leg.

Reactive pain symptoms
If you tap on the zygomatic arch with a finger or a neurological hammer, there is a contraction of the zygomatic muscles, increased headaches and an involuntary grimace of pain. In this way, a positive ankylosing spondylitis symptom is determined.
When pressing on the external auditory canal and on the exit points of the facial nerves ( brow ridges, chin, zygomatic arches) pain and a characteristic painful grimace also appear.

I>Lessage's symptom
In infants and small children, all these meningeal symptoms are mild. Increased intracranial pressure and cerebral edema can be detected by feeling the large fontanel. If it is enlarged, bulging and pulsating, then the baby’s intracranial pressure has increased significantly. Infants are characterized by Lessage's symptom.
If you take the baby under the armpits and lift him up, he involuntarily takes on the characteristic “cocked hammer” pose. He immediately throws his head back and bends his knees, pulling them towards his stomach.

In severe cases, when the pressure in the spinal canal increases and the membranes of the spinal cord become inflamed, the spinal nerves are affected. In this case, motor disturbances appear - paralysis and paresis on one or both sides. The patient cannot move his limbs, move around, or do any work.

Diagnosis of meningitis

If symptoms are pronounced, the patient should contact the ambulance service with further urgent hospitalization in an infectious diseases hospital.

Meningitis is an infectious pathology and therefore it is necessary to consult an infectious disease specialist. If the course of the disease is sluggish, with a blurred picture, then the patient, due to headaches that bother him, may initially turn to a neurologist.
However, treatment of meningitis is carried out jointly by an infectious disease specialist and a neurologist.


Diagnosis of meningitis includes:

• interview and neurological examination at a doctor’s appointment;
• laboratory and instrumental examinations ( blood test, spinal puncture, computed tomography).

Survey

To diagnose meningitis, your doctor needs the following information:

• What diseases does the patient suffer from? Does he suffer from syphilis, rheumatism or tuberculosis?
• If this is an adult, was there any contact with children?
• Was the disease preceded by injury, surgery or other surgical procedures?
• Does the patient suffer from chronic pathologies, such as otitis media, sinusitis, sinusitis?
• Has he recently had pneumonia or pharyngitis?
• Which countries and regions has he visited recently?
• Was there a fever, and if so, for how long?
• Did he take any treatment? ( taken antibiotics or antiviral agents can erase the clinical picture)
• Does light and sounds irritate him?
• If there is a headache, where is it located? Namely, is it localized or spread throughout the skull?
• If there is vomiting, is it related to food intake?

Neurological examination

A neurological examination is aimed at identifying characteristic symptoms of meningitis, namely:

• stiff neck and Brudzinski's symptom;
• Kernig's sign;
• Lessage's symptom in infants;
• symptoms of Mondonesi and Bekhterev;
• examination of cranial nerves.

Nuchal rigidity and Brudzinski's sign
The patient is in a supine position on the couch. When the doctor tries to bring the patient's head to the back of the head, a headache occurs and the patient throws his head back. At the same time, the patient’s legs reflexively bend ( Brudzinski's sign 1).

Kernig's sign
With the patient lying on his back, the leg is bent at the hip and knee joints at a right angle. Further extension of the leg at the knee with a bent hip is difficult due to tension in the thigh muscles.

Lessage's sign
If you take the child by the armpits and lift him up, an involuntary pulling of the legs towards the stomach occurs.

Mondonesi and Bechterew's sign
Mondonesi's sign is light pressure on the eyeballs ( eyelids are closed). The manipulation causes headaches. Ankylosing spondylitis's symptom involves identifying painful points when tapping the zygomatic arch with a hammer.

Sensitivity is also examined during the neurological examination. With meningitis, hyperesthesia is observed - increased and painful sensitivity.
With complicated meningitis, symptoms of damage to the spinal cord and its roots are revealed in the form of motor disorders.

Examination of cranial nerves
The neurological examination also includes examination of the cranial nerves, which are also often affected by meningitis. The oculomotor, facial and vestibular nerves are most often affected. To examine a group of oculomotor nerves, the doctor examines the reaction of the pupil to light, the movement and position of the eyeballs. Normally, in response to light, the pupil narrows. This is not observed with paralysis of the oculomotor nerve.

To examine the facial nerve, the doctor checks facial sensitivity, corneal and pupillary reflexes. Sensitivity can be reduced, increased, or asymmetrical. Unilateral or bilateral hearing loss, staggering and nausea indicate damage to the auditory nerve.

The doctor's attention is also drawn to the patient's skin, namely the presence of a hemorrhagic rash.

Laboratory tests include:

• latex tests, PCR method.

General blood analysis
A general blood test reveals signs of inflammation, namely:

• Leukocytosis. The increase in the number of leukocytes is more than 9 x10 9. With bacterial meningitis, 20 – 40 x 10 9 is observed, due to neutrophils.
• Leukopenia. Decrease in white blood cell count to less than 4 x 109. It is observed in some viral meningitis.
• Shift of the leukocyte formula to the left– an increase in the number of immature leukocytes, the appearance of myelocytes and metamyelocytes. This shift is especially pronounced in bacterial meningitis.
• Increased erythrocyte sedimentation rate– more than 10 mm per hour.

Anemia may sometimes be present:

• a decrease in hemoglobin concentration of less than 120 grams per liter of blood;
• decrease in the total number of red blood cells less than 4 x 10 12.

In severe cases:

• Thrombocytopenia. Decrease in platelet count less than 150 x 109. It is observed in meningococcal meningitis.

Blood chemistry
Changes in the biochemical blood test reflect disturbances in the acid-base balance. As a rule, this manifests itself in a shift in the balance towards increasing acidity, that is, acidosis. At the same time, the concentration of creatinine increases ( above 100 – 115 µmol/liter), urea ( above 7.2 – 7.5 mmol/liter), the balance of potassium, sodium and chlorine is disturbed.

Latex tests, PCR method
To determine the exact causative agent of meningitis, latex agglutination or polymerase chain reaction methods are used ( PCR). Their essence is to identify pathogen antigens contained in the cerebrospinal fluid. In this case, not only the type of pathogen is determined, but also its type.
The latex agglutination method takes 10 to 20 minutes, and the agglutination reaction ( gluing) is carried out before our eyes. The disadvantage of this method is low sensitivity.
The PCR method has the highest sensitivity ( 98 – 99 percent), and its specificity reaches 100 percent.

Cerebrospinal puncture

Cerebrospinal puncture is mandatory in making the diagnosis of meningitis. It consists of inserting a special needle into the space between the pia mater and the arachnoid membrane of the spinal cord at the level of the lumbar region. In this case, spinal fluid is collected for further study.

Cerebrospinal puncture technique
The patient is in a position lying on his side with his legs bent and adducted to the stomach. By piercing the skin between the fifth and fourth lumbar vertebrae, a needle with a mandrel is inserted into the subarachnoid space. After the sensation of “sinking through,” the mandrin is removed, and a glass tube is brought to the needle pavilion to collect spinal fluid. As it flows out of the needle, pay attention to the pressure under which it flows. After the puncture, the patient needs rest.
The diagnosis of meningitis is based on inflammatory changes in the cerebrospinal fluid.

Instrumental examination includes

• electroencephalogram ( EEG);
• computed tomography ( CT).

Electroencephalography
EEG is one of the methods for studying the functioning of the brain by recording its electrical activity. This method is non-invasive, painless and easy to use. He is very sensitive to any slightest changes in the functioning of all brain structures. All types of brain activity are recorded using a special device ( electroencephalograph) to which the electrodes are connected.

EEG technique
The ends of the electrodes are attached to the scalp. All bioelectric signals received from the cerebral cortex and other brain structures are recorded in the form of a curve on a computer monitor or printed on paper. In this case, tests with hyperventilation are often used ( the patient is asked to breathe deeply) and photostimulation ( in a dark room where the study is being carried out, the patient is exposed to bright light).

Indications for the use of EEG are:

• epileptic seizures;
• seizures of unknown etiology;
• attacks of headaches, dizziness and neurological disorders of unknown etiology;
• disturbances in sleep and wakefulness, nightmares, sleepwalking;
• injuries, tumors, inflammatory processes and circulatory disorders in the medulla.

With meningitis, the EEG indicates a diffuse decrease in the bioelectrical activity of the brain. This study is used in cases of residual effects and complications after meningitis, namely the appearance of epileptic seizures and frequent convulsions. An EEG helps determine which brain structures have been damaged and what type of seizures are occurring. In other cases of meningitis, this type of research is not informative. It only confirms the presence of damage to brain structures.

CT scan

CT is a method of layer-by-layer examination of the structure of organs, in this case the brain. The method is based on circular transillumination of the organ with a beam of X-ray radiation with further computer processing. The information captured by X-rays is translated into graphic form in the form of black and white images.

CT technique
The patient lies on the tomograph table, which moves towards the tomograph frame. Over a period of time, the X-ray tube moves in a circle, taking a series of images.

Symptoms detected by CT scan
A CT scan shows the structures of the brain, namely the gray and white matter of the brain, meninges, ventricles of the brain, cranial nerves and blood vessels. Thus, the main syndrome of meningitis is visualized - the syndrome of increased intracranial pressure and, as a consequence, cerebral edema. On CT, edematous tissue is characterized by reduced density, which can be local, diffuse or periventricular ( around the ventricles). With severe edema, dilation of the ventricles and displacement of brain structures are observed. With meningoencephalitis, heterogeneous areas of reduced density are found, often bordered by a zone of increased density. If meningoencephalitis occurs with damage to the cranial nerves, then signs of neuritis are visualized on CT.

Indications for use of CT
The CT method is necessary in the differential diagnosis of meningitis and volumetric processes in the brain. In this case, spinal puncture is initially contraindicated and is done only after a computed tomography scan. However, in terms of information content, CT is inferior to MRI ( magnetic resonance imaging). MRI can detect inflammatory processes in both brain tissue and meninges.

Treatment of meningitis

Treatment of meningitis is complex, it includes etiotropic therapy ( aimed at eliminating the infection), pathogenetic ( used to eliminate the development of cerebral edema, increased intracranial pressure syndrome) and symptomatic ( aimed at eliminating individual symptoms of the disease).

Eliminating the cause of meningitis

Eliminating the causes of bacterial ( meningococcal, staphylococcal, streptococcal) meningitis

A drug	Mechanism of action	How to use
benzylpenicillin	has a bactericidal effect against streptococci, pneumococci and meningococci	4,000,000 units each. intramuscularly every 6 hours. For children, the dose is calculated based on 200,000 - 300,000 units. per 1 kg of weight per day. The dose is divided into 4 doses
ceftriaxone	has a bactericidal effect against streptococci, pneumococci and Escherichia coli	adults: 2 grams intravenously every 12 hours. Children 50 mg per 1 kg of body weight per day in 2 divided doses
ceftazidime	effective against group B hemolytic streptococci, listeria and shigella	2 grams every 8 hours
meropenem	effective against hemolytic streptococci and Haemophilus influenzae	2 grams every 8 hours. Children: 40 mg per kg of body weight three times a day
chloramphenicol	effective against Escherichia coli, Shigella and Treponema pallidum	50 – 100 mg per kg of body weight per day, the dose is divided into 3 doses ( interval every 8 hours)

For meningococcal meningitis, penicillin therapy is appropriate; for streptococcal and staphylococcal meningitis - a combination of penicillins and sulfonamide drugs ( ceftriaxone, ceftazidime); with meningitis caused by Haemophilus influenzae ( H.Influenzae) – a combination of chloramphenicol and sulfonamides.

Eliminating the causes of tuberculous meningitis

A drug	Mechanism of action	How to use
isoniazid	has a bactericidal effect against the causative agent of tuberculosis	from 15 to 20 mg per kg of body weight per day. The dose is divided into three doses and taken half an hour before meals.
ftivazid	anti-tuberculosis drug	40 mg per kg of patient weight per day
streptomycin	active against Mycobacterium tuberculosis, gonococci, Klebsiella, Brucella	1 gram per day intramuscularly. When combined with other drugs ( for example, with ftivazid) streptomycin is administered every other day

The average duration of treatment for tuberculous meningitis is 12 – 18 months.

Elimination of the causes of meningitis caused by malarial plasmodium or toxoplasma

Elimination of the causes of herpetic meningitis, as well as meningitis caused by the Epstein-Barr virus

There is no specific treatment for other types of viral meningitis. Basically, treatment for viral meningitis is pathogenetic and aimed at reducing intracranial pressure. Some clinicians use corticosteroids for viral meningitis, but data on their effectiveness are mixed.

Eliminating the causes of candidal meningitis

Symptomatic treatment

Symptomatic treatment consists of the use of diuretics, drugs that replenish fluid deficiency, vitamins, painkillers and antipyretics.

A drug	Mechanism of action	How to use
20% mannitol solution	increases the pressure in the plasma, and thereby promotes the transfer of fluid from the tissue ( in this case from the brain) into the bloodstream. Reduces intracranial pressure	at the rate of 1.5 g per kg of weight, administered intravenously
furosemide	inhibits Na reabsorption in the tubules, thereby increasing diuresis	for cerebral edema, the drug is administered in a stream, in a single dose of 80–120 mg, most often combined with colloidal solutions; for moderate edema syndrome in the morning on an empty stomach, one to two tablets ( 40 – 80 mg)
dexamethasone	used to prevent complications, prevent hearing loss	initially 10 mg intravenously four times a day, then switch to intramuscular injections
hemodesis	has a detoxifying effect	300 - 500 ml of solution, heated to 30 degrees, is administered intravenously at a rate of 40 drops per minute
vitamin B1 and B6	improve metabolism in tissues	administered intramuscularly 1 ml daily
cytoflavin	has cytoprotective ( protects cells) action	10 ml of solution is diluted in 200 ml of 5% glucose solution and administered intravenously, drip for 10 days
acetaminophen	has analgesic and antipyretic	one to two tablets ( 500 mg – 1g), every 6 hours. The maximum daily dose is 4 grams, which is equal to 8 tablets
calcium carbonate	In conditions of acidosis, corrects acid-base balance	5% solution 500 ml is administered intravenously
cordiamine	stimulates metabolism in brain tissue	intramuscularly or intravenously, 2 ml one to three times a day

Anticonvulsant therapy

If meningitis is accompanied by convulsions, psychomotor agitation, and anxiety, then anticonvulsant therapy is prescribed.

Anticonvulsant therapy for meningitis

A drug	Mechanism of action	How to use
diazepam	has a calming, anti-anxiety and anticonvulsant effect	for psychomotor agitation, 2 ml ( 10 mg) intramuscularly; for generalized attacks, 6 ml ( 30 mg) intravenously, then repeat after an hour. The maximum daily dose is 100 mg.
aminazine	has an inhibitory effect on the central nervous system	2 ml intramuscularly
mixture of aminazine + diphenhydramine	has a calming effect, relieves stress	in case of severe psychomotor agitation, chlorpromazine is combined with diphenhydramine - 2 ml of chlorpromazine + 1 ml of diphenhydramine. To prevent hypotension, the mixture is combined with cordiamine.
phenobarbital	has anticonvulsant and sedative effects	50 – 100 mg 2 times a day, orally. Maximum daily dose 500 mg

From the very first minutes of the patient's admission to the hospital, it is necessary to carry out oxygen therapy. This method is based on inhaling a gas mixture with a high concentration of oxygen ( since pure oxygen is toxic). The method is indispensable, since cerebral edema during meningitis is accompanied by oxygen starvation ( brain hypoxia). With prolonged hypoxia, brain cells die. Therefore, as soon as the first signs of hypoxia appear ( tissue cyanosis is observed, breathing becomes shallow) it is necessary to carry out oxygen therapy. Depending on the severity of the patient's condition, it can be performed using an oxygen mask or by intubation.

In case of traumatic meningitis with the presence of purulent foci in the bones, in addition to intensive antibiotic therapy, surgical intervention with removal of the purulent foci is indicated. Surgical treatment is also indicated in the presence of purulent foci in the lungs.

Patient care

People who have had meningitis need special care, which is based on diet, proper daily routine and a balanced distribution of physical activity.

Diet
When recovering from meningitis, you should eat in small portions, at least five to six times a day. The patient's diet should ensure a decrease in the level of intoxication in the body and normalization of metabolism, water-salt, protein and vitamin balance.

The menu should be balanced and include products containing easily digestible animal proteins, fats and carbohydrates.

These products include:

• lean meat - beef or pork tongue, veal, rabbit, chicken, turkey;
• lean fish - herring, balyk, tuna;
• eggs - boiled or soft-boiled, as well as steamed omelets, soufflé;
• dairy and fermented milk products – kefir, yogurt, cottage cheese, mild cheese, kumiss;
• milk fats – cream, butter, sour cream;
• low-fat broths and soups prepared on their basis;
• vegetables and fruits with a small content of coarse fiber - zucchini, tomatoes, cauliflower, cherries, cherries, plums;
• dried wheat bread, crackers, products made from rye flour, bran.

When preparing meat, fish and vegetables, preference should be given to such types of heat treatment as boiling, stewing, and steaming.

When caring for a patient after meningitis, the consumption of animal fats should be minimized, as they can provoke metabolic acidosis. It is also worth minimizing the consumption of easily digestible carbohydrates, which can cause intestinal fermentation processes, cause allergies and inflammatory processes.

The diet of a person who has had meningitis should not contain the following foods:

• fatty types of meat - lamb, pork, goose, duck;
• cooked pork and fish products by smoking or salting;
• sweet drinks, desserts, creams, mousses, ice cream;
• fresh wheat bread, puff pastry, baked goods;
• whole milk;
• buckwheat, pearl barley, legumes;
• vegetables and fruits with coarse plant fiber - carrots, potatoes, cabbage, red and white currants, strawberries;
• dried fruits;
• spicy and fatty sauces and dressings for dishes based on mustard and horseradish.

Water mode
In order to improve metabolism and speed up the removal of toxins from the body, the patient should consume about two and a half liters of fluid per day.

You can drink the following drinks:

• weakly brewed tea;
• tea with milk;
• rosehip decoction;
• table mineral water;
• jelly;
• fresh fruit compote;
• natural sweet and sour juices from fruits.

Schedule
The main factors in recovery from meningitis are:

• bed rest;
• lack of stress;
• timely sound sleep;
• psychological comfort.

Going to bed should be no later than 10 pm. In order for the healing effect of sleep to be most noticeable, the air in the room must be clean, with a sufficient level of humidity. Water treatments - a bath with herbal infusions or sea salt - help you relax before bed.
A foot massage helps improve your well-being and relaxation. You can do this procedure yourself, or use the Kuznetsov applicator. You can purchase this product in pharmacies or specialty stores.

Distribution of physical activity
You should return to an active lifestyle gradually, in accordance with your doctor’s recommendations. You need to start with daily walks in the fresh air and exercise in the morning. Complex physical activity should be avoided. You should also minimize your exposure to the sun.

Rehabilitation of patients after meningitis

After discharge from the infectious diseases hospital, the patient is sent to specialized rehabilitation centers and for outpatient treatment at home. Rehabilitation therapy begins in the hospital during the early recovery of the patient. All activities must be in strict sequence at different stages of recovery. Rehabilitation should be comprehensive and include not only recovery procedures, but also visits to specialist doctors. All activities and loads must be adequate for the patient’s physical condition and gradually increase. Constant monitoring of the effectiveness of these rehabilitation measures and correction of methods if necessary is also necessary. Recovery is carried out in three stages - in the hospital ( during treatment), in a sanatorium, in a clinic.

The complex of all rehabilitation measures includes:

• therapeutic nutrition;
• physical therapy;
• physiotherapy ( myostimulation, electrophoresis, warming, massage, water procedures, etc.);
• drug correction;
• psychotherapy and psychorehabilitation;
• sanitary resort rehabilitation;
• vocational rehabilitation
• social rehabilitation.

Rehabilitation programs are selected individually, depending on the patient’s age and the nature of the dysfunction.

With a mild form of meningitis, which was diagnosed in time and the correct course of treatment was started, there are practically no residual effects. However, such cases are rare in medical practice, especially if children suffer from meningitis.

Often, the primary symptoms of meningitis are ignored or mistaken for symptoms of other diseases ( colds, poisonings, intoxications). In this case, the disease progresses with damage to nerve structures, which recover very slowly after treatment or do not recover at all.

Residual effects

Possible residual effects after meningitis include:

• headaches depending on meteorological conditions;
• paresis and paralysis;
• hydrocephalus with increased intracranial pressure;
• epileptic seizures;
• mental impairment;
• hearing impairment;
• disruption of the endocrine system and autonomic nervous system;
• damage to the cranial nerves.

The recovery of patients with such complications of meningitis is long and requires special attention and treatment.

Elimination of complications of meningitis

In case of paresis and paralysis, which lead to motor disorders, it is necessary to undergo a rehabilitation course with various types of massage, water procedures, therapeutic exercises, and acupuncture. Consultations and observations of a neurologist are required.

In fulminant forms of meningitis or undiagnosed forms, when the circulation of cerebrospinal fluid is disrupted and it accumulates in large quantities in the cavities of the brain, hydrocephalus with high intracranial pressure develops. This is especially common in children. Headaches persist, mental disorders and slowed mental development are noted. Convulsions and epileptic seizures appear periodically. The introduction of such children into public life undergoes some difficulties, so first of all they should undergo courses of psychotherapy and psychorehabilitation. They are under clinical observation and must regularly visit a neurologist, neurologist and psychiatrist.

Hearing loss most often occurs when the inner ear becomes infected or inflamed. To restore patients, they resort to physiotherapy ( electrophoresis, heating). In cases of deafness, patients need special training ( deaf language) and special hearing aids.

Due to malfunctions of the nervous system, all organs and systems suffer, especially the endocrine and immune systems. Such people are more susceptible to environmental factors. Therefore, during the rehabilitation period it is necessary to take measures to strengthen the immune system. They include vitamin therapy, heliotherapy ( solar treatments), sanatorium rehabilitation.
Lesions of the cranial nerves are often accompanied by strabismus, facial asymmetry, ptosis ( drooping eyelid). With adequate anti-infective and anti-inflammatory treatment, their risk is minimal and they resolve on their own.

Periods of incapacity for work

Depending on the severity of meningitis and the presence of complications, the period of incapacity for work varies from 2 to 3 weeks ( in mild serous forms of meningitis) up to 5 – 6 months or more. In some cases, an early start to work is possible, but with easier working conditions. With mild serous meningitis, residual effects are rare, and the period of disability ranges from three weeks to three months. For purulent meningitis with various residual effects ( hydrocephalus, epileptic seizures) the period of incapacity for work is about 5 – 6 months. Only in case of complete regression of symptoms can the recovering person return to work ahead of schedule, but with certain work restrictions. You should alternate physical and mental stress and dose them correctly. The worker must be exempt from night shifts and overtime for at least six months. If the symptoms of complications return, then the sick leave is extended for another couple of months.

If within 4 months after discharge from the hospital the symptoms of complications do not subside and the disease becomes chronic, the patient is referred for a medical and social examination to determine the disability group.

The main indications for referral to a medical and social examination are:

• persistent and severe complications that limit the patient’s life activity;
• slow recovery of functions, which causes a long period of disability;
• chronic forms of meningitis or constant relapses with disease progression;
• the presence of consequences of the disease due to which the patient cannot perform his work.

To undergo a medical and social examination, you must first undergo an examination by specialists and provide their findings.

The main package of analyzes and consultations consists of:

• general and biochemical blood test;
• all results of bacteriological, serological and immunological studies during the period of acute meningitis;
• results of cerebrospinal fluid analysis over time;
• results of psychological and psychiatric research;
• results of consultations with an ophthalmologist, otorhinolaryngologist, neurologist and neurologist.

Children with severe motor, mental, speech, and hearing impairments ( complete restoration of which is impossible) are registered as disabled for a period of one to two years. After this period, children again undergo a medical and social examination. Children with persistent speech and mental disorders, frequent epileptic seizures and hydrocephalus are assigned a disability group for two years. In case of severe complications ( deafness, dementia, deep paresis and paralysis) the child is assigned a disability group until he reaches 18 years of age.

Disability determination system

Adults are assigned three different categories of disability, depending on the severity of the complications and the degree of disability.

If, as a result of meningitis, the patient is limited in his ability to self-care due to blindness, decreased intelligence, paralysis of the legs and arms and other disorders, he is given the first disability group.

The second disability group is given to patients who cannot perform work in their specialty under normal production conditions. These patients have significantly impaired motor functions, some mental changes are observed, epileptic seizures and deafness appear. This group also includes patients with chronic and recurrent forms of meningitis.

The third disability group includes persons with partial disabilities. These are patients with moderate motor dysfunction, moderate hydrocephalus, and maladjustment syndrome. The third group includes all cases in which a person has difficulties performing work in his specialty, and it is necessary to reduce his qualifications or reduce the amount of work. This includes cases with epileptic seizures and intellectual disabilities.

The third disability group is determined during retraining or learning a new profession and new employment.

Dispensary observation

After meningitis, clinical observation is required for at least 2 years, depending on the severity of the disease and complications. For mild forms of meningitis, observation by doctors in the clinic is once a month for the first three months, then once every three months for a year. For purulent meningitis and severe forms with complications, visits to doctors should be at least twice a month for the first three months. The following year, inspection is required every three months and every six months during the second year. Visits to specialists such as a neurologist, psychiatrist, therapist and infectious disease specialist are required. According to the testimony of specialists, dispensary observation may be extended.

Prevention of meningitis

Prevention can be specific and nonspecific. Specific prevention includes vaccination.

Vaccination

The main vaccines to prevent bacterial and viral meningitis are:

• Meningococcal vaccine– provides protection against a number of bacteria that can cause meningitis. This vaccination is given to children 11-12 years old, and is also recommended for first-year students living in a dormitory, military recruits, tourists visiting places where there are epidemics of this disease;
• Haemophilus influenzae type B vaccine– intended for children aged from two months to five years;
• Pneumococcal vaccine– can be of two types: conjugative and polysaccharide. The first category of vaccine is intended for children under two years of age, as well as for at-risk children whose age does not exceed five years. The second type of vaccine is recommended for older people, as well as for middle-aged people whose immunity is weakened or there are certain chronic diseases;
• Vaccines against measles, rubella and mumps– are administered to children in order to prevent meningitis, which can develop against the background of these diseases;
• Vaccination against chickenpox.

Vaccinated children and adults may experience a variety of side effects, such as weakness, flushing, or swelling at the injection sites. In most cases, these symptoms disappear after one to two days. In a small percentage of patients, vaccines can provoke severe allergic reactions, which manifest themselves in the form of swelling, shortness of breath, high fever, and tachycardia. In such cases, you should consult a doctor, stating the date of vaccination and the time of occurrence of side effects.

Nonspecific prevention

Nonspecific prevention of meningitis is a series of measures aimed at increasing the body's immunity and preventing contacts with possible pathogens of the disease.

What should I do?

To prevent meningitis you need to:

• strengthen immunity;
• maintain a balanced diet;
• observe personal hygiene rules and precautions;
• carry out vaccination.

Strengthening the immune system
Hardening strengthens the body's immune system, increasing its resistance to negative environmental factors. Hardening activities should begin by taking air baths, for example, by exercising in a room with an open window. Subsequently, classes should be moved to the open air.
Water procedures are an effective method of hardening, which should be used if the body is healthy. You should start by dousing with water, the temperature of which is not lower than +30 degrees. Next, the temperature must be gradually reduced to +10 degrees. When drawing up a schedule and choosing the type of hardening manipulations, you should take into account the individual characteristics of the body and consult a doctor.
Helps increase the body's resistance to walking and playing various outdoor sports. If possible, you should choose places away from highways and roads, closer to green spaces. Exposure to the sun has a beneficial effect, as exposure to it promotes the production of vitamin D.

Diet
Eating a balanced, healthy diet is an important factor in preventing meningitis. In order to effectively resist bacteria and viruses, the body should receive sufficient amounts of protein, fats, carbohydrates, vitamins and minerals.

The diet should include the following elements:

• Plant and animal proteins– immunoglobulins synthesized from amino acids help the body resist infections. Protein is found in meat, poultry, eggs, sea fish, legumes;
• Polyunsaturated fats– increase the body's endurance. Included in nuts, fatty fish, flaxseed, olive and corn oils;
• Fiber and complex carbohydrates– essential for strengthening the immune system. Included in cabbage, pumpkin, dried fruits, wheat and oat bran, wholemeal products. Also with these products the body receives B vitamins;
• Vitamins A, E, C– are natural antioxidants, increase the body’s barrier resistance. Contained in citrus fruits, sweet peppers, carrots, fresh herbs, apples;
• Vitamins of group P– immune stimulants. Contains black currants, eggplant, blueberries, dark grapes, red wine;
• Zinc– increases the number of T-lymphocytes. Found in quail eggs, apples, citrus fruits, figs;
• Selenium– activates the formation of antibodies. Garlic, corn, pork, chicken and beef liver are rich in this element;
• Copper and iron– ensure good functioning of the blood supply system and are found in spinach, buckwheat, turkey meat, soybeans;
• Calcium, magnesium, potassium– elements necessary to strengthen the immune system. The sources of these substances are dairy products, olives, egg yolks, nuts, and dried fruits.

Gastrointestinal problems have a negative impact on the immune system. To maintain intestinal microflora, you should consume low-fat lactic acid products. These products include: kefir, fermented baked milk, yoghurts. Also, beneficial bacteria that synthesize amino acids and promote digestion are found in sauerkraut, pickled apples, and kvass.

It is quite difficult to obtain the necessary complex of vitamins from the diet. Therefore, the body should be supported with vitamins of synthetic origin. Before using these drugs, you should consult a physician.

Hygiene rules and precautions
In order to prevent the likelihood of contracting bacterial meningitis, the following rules should be followed:

• for drinking and cooking, use bottled water, filtered or boiled;
• Vegetables and fruits should be doused with boiling water before consumption;
• before eating you need to wash your hands with soap;
• Avoid using other people's handkerchiefs, toothbrushes, towels and other personal items.

You should be careful in crowded places. A person who is coughing or sneezing should turn away or leave the room. For those whose profession involves constant contact with a large number of people ( salesman, hairdresser, ticket taker) you must have a gauze bandage with you. In transport and other public places, when grasping door handles or handrails, you should not take off your gloves.

Some forms of meningitis are carried by insects.

Therefore, when going to a forest or park, you need to:

• use insect and tick repellents;
• dress in tight, closed clothing;
• wear a headdress.

If a tick is found on the skin, remove the insect with tweezers, after pouring alcohol or vodka on it. Do not crush or tear off the tick, as the virus is in its salivary glands. After completing all manipulations, the wound should be treated with an antiseptic.

To prevent meningitis, you should avoid swimming in lakes, ponds and other bodies of water with standing water. When planning to travel to countries where epidemics of viral or other types of meningitis are common, you should get the necessary vaccines. Also, when visiting exotic places, doctors recommend taking antifungal drugs. During tourist trips, it is imperative to refrain from contact with animals and insects.

In residential and office premises, the required level of cleanliness should be maintained and the destruction and prevention of rodents and insects should be systematically carried out.
If one of your family members gets meningitis, you need to isolate the patient, minimizing any kind of contact with him as much as possible. If communication with a person infected with meningitis is unavoidable, you should consult a doctor. The doctor will prescribe an antibiotic depending on the nature of the disease and the type of contact.

What not to do?

To prevent meningitis, you should not:

• trigger otolaryngological diseases ( otitis, sinusitis, sinusitis);
• neglect preventive treatment in the presence of chronic diseases;
• ignore the vaccination schedule;
• do not comply with sanitary and hygienic standards at work and at home;
• eat dirty fruits and vegetables;
• do not observe precautions when interacting with a patient;
• ignore protection methods when visiting potentially dangerous places ( transport and other public places).

Meningitis - causes, symptoms, complications and what to do? - Video

Inflammatory changes in the cerebrospinal fluid are determined in the absence of clinical symptoms of meningitis. Changes in the cerebrospinal fluid appear in the first 2-3 years after infection with syphilis. Characterized by lymphocytic pleocytosis (8-100 cells in 1 μl), increased protein content (0.4-2 g/l), weakly positive globulin reactions (++), positive serological reactions in the study of cerebrospinal fluid and blood serum. Manifesting asymptomatic neurosyphilis develops in almost all patients, and pathological changes in the cerebrospinal fluid persist for over 5 years.

Syphilitic meningitis.

Considering the nature of the course, there are 2 clinical forms of meningitis: acute and chronic. Most often found among young patients with syphilis who have not received adequate penicillin therapy. Occurs within the first year after infection. A constant symptom of acute syphilitic meningitis is a paroxysmal headache that occurs at night. Nausea, vomiting, dizziness, tinnitus, and photophobia are often observed. Meningeal symptoms are positive, although mildly expressed.

Due to the fact that the pathological process is usually localized on the basal surface of the brain, the cranial nerves are often affected: oculomotor, abducens, optic, trigeminal, facial, vestibulocochlear.

Positive direct sign of Argyll Robertson: absence of pupillary reaction to light with preserved reaction to convergence and accommodation. Miosis, anisocoria, and irregular pupil shape are often observed.

In the cerebrospinal fluid, an increased number of lymphocytes (lymphocytic pleocytosis) is determined up to 200-2000 in 1 μl, protein - up to 0.6-2 g/l, as well as a positive Wasserman reaction. In syphilitic meningitis, the cerebrospinal fluid has a composition that is characteristic of serous meningitis (pronounced cell-protein dissociation). Its only distinguishing feature is positive serological reactions. Syphilitic meningitis most often occurs in the first year after contracting syphilis. In 10% of cases, meningitis is combined with clinical manifestations of secondary syphilis.

Chronic syphilitic meningitis is more common than acute meningitis and occurs 3-5 years after infection with syphilis. The diagnosis is based on a slow, gradual increase in neurological symptoms, without a febrile period with damage to the cranial nerves, characteristic changes in the cerebrospinal fluid (lymphocytic pleocytosis: up to 200-300 cells in 1 μl), positive serological reactions.

Meningovascular syphilis.

It usually occurs 5-30 years after the onset of infection. This form is characterized by moderate involvement of the meninges in the process and the presence of focal neurological symptoms, which come to the fore. Meningeal symptoms are mild or absent. In the cerebrospinal fluid there is lymphocytic pleocytosis - 20-30 cells in 1 μl, protein - 0.6-0.7 g/l, positive globulin reactions, positive Wasserman reaction.

In addition to damage to the meninges, cerebral vessels are affected (specific endarteritis), which causes infarctions in the brain and spinal cord. The clinic is characterized by general cerebral and focal symptoms. At the onset of the disease, a headache occurs, which can intensify in attacks. It is accompanied by memory impairment and decreased intelligence. There is a gradual, over several days, emergence and increase in focal symptoms: mono- or hemiparesis, aphasia, sensitivity disorders, extrapyramidal disorders. In some cases, focal symptoms may be preceded by personality changes, memory loss, disorientation, and prolonged headache.

Damage to the spinal cord in meningovascular syphilis manifests itself as acute or subacute meningomyelitis. Spinal cord infarctions lead to the development of central paralysis, sensory conduction disturbances, trophic changes and dysfunction of the pelvic organs. If there is damage to the spinal cord at the lumbosacral level, meningoradiculitis with severe pain syndrome may develop.

Magnetic resonance angiography (MRA), MRI and CT are of leading importance in diagnosis. MRA reveals clear changes in the arteries, most often the anterior and middle cerebral arteries. In contrast to atherosclerotic vascular lesions, in the case of syphilitic vasculitis, narrowing of the lumen of the vessels is observed over a longer period; the absence of signs of damage to the bifurcation of the common carotid artery is also characteristic. MRI or CT reveals numerous small foci of ischemic cerebral infarctions. Lesions of the vascular system of the brain and spinal cord may be the only manifestation of early neurosyphilis.

Early syphilitic meningitis.

Damage to the meninges can be of varying degrees of severity and type of course: asymptomatic, acute and chronic forms. Acute syphilitic meningitis manifests itself with typical symptoms - increasing headache, positive Kernig and Brudzinski symptoms. No other pathological (focal) neurological symptoms are found. In the fundus, congestion and hyperemia of the optic discs are possible, so this type of meningitis is often accompanied by acute hydrocephalus, increased intracranial pressure. When examining the cerebrospinal fluid - lymphocytic pleocytosis (tens and hundreds of cells in 1 mm 3) - syndrome cellular protein dissociation. In the blood and in the cerebrospinal fluid there are positive serological reactions to syphilis (Wassermann test, RIBT - immobilization reaction of Treponema pallidum), the so-called syphilitic curve of the Lange colloid reaction in the cerebrospinal fluid is also specific, which serves as the main argument for the etiological diagnosis.

Another option is chronic syphilitic meningitis, which is also called basilar form, because the process primarily affects the membranes at the base of the brain along with the vessels (in fact, this is meningovascular, mesenchymal syphilis). In these cases, the onset of the process (which often occurs later than acute meningitis in terms of time from the primary infection - after a month or one to two years) is slower, weeks and even months, and in the clinical picture the meningeal syndrome is blurred and does not appear on first plan. At the same time, damage to the cranial nerves is typical: oculomotor or abducens (diplopia), facial (paresis of facial muscles), auditory (hearing loss, dizziness) and visual (decreased visual acuity, optic nerve atrophy). In the latter case, a symptom occurs Argyll-Robertson(Argyle-Robertson): lack of pupillary response to light while maintaining pupillary constriction during the convergence test. The symptom is not specific enough (can occur with multiple sclerosis, chronic alcoholism and diabetes), because it is a consequence of optic nerve atrophy and uveitis, but the small size of the pupils, their unevenness and deformation most likely indicates syphilis.

More rare forms of manifestations are acute meningoencephalitis (with the development of cortical paresis, convulsive seizures, impaired consciousness, etc.), myelitis(the occurrence of lower paraparesis with pelvic disorders or Brown-Séquard syndrome), syphilitic radiculoneuritis or polyneuritis, ischemic strokes (including multiple and recurrent). The course can last for many months with periodic remissions. The basis for diagnosis remains the study of cerebrospinal fluid with the obligatory performance of serological reactions in it. It is known that a certain part of syphilitic patients are seronegative (negative serological tests), but in the cerebrospinal fluid, in the presence of an ongoing process, the samples are always positive.