Timing of lumbar puncture in severe childhood meningitis.
Timing of lumbar puncture in severe childhood meningitis.
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严重儿童脑膜炎腰椎穿刺的时机。
DOI：
10.1136/bmj.291.6496.651
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发表时间：
1985
期刊：
影响因子：
--
通讯作者：
S. Eykyn
中科院分区：
文献类型：
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作者：
J. Harper;J. Lorber;G. Hillas Smith;B. Bower;S. Eykyn
北安普顿总医院的儿科医生顾问 JR Harper 博士在信中描述了以下病例：最近，一名 20 个月大的男孩在我的照顾下入院，他已经连续三天感到不适和昏昏欲睡，颈部有些僵硬，并出现非特异性皮疹。家庭医生的入院诊断是很可能是脑膜炎。入院时，孩子发烧、昏昏欲睡，但可清醒，颈部中度僵硬，眼底正常，有少量紫癜皮疹。入院后立即进行腰椎穿刺，在明显正常压力下抽出3ml液体。这是混浊的，显示白细胞 1 0x 109/l，蛋白质 0-85 g/l，葡萄糖浓度 1-3 mmol/l (23-4 mg/100 ml)。在染色膜中可见大量革兰氏阴性双球菌。血尿素、血红蛋白和电解质浓度正常，白细胞计数和血小板也正常。诊断为脑膜炎球菌性脑膜炎，他立即开始静脉注射大剂量青霉素和氯霉素。入院两小时后，孩子呼吸变浅，然后停止。他的瞳孔固定且散大，并且从未恢复自主呼吸。经过 48 小时的呼吸器支持后，他去世了。父母拒绝尸检。虽然我没有理由怀疑这个孩子的病情恶化与腰椎穿刺有关，但这个病例让我思考，对于这个年龄的患病孩子，是否应该推迟腰椎穿刺，直到抗生素治疗进行了几个小时，孩子的全身状况和意识水平明显改善。在这个年龄，脑膜炎的诊断通常可以在临床上有一定的信心，并且初始抗生素的选择不太可能受到脑脊液检查的影响。-J R HARPER
Dr JR Harper, consultant paediatrician at Northampton General Hospital, wrote describing the following case: Recently a 20 month old boy was admitted under my care having been unwell and drowsy for three days, with some stiffness of the neck and a non-specific rash. The admitting diagnosis from the family doctor was probable meningitis. On admission the child was febrile, drowsy but rousable, with moderate stiffness of the neck, normal fundi, and a scanty purpuric rash. Lumbar puncture was carried out soon after admission and 3 ml fluid removed under apparently normal pressure. This was turbid, showing leucocytes 1 0x 109/l, proteins 0-85 g/l, and glucose concentration 1-3 mmol/l (23-4 mg/100 ml). Numerous Gram negative diplococci were seen in the stained film. Blood urea, haemoglobin, and electrolyte concentrationswere normal, as were white blood cell count and platelets. A diagnosis of meningococcal meningitis was made and he was immediately started on high dose intravenous penicillin and chloramphenicol. Two hours after admission the child's respiration became shallow and then ceased. He developed fixed, dilated pupils and never regained spontaneous respiration. He died after 48 hours' support on a respirator. The parents refused necropsy.Although I have no reason to suspectthat this child's deterioration was related to the lumbar puncture, this case leads me to wonder if lumbar puncture should be delayed in an ill child of this age until antibiotic treatment has been in progress for some hours and the child's general condition and level of consciousness are obviously improving. The diagnosis of meningitis can usually be made clinically at this age with some confidence, and it isunlikely that the choice of initial antibiotics would be influenced by the cerebrospinal fluid examination.-J R HARPER