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Encoding QR-Code in Microsoft Office PART 4

PART 4
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by bacteria and should therefore be regarded as a noninfectious encephalopathy When macrophages and astrocytes are exposed to endotoxins in vitro, the cells synthesize and release cytokines, among which are interleukin-1 and tumor necrosis factor These cytokines are believed to stimulate and modulate the local immune response but may also affect cortical neurons In the early stages of meningitis, there is little change in the ependyma and the subependymal tissues; but in later stages, conspicuous changes are invariably found The most prominent nding is in ltration of the subependymal perivascular spaces and often of the adjacent brain tissue with neutrophilic leukocytes and later with lymphocytes and plasma cells Microglia and astrocytes proliferate, the latter sometimes overgrowing and burying remnants of the ependymal lining We believe that the bacteria pass through the ependymal lining and set up this in ammatory reaction in part because this sequence of events is favored by a developing hydrocephalus, which stretches and breaks the ependymal lining Collections of subependymal astrocytes then begin to protrude into the ventricle, giving rise to a granular ependymitis, which, if prominent, may narrow and obstruct the aqueduct of Sylvius The choroid plexus is at rst congested, but within a few days it becomes in ltrated with neutrophils and lymphocytes and eventually may be covered with exudate As in the case of the meningeal exudate, lymphocytes, plasma cells, and macrophages later predominate Eventually there is organization of the exudate covering the plexus As any meningitis becomes more chronic, the pia-arachnoid exudate tends to accumulate around the base of the brain (basilar meningitis), obstructing the ow of CSF and giving rise to hydrocephalus The exudate may also encircle cranial nerves and lead to focal cranial neuropathies The reader may question this long digression into matters that are more pathologic than clinical, but only a knowledge of the morphologic features of meningitis enables one to understand the clinical state and its sequelae The meningeal and ependymal reactions to bacterial infection and the clinical correlates of these reactions are summarized in Table 32-1, which may be consulted together with this section
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Pneumococcal, in uenzal (H in uenzae), and meningococcal forms of meningitis have a worldwide distribution, occurring mainly during the winter and early spring and, in the case of the rst two, also in the fall, and predominating slightly in males Each has a relatively constant incidence, although epidemics of meningococcal meningitis seem to occur roughly in 10-year cycles Drugresistant strains appear with varying frequency, and such information, gleaned from surveillance reports issued by the Centers for Disease Control and Prevention and from reports of local health agencies and hospital infection surveillance, are of great practical importance H in uenzae meningitis, formerly encountered mainly in infants and young children, has been nearly eliminated in this age group as a result of vaccination programs in developed countries It continues to be common in less developed nations and is now occurring with increasing frequency in adults (in the United States there are 15,000 cases each year) Meningococcal meningitis occurs most often in children and adolescents but is also encountered throughout much of adult life, with a sharp decline in incidence after the age of 50 Pneumococcal meningitis predominates in the very young and in older adults Perhaps the greatest change in the epidemiology of bacterial meningitis, aside from the one related to H in uenzae vaccination, has been the increasing incidence of nosocomial infections, accounting for 40 percent of cases in large urban hospitals (Durand and colleagues); staphylococcus and gram-negative bacilli account for a large proportion of these Noteworthy is the report of Schuchat et al, who found that in 1995, some 5 years after the introduction of the conjugate H in uenzae vaccine, the overall incidence of bacterial meningitis in the United States had been halved The yearly incidence rate (per 100,000) of the responsible pathogens is now approximately as follows: Strep pneumoniae, 11; N meningitidis, 06; group B streptococcus (newborns), 03; L monocytogenes, 02; and H in uenzae, 02
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