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0 g
0 Tw
( )Tj
0 0 0 1 k
-3.5913 -6.0368 TD
0.0752 Tw
(vomissements, raideur )Tj
/F10 1 Tf
0 g
3.8913 6.0368 TD
0 Tw
( )Tj
0 0 0 1 k
6.0345 -6.0368 TD
0.0752 Tw
(ou hypotonie)Tj
/F9 1 Tf
0 g
-5.7345 6.0368 TD
0 Tw
( )Tj
0 0 0 1 k
12.142 -6.0368 TD
( )Tj
0.3532 0 TD
0.0752 Tw
(de la nuque, troubles de conscience\). Les)Tj
-16.6865 -1.2 TD
0.1087 Tw
(convulsions en contexte fbrile imposent la ponction lombaire chez lÕenfant de)Tj
T*
0.0833 Tw
(moins de 9 mois.)Tj
0 -1.8525 TD
0.0896 Tw
[(Chez lÕadulte, le Ē )89.6(syndrome mning )89.6(Č classique \(fivre, cphales ou troubles)]TJ
0 -1.2 TD
0.1491 Tw
(de conscience, raideur de nuque\), nÕest retrouv dans sa forme complte que)Tj
T*
0.3258 Tw
[(chez 45 )325.8(% des malades \(donc avec une faible sensibilit\), mais 95 )325.8(% des)]TJ
T*
0.0969 Tw
[(malades en ont au moins 2. Un purpura nÕest prsent que dans 26 )96.9(% des cas,)]TJ
T*
0.0833 Tw
[(et les signes neurologiques focaux dans 33 )83.3(% des cas. )]TJ
0 -1.8525 TD
[(La prise en charge prhospitalire est centre sur 2 repres essentiels )83.3(:)]TJ
0 -1.5525 TD
0.0834 Tw
[(Š )83.4( )83.4(lÕacheminement du patient vers lÕhpital constitue une urgence absolue dans)]TJ
0 -1.2 TD
0.0833 Tw
[(les dlais les plus brefs ds lors que le diagnostic est voqu la rgulation )83.3(;)]TJ
0 -1.5525 TD
0.0025 Tw
(Š lÕantibiothrapie prhospitalire sÕimpose ds lors que le diagnostic de purpura)Tj
0 -1.2 TD
0.2306 Tw
(fulminans est voqu sur la constatation dÕau moins un lment purpurique)Tj
T*
0.0833 Tw
(ncrotique dÕun diamtre suprieur ou gal 3 mm.)Tj
/F10 1 Tf
0 g
4.3913 23.6468 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 418.34 Tm
0 0 0 1 k
-0.0009 Tw
(1.2. Les examens biologiques indispensables)Tj
/F9 1 Tf
10 0 0 10 101 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-4.6913 -27.8519 TD
0.0067 Tw
(La ponction lombaire demeure au centre de la prise en charge initiale des mnin-)Tj
0 -1.2 TD
0.0228 Tw
(gites. Les rsultats dÕune ponction lombaire doivent tre connus dans lÕheure qui)Tj
T*
0.1189 Tw
(suit le prlvement. Cette exigence suppose que le laboratoire de biologie soit)Tj
T*
0.0759 Tw
(organis pour rpondre cette exigence. 2 5 ml \(soit 40 100 gouttes\) chez)Tj
T*
0.0833 Tw
[(lÕadulte et 2 )83.3(ml chez lÕenfant sont ncessaires pour une analyse correcte.)]TJ
/F7 1 Tf
0 g
4.9913 32.6519 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 332.29 Tm
0 0 0 1 k
-0.0058 Tw
[(1.2.1. )-5.2(La )-5.8(cytologie)]TJ
/F9 1 Tf
10 0 0 10 107 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-5.2913 -36.4569 TD
0.1242 Tw
(Un LCR normal comporte moins de 5 lments figurs par mm)Tj
6 0 0 6 110 680 Tm
0 g
0 Tw
( )Tj
5.628 0 0 7.5 333.695 318.731 Tm
0 0 0 1 k
(3)Tj
10 0 0 10 111 680 Tm
0 g
( )Tj
0 0 0 1 k
22.6865 -36.4569 TD
0.1242 Tw
(. Une PL trau-)Tj
-28.3778 -1.2 TD
0.0118 Tw
(matique est ininterprtable sur le plan cytologique. En vue de la ralisation dÕune)Tj
T*
0.1075 Tw
[(PCR, 10 gouttes doivent tre congeles Š )107.5(20 )107.5(”C avant toute manipulation. Si)]TJ
T*
0.0631 Tw
[(99 )63.1(% des patients porteurs de mningite bactrienne ont plus de 100 lments)]TJ
T*
0.1349 Tw
(par mm)Tj
6 0 0 6 114 680 Tm
0 g
0 Tw
( )Tj
5.628 0 0 7.5 88.756 270.731 Tm
0 0 0 1 k
(3)Tj
10 0 0 10 116 680 Tm
0 g
( )Tj
0 0 0 1 k
-2.3074 -41.2569 TD
0.1349 Tw
(, il faut savoir quÕexceptionnellement, surtout si la PL est ralise trs)Tj
-3.8839 -1.2 TD
0.0939 Tw
(prcocement aprs le dbut des symptmes, la cytologie peut tre normale. La)Tj
T*
0.1455 Tw
(formule est typiquement prdominance de polynuclaires, mais une formule)Tj
T*
0.0351 Tw
(lymphocytaire est possible la phase initiale, voire une formule panache en cas)Tj
T*
0.1237 Tw
(dÕantibiothrapie pralable. Les mningites virales sont habituellement lympho-)Tj
T*
0 Tw
(cytaires.)Tj
/F7 1 Tf
0 g
6.3913 47.2569 TD
( )Tj
9.9 0 0 11 54.087 186.24 Tm
0 0 0 1 k
-0.0002 Tw
[(1.2.2. )5.6( LÕexamen microbiologique direct)]TJ
/F9 1 Tf
10 0 0 10 121 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-6.6913 -51.0619 TD
0.1911 Tw
(Ralis aprs cytocentrifugation, son rsultat dpend beaucoup de lÕinoculum)Tj
0 -1.2 TD
0.0976 Tw
(bactrien prsent \(cÕest--dire de la densit de la population bactrienne\), mais)Tj
T*
0.0783 Tw
(aussi de lÕexprience du biologiste, et de lÕexistence ou non dÕune antibiothra-)Tj
T*
0.0178 Tw
(pie pralable. En lÕabsence dÕantibiothrapie pralable, et selon les sries, sa sen-)Tj
T*
0.0854 Tw
[(sibilit varie entre 65 et 97 )85.4(%, mais elle chute au-dessous de 40 )85.4(% dans le cas)]TJ
T*
0.0646 Tw
[(contraire. En revanche, la spcificit est de 100 )64.6(% \(= )64.6(la prsence dÕune bactrie)]TJ
T*
0.1179 Tw
(visible lÕexamen direct signe lÕexistence dÕune mningite. Il nÕy a pas de faux)Tj
T*
0 Tw
(positifs\).)Tj
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0.961 0.51 0.122 scn
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(URGENCES)Tj
/F5 1 Tf
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(2010)Tj
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[(co-f)17.7(ondateurs)]TJ
ET
EMC
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/F7 1 Tf
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0 g
/GS2 gs
( )Tj
0 0 0 1 k
/GS4 gs
-12.1522 -106.0647 TD
0.0833 Tw
(MNINGITES BACTRIENNES. LE POINT SUR LES RECOMMANDATIONS DE 2008)Tj
10 0 0 10 128 680 Tm
0 g
0 Tw
( )Tj
9.9 0 0 11 54.087 618.965 Tm
0 0 0 1 k
-0.0001 Tw
[(1.2.3. )5.7( La recherche des antignes solubles)]TJ
/F9 1 Tf
10 0 0 10 131 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-7.6913 -7.8209 TD
0.0281 Tw
(Seul le test en immunochromatographie est retenu par la confrence de consen-)Tj
0 -1.2 TD
0.0016 Tw
(sus. La sensibilit de ce test est de 95 100 %, et la spcificit de 100 %. Il nÕest)Tj
T*
0.1348 Tw
(utile que dans les cas de forte suspicion clinique, ds lors que lÕexamen direct)Tj
T*
0.0833 Tw
(est ngatif.)Tj
/F7 1 Tf
0 g
7.9913 11.4209 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 544.284 Tm
0 0 0 1 k
-0.0058 Tw
[(1.2.4. )-5.1(La )-5.8(culture)]TJ
/F9 1 Tf
10 0 0 10 137 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-8.2913 -15.2891 TD
0.1094 Tw
(LorsquÕelle est positive, elle permet dÕaffirmer le diagnostic, mais elle peut tre)Tj
0 -1.2 TD
0.0398 Tw
(prise en dfaut si lÕinoculum bactrien est trop faible, si les conditions dÕachemi-)Tj
T*
0.1196 Tw
(nement ont t dfaillantes, ou en cas dÕantibiothrapie pralable. Un antibio-)Tj
T*
0.0595 Tw
(gramme avec dtermination des CMI \(vis--vis de lÕamoxicilline, le cfotaxime et)Tj
T*
0.0285 Tw
(la ceftriaxone\) doit alors tre ralis en conformit avec les recommandations du)Tj
T*
0.0833 Tw
(Comit Franais de lÕAntibiogramme. )Tj
/F7 1 Tf
0 g
8.5913 21.2891 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 445.602 Tm
0 0 0 1 k
-0.0001 Tw
[(1.2.5. )5.7( La dtection par PCR)]TJ
/F9 1 Tf
10 0 0 10 142 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-8.7913 -25.1572 TD
0.0916 Tw
[(Les tests \(dirigs vers le mningocoque ou le pneumocoque, ou Ē )91.6(universelle )91.6(Č\))]TJ
0 -1.2 TD
0.1544 Tw
(nÕont dÕintrt quÕen cas de ngativit des recherches classiques \(y compris la)Tj
T*
0.0958 Tw
(recherche dÕantignes solubles\) et si la probabilit dÕune mningite bactrienne)Tj
T*
0.0583 Tw
(est forte. Dans un contexte de suspicion de mningite virale, il existe galement)Tj
T*
0.0833 Tw
(un test de PCR pour lÕidentification des entrovirus.)Tj
/F7 1 Tf
0 g
9.0913 29.9572 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 358.92 Tm
0 0 0 1 k
-0.0001 Tw
[(1.2.6. )5.7( Les autres examens bactriologiques)]TJ
/F9 1 Tf
10 0 0 10 148 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-9.3913 -33.8254 TD
0.1409 Tw
(Au moins une hmoculture doit tre ralise \(et si possible 2\) qui ne doit pas)Tj
0 -1.2 TD
0.1038 Tw
(retarder la mise en route de lÕantibiothrapie. La biopsie cutane dÕun lment)Tj
T*
0.133 Tw
(purpurique est recommande en cas dÕantibiothrapie pralable et si lÕexamen)Tj
T*
0.1507 Tw
(direct du LCR est ngatif, car le mningocoque reste prsent dans ces lsions)Tj
T*
0.0683 Tw
[(jusquÕ 24 )68.3(h aprs le dbut de lÕantibiothrapie. La ralisation pratique de cette)]TJ
T*
0.0476 Tw
(recommandation dans un service dÕurgence la rend nanmoins difficile envisa-)Tj
T*
0.0833 Tw
(ger dans la majorit des cas \(note personnelle\).)Tj
/F7 1 Tf
0 g
9.6913 41.0254 TD
0 Tw
( )Tj
9.9 0 0 11 54.087 248.238 Tm
0 0 0 1 k
-0.0002 Tw
[(1.2.7. )5.6( Les examens biochimiques)]TJ
/F9 1 Tf
10 0 0 10 153 680 Tm
0 g
0 Tw
( )Tj
0 0 0 1 k
-9.8913 -44.8936 TD
0.1089 Tw
[(La recherche dÕune hypoglycorachie \(infrieure 40 )108.9(% de la glycmie contem-)]TJ
0 -1.2 TD
0.1806 Tw
[(poraine\) demeure un examen ayant une haute spcificit \(98 )180.6(%\), condition)]TJ
T*
0.1292 Tw
(que la PL ne soit pas traumatique. LÕhyperprotinorachie \(avec un seuil variant)Tj
T*
0.2815 Tw
[(entre 0,4 et 1,20 )281.5(g/l\) reste significativement associe aux mningites bact-)]TJ
T*
0.0788 Tw
(riennes. La mesure des lactates dans le LCR est dsormais recommande. Facile)Tj
T*
0.1811 Tw
(et peu coteux, cet examen permet dÕliminer une mningite bactrienne sÕil)Tj
T*
0.0833 Tw
(rvle un rsultat infrieur 3,2 mmol/l.)Tj
0 -1.8841 TD
0.0894 Tw
(Dans le sang, la mesure de la Procalcitonine doit tre prfre au dosage de la)Tj
0 -1.2 TD
0.0907 Tw
[(CRP. Au seuil de 0,5 ng/ml, ce test a une sensibilit de 99 )90.7(% et une spcificit)]TJ
T*
0.0833 Tw
[(de 83 )83.3(%.)]TJ
0 -1.8841 TD
-0.02 Tc
0.0714 Tw
(La combinaison des tests a abouti recommander lÕutilisation de rgles de dcision)Tj
0 -1.2 TD
0.1065 Tw
(clinique. La plus simple, disponible sur le web sous forme dÕun calcul automatique)Tj
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T*
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