CNS infections

List the DIFFERENTIAL DIAGNOSIS: PYOGENIC/BACTERIAL MENINGITIS

DIFFERENTIAL DIAGNOSIS: PYOGENIC/BACTERIAL MENINGITIS

• Bacterial Meningitis

• Fungal meningitis

• Tuberculosis Meningitis

• Parameningeal infections

Describe Aseptic Meningitis

• What is it?

• DDX

Aseptic Meningitis

What is it?

• Meningitis accompanied by mononuclear pleocytosis without evidence of bacterial infection

DDX

• Viral Meningitis

• Chemical meningitis

• Subarachnoid hemorrhage

Describe MENINGITIS

• Predisposing Factors

  • Infections

  • Surgery/Diseases

• Clinical Presentation

MENINGITIS:

PREDISPOSING FACTORS

• Infections:

  • Otitis Media

  • Mastoiditis

  • Pneumonia

  • Sinusitis

  • Endocarditis

• Surgery or Diseases:

  • Head injury

  • Cochlear implants

  • Shunts

  • Sickle cell anemia

  • Alcoholism

  • HIV

---

CLINICAL PRESENTATION

• Acute onset

• Fever

• Stiff neck

• Generalized headache

• Nausea/Vomiting

• Fontanele bulges: infants

• Rash

• Altered mental status

• Confused or obtunded

• Myalgias

• Backache

• Generalized weakness

• Drowsiness

• Decreased mentation

• kernigs or brudzinskis signs

What does the Brudzinski/Kernig Sign look like?

What does Optic N Edema look like?

List the Signs Brain Herniation -> CT Scan:

Signs Brain Herniation -> CT Scan:

• aphasia

• prior hx CNS disease

• mass lesion suspected

• decreased LOC

• >60 yrs

• seizure

LIst the DIagnostic Tests you order

DIAGNOSTIC TESTS: LABS AND IMAGING

• LP with CSF exam

• Blood Cultures

• Nasopharyngeal swabs

• CBC

• CMP

• PT INR, PTT

• UA

List the age groups/Common Pathogens → Meningitis:

• Neonates

• Children/Adolescent

• 18-59 y/o

• >60 y/o

• Nocosomial

AGE GROUPS AND COMMON PATHOGENS

• Neonates

  • Group B Streptococcus: Streptococcus agalactiae

  • E. coli

  • Listeria monocytogenes

• Children & adolescents

  • Streptococcus pneumoniae

  • Neisseria meningitidis

  • Haemophilus influenzae

• 18 - 59 years

  • Streptococcus pneumoniae

  • Neisseria meningitidis

• > 60 years

  • Streptococcus pneumoniae

  • Listeria monocytogenes

• Nosocomial

  • Staphylococcus aureus

  • Gram negative rods

    • E. coli, Klebsiella, Pseudomonas, Acinetobacter, Enterobacter

Describe MENINGOCOCCEMIA

• What is it

• Cause

• Epidemiology

• Vaccine

MENINGOCOCCEMIA

• What is it?

  • Infection of the blood stream with or without meningitis

• Cause:

  • Neisseria menigitis

• Epidemiology:

  • Peak in February & March

  • Dorms & Military barracks common

• Vaccine: 

  • common strains Neisseria menigitis

PHYSICAL EXAM FINDINGS: PETECHIAL OR ECCHYMOTIC LESIONS

1. How do we treat BACTERIAL MENINGITIS

2. Propholaxis

Treatment:

• Begin antimicrobial treatment STAT

  • based on age and risk factors

• Fluid support

• Seizure precautions

• Hospital admission

• Repeat CSF exam if no improvement after 24 hrs

  • Usually afebrile within 2 – 5 days

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Chemoprophylaxis for Meningococcal Meningitis

• Adult

  • Rifampin 600 mg bid for 2 days

• Pediatric

  • Rifampin 10mg/kg bid for 2 days

NOTE:

• Illness develops 2-5 days after initial case

Describe the Species Responsible: for ASEPTIC MENINGITIS

• types w/in

• Transmission

Species Responsible:

• Enterovirus 60%

  • Cocksackie virus, Echo virus

  •  fecal-oral route +  hematogenous 

  • Peak summer, fall

• Herpes simplex virus 1-3%

  • Sexually active adult and adolescent (HSV 2)

  • Neuronal spread

  • Temporal lobe signs: Seizures common

What are the clinical presentation for Aseptic meningitis:

• Entero

• HSV

Enteroviral

• Prodromal Phase

  • Low grade fever

  • Malaise

  • Sore throat

• Headache

• Fever

• Stiff Neck

• Nausea/Vomiting

• Myalgia

• Photophobia

---

HSV – 2

• Headache

• Stiff neck

• Photophobia

• Neuro complications

  • Paresthesias

  • Urinary retention

  • Weakness LE

  • Hyporeflexia

Describe Arbo Virus

• Transmission

• 3 Genera

• Diseases Caused

Arbo Virus: 

Transmission:

• by arthropods

3 Genera:

• flavivirus, togavirus, bunyavirus

---

Diseases caused:

• Dengue Fever

• Yellow Fever

• LaCrosse

• Zika

• Jamestown Canyon

• Eastern Equine

• Western Equine

• Ross River

1. List the Diagnosis Tools for Aseptic Meningitis

2. Treatment

ASEPTIC MENINGITIS - DIAGNOSIS

• CSF Analysis

  • WBC increased with Lymphocytic shift

  • Normal glucose

  • Mildly elevated protein

• PCR

  • Diagnosis in hours

  • High Sensitivity: 85 -100%

• Viral Culture

  • Diagnosis in days

  • Moderate Sensitivity: 65-75%

---

TREATMENT

• Supportive care

• HSV

  • Acyclovir IV

• HIV

  • Antiretrovirals

Subacute or Chronic Meningitis Causes

Subacute or Chronic Meningitis Causes

• Cryptococcus neoformans

• Coccidioides immites

• Histoplasma capsulatum

• Mycobacterium tuberculosis

• Treponema pallidum

• Lyme disease

• HIV

Describe HSV Encephalitis:

• Presentation

• LAB

• Imaging

• Tx

HSV Encephalitis: Presentation

Presentation

• Prodrome: URI like symptoms for 1-7 days

• Symptoms: 

  • fever, headache, behavioral abnormalities, memory loss, seizure

---

LAB:

• CSF: Increased WBC (lymphocytes)

• PCR for HSV DNA

Imaging:

• Focal EEG changes

• MRI - changes in Temporal and Frontal lobes

Tx: Acyclovir IV

Describe the presentation of Encephalitis

ENCEPHALITIS - PRESENTATION

• Neurologic symptoms

  • Altered LOC

  • Motor abnormality

  • Weakness with myoclonus or tremor & incoordination

  • Seizures

  • Temperature control

• Fever

• Malaise

• Myalgia

• Respiratory symptoms

• GI upset

---

• Meningeal irritation

  • Heachache

  • Photophobia

  • Stiff neck

1. Diagnosis Tools for encephalitis

2. Tx

ENCEPHALITIS - DIAGNOSIS

• CT scan

  • Exclude mass lesion

• MRI

  • Herpes Simplex Encephalitis

    • Hyperintensity temporal and frontal lobes +/-- edema

  • Other Viral Encephalitis

    • Early disease – normal

    • Late disease – edema with multifocal areas of parenchymal injury

• Viral specific antibodies in blood or CSF

• Lumbar Puncture for CSF examination

  • Opening pressure +/-- elevation

  • Glucose normal

  • Protein elevated (50-100 mg/dL)

  • 10-1000 mononuclear cells / mm3

---

ENCEPHALITIS - TREATMENT

• HSV, CMV, Varicella

  • Acyclovir IV

• Management

  • Headache: Analgesia!

  • Hyperthermia: cooling blanket

  • Supportive care

  • Treatment or prophylaxis of seizures as appropriate

• Isolation

• Handwashing

Describe BRAIN ABSCESS

• What is it?

• Common Pathogens

What is it?

• Affects brain parenchyma

• Collection of purulent material and organisms

---

Common Pathogens

• Dental Abscess: Streptococci, Bacteroides

• Chronic Otitis: Bacteroides, Pseudomonas, Proteus

• Sinusitis: Streptococci, Haemophilus

• Penetrating Trauma, Post Surgical: Staphylococcus,Pseudomonas

• Bacterial Endocarditis: Mixed flora

• Congenital Heart Disease: Streptococci

• Pulmonary Infection: Nocardia, Bacteroides

• HIV infection: Toxoplasma gondii

Describe the Clinical Manifestation of Brain Abscessse:

• MOA

• Manifestations

• Presentation

CLINICAL MANIFESTATIONS

MOA:

• Increasing intracranial mass effect -> focal brain involvement

Manifestations:

• Temporal lobe

  • contralateral homonymous superior quadrantic visual field defect

  • aphasia

• Supratentorial

  • motor deficit

• Cerebellar

  • ipsilateral limb ataxia

  • nystagmus

---

PRESENTATION

• Fever

• Headache

• Disturbed consciousness

• Hemiparesis

• Nausea, vomiting

• Nuchal rigidity

• Dysarthria

• Seizures

• Sepsis or septic shock

• Visual disturbance

1. Diagnostic Tools for Brain Abscess

2. Tx

 DIAGNOSTIC Brain Abscess

• MRI or CT

• Blood or sputum culture

• LP

  • contraindicated if brain herniated due to mass effect

• Surgical Aspiration

  • gram Stain culture

---

TREATMENT

• Decompression of abscess

  • needle drainage

  • surgical removal

• Dexamethasone to control edema

• Non surgical intervention

  • small lesion

  • already know the pathogen

  • no signs of increased intracranial pressure

  • deep or multiple lesions

• Antibiotic therapy

  • based on culture sensitivity

Describe these parasitic infections on CNS

• Cystericosis

  • Larvae: 

  • Transmission: 

  • Dx: 

  • Tx: 

• Toxoplasmosis

  • Cause:

  • Dx: 

  • Tx:

  
  

Cystericosis

• Larvae: 

  • Taenia solium

• Transmission: 

  • Ingesting food or water with eggs

• Dx: 

  • CT/MRI brain: single or multiple cysts, ELISA

• Tx: 

  • Praziquantel

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Toxoplasmosis

• Cause:

  • Toxoplasma gondii

  • Often with immunosuppression

• Dx: 

  • CT/MRI multiple ring enhancing lesions, ELISA

• Tx: Pyrimethamine and Sulfadiazine

Describe SPINAL EPIDURAL ABSCESS

• What is it?

• Predisposing factors

• MC organism

SPINAL EPIDURAL ABSCESS

• What is it?

  • Infection within the epidural space around spinal cord

• Predisposing factors

  • Diabetes

  • Malignancy

  • IV drug use

  • Hematogenous spread of infection

  • Organ transplantation

  • Chronic steroid use

  • Acupuncture or epidural anesthesia

  • Osteomyelitis

• MOST COMMON ORGANISM: Staph. aureus

Describe SPINAL EPIDURAL ABSCESS: HISTORY AND PRESENTATION

• Presentation

• Stages

• Diagnostic

• Tx

Presentation:

• radicular pain or neurologic deficit

Stages:

• Stage 1

  • Back pain and fever

• Stage 2

  • Radicular pain

• Stage 3

  • Muscle weakness, incontinence, sensory deficit

• Stage 4

  • Paralysis or quadriplegia

---

DIAGNOSTIC STUDIES

• No LP: risk of spreading meningitis

• MRI

• Gram stain and culture

---

TREATMENT

• Surgical Drainage

• CT guided aspiration

• Antibiotics

Describe SUBDURAL EMPYEMA

• What is it?

• Predisposing Factor

• Symptoms

• Diagnostic

• Tx

SUBDURAL EMPYEMA

• What is it?

  • Infection in space btw dura and the arachnoid

• Predisposing factor : 

  • Paranasal sinus infection, 

    • usually unilateral

• Symptoms 

  • headache, fever, neurologic deficit, stiff neck

  • Can have later features due to increased ICP

• Diagnostic:

  • MRI

• Tx

  • surgical drainage, antibiotics

NOTE:

Mortality 25%