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ADAMS > Infections of the CNS (Bacterial, fungal, spirochetal, parasitic) and Sarcoidosis > Flashcards

Infections of the CNS (Bacterial, fungal, spirochetal, parasitic) and Sarcoidosis Flashcards

1
Q

ways by which infections reach intracranial structures

A

hematogenous or by extension from cranial structures adjacent to the brain

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2
Q

Most common pathogenic organisms in adult

A

pneumococcus (Strep penumo) meningococcus (Neisseria meningitides) haemophilus influenza

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3
Q

Most common pathogenic organisms in neonate

A

E. coli Group B strep

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4
Q

Most common pathogenic organisms in infants and unvaccinated child

A

H. influenzae

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5
Q

organism after neurosurgery or insertion of a cranial appliance

A

staphylococcal

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6
Q

Most common bacteria acocunting for 75% of cases

A

H. influenzae N. meningitidis S. penumoniae 4th most common L. monocytogenes

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7
Q

implicated organisms after lumbar puncture, spinal anesthesia, shunting procs

A

Pseudomonas Enterobacteriaceae - Klebsiella, Proteus

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8
Q

Pneumococcal meningitis is usually suspected in

A

alcoholics

splenectomized patients

very elderly

recurrent Bact Men

Dermal sinus tracts

sickle cell anemia

basilar skull fracture

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9
Q

seizures are most often encountered in

A

H. influenza meningitis

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10
Q

Most significant factor in the pathogenesis of meningitis in newborns

A

maternal infection UTI, puerperal fever

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11
Q

T/F Children in whom meningitis is complicated by subdural effusions are no more likely to have residual neurologic signs and seizures than are those without effusions

A

True

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12
Q

T/F Bacteremia is a contraindication to lumbar puncture.

A

False

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13
Q

criteria that classifies patient at high risk of bact men

A

positive CSF gram stain CSF absolute neutrophil count at least 1000cells/mL CSf protein at least 80mg/dL. peripheral absolute neutrophil count of at least 10,000 cells/mL history of seizure or after the time of presentation

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14
Q

T/F In children, fever subsided more rapidly and the incidence of sensorineural deafness and other nemologic sequelae was reduced, particularly in those children with H. influenzae meningitis

A

True dexamethasonegiven as 0.15mg/kg qid for 4 days

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15
Q

prophylaxis for household members of patients with meningococcal meningitis

A

ciprofloxacin single dose rifampin 600mg q12 in adults and 10mg/kg q12 in children for 2 days

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16
Q

Osler Triad

A

pneumococcal meningitis

pneumonia

endocarditis

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17
Q

Deafness in meningitis is due to

A

suppurative cochlear destruction or aminoglycoside ototoxicity

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18
Q

Usually affects immunocompromised individuals and takes the form of brainstem encephalitis treatment

A

Listeria monocytogenes tx: ampicillin 2g IV q4 + gentamicin 5mg per kg IV in 3 divided doses

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19
Q

conditions with low CSF glucose

A

sarcoidosis of CNS fungal or TB Meningitis some cases of SAH meningeal carcinomatosis chemically induced inflammation from craniopharyngioma or teratoma meningeal gliomatosis

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20
Q

blood cultures are positive in ___% of cases with H.influenzae, meningococcal and pneumococcal meningitis

A

40-60%

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21
Q

two ways of differentiating CSF rhinorrhea from nasal secretions

A

nasal secretions have low glucose, CSffrhinorrhea approximates the one obtained via LP protein content high protein - which makes handkerchief stiff - nasal

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22
Q

Most specific and sensitive test for CSF otorrhea and rhinorrhea

A

finding of Beta2-transferrin (tau)

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23
Q

Recurrent oropharyngeal ulceration, uveitis, orchitis, meningitis

A

Behcet disease

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24
Q

recurrent episodes of fever and headache in addition to signs of meningeal irritation

A

Mollaret meningitis

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25
Q

recurrent meningitis associated with iridocyclitis and depigmentation of the hair and skin

A

Vogt-Koyanagi-Harada syndrome

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26
Q

Empiric Therapy for Bact Men 0-4 wk

A

cefotaxime plus ampicillin

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27
Q

Empiric therapy for Bact Men 4-12 wk

A

3rd gen cephalosphorin plus ampicillin plus dexa

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28
Q

Empiric Therapy for Bact Men 3mo - 18y

A

3rd gen cephalopshorin plus vancomycin (+/-ampicillin)

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29
Q

Empiric Therapy for Bact Men 18-50 y

A

3rd gen cephalopshorin plus vancomycin (+/- ampicillin)

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30
Q

Empiric Therapy for Bact Men Immunocompromised state

A

Vanco plus ampicillin and ceftazidime

Intravenous drug abusers have high rates of meningitis due to S. aureus and should receive cefepime or ceftazidime with vancomycin

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31
Q

Empiric Therapy for Bact Men Basilar skull fracture

A

3rd gen cephalosphorin + vanco

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32
Q

Empiric Therapy for Bact Men head trauma, neurosurgery CSF shunt

A

Vanco plus ceftazidime

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33
Q

If pseudomonas is considered after neurosurgery

A

antipseudomonal ceftazidime or cefapim may be revised once with sensitivity of organisms

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34
Q

Duration of therapy for most cases of Bact Meningitis

A

10-14 days

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35
Q

T/F The CSF glucose may remain low for many days after other signs of infection have subsided and should occasion concern only if bacteria are present in the fluid and the patient remains febrile and ill,

A

True

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36
Q

Recommended doses for Bact Men with normal renal and hepatic function amikacin ampicillin cefepime ceftazidime ceftriaxone meropenem oxacillin Pen G Vancomycin

A

Total daily dose/ dosing interval Amikacin 15mg/kg / 8 ampicillin 12 g / 4 cefepime 4-6g / 8 -12 ceftaz 6g / 8 ceftri 4g / 12-24 merop 3-6g / 8 oxacillin 9-12g / 4 pen G 24 million units / 4 vanco 2-4g / 6-12

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37
Q

The essential lesion in __________ consists of focal collections of epithelioid cells surrounded by a rim of lymphocytes; frequently there are giant cells, but caseation is lacking

A

sarcoidosis

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38
Q

Syphilis is caused by

A

Treponema pallidum

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39
Q

The treponeme usually invades the CNS within ___to ____months of inoculation with the organism

A

3 to 18

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40
Q

Neurosyphilis If the nervous system is not involved by the end of the second year, as shown by completely negative CSF, there is _________ chance that the patient will develop neurosyphilis as a result of the original infection; if the CSF is negative at the end of 5 years, the likelihood of developing neurosyphilis falls to ___ percent.

A

1 in 20 or 5percent after 2nd year 1 percent after 5 years

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41
Q

The initial event in the neurosyphilitic infection is ________ , which occurs in approximately ____ percent of all cases of syphilis.

A

meningitis 25%

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42
Q

True or False

All forms of neurosyphilis begin as meningitis and meningeal inflammation are the invariable accompaniment of all forms of neurosyphilis

A

True

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43
Q

The early clinical syndromes are _____________ and ___________; the late (secondary) ones are ___________ syphilis (1 to 12 years), followed even later by tertiary syphilis, general paresis, __________ , optic atrophy, or subacute myelitis.

A

aseptic meningitis and meningovascular syphilis

vascular

tabes dorsalis

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44
Q

True or False

Because asymptomatic neurosyphilis can be recognized only by the changes in the CSF, it is advisable that all patients with syphilis should have a spinal fluid examination.

A

True

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45
Q

The CSF has been a sensitive indicator of the presence of active neurosyphilitic infection. Enumerate CSF abnormalities

A

The CSF abnormalities consist of

(1) a pleocytosis of up to 100 cells/mm3, sometimes higher, mostly lymphocytes and a few plasma cells and other mononuclear cells (the counts may be lower in patients with AIDS and those with leukopenia);
(2) elevation of the total protein, from 40 to 200 mg/dL
(3) an increase in gamma globulin (IgG), usually with oligoclonal banding; and
(4) positive serologic tests.

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46
Q

True or False In neurosyphilis, The positive serologic tests are the last to revert to normal.

A

True

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47
Q

Most common form of neurosyphilis

A

Meningovascular syphilis common occurrence after 6-7 years but may occur as early as 9 months up to 10-12 yrs main manifestation of secondary syphilis

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48
Q

pathologic changes in meningovascular syphils

A

The pathologic changes in this disorder consist not only of meningeal infiltrates but also of inflammation and fibrosis of small arteries (Heubner arteritis), which lead to narrowing and, finally, occlusion

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49
Q

duration prior to occurrence of paretic neurosyphilis (general paresis, dementia paralytica)

A

15 to 20 yrs from original infection middle years (35 to 50) are the usual time of onset of paretic symptoms

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50
Q

clinical picture in the fully developed form of paretic neurosyphilis

A

progressive dementia, dysarthria, myoclonic jerks, action tremor, seizures, hyperreflexia, Babinski, Argyll Robertson pupils

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51
Q

Pathologic changes in Paretic Neurosyphilis

A

meningeal thickening

brain atrophy

ventricular enlargement granular ependymitis

special stains: spirochetes are visible in the cortex changes are more pronounced in the frontal and temporal lobes

ependymal surfaces of the ventricles are studded with granular elevations protruding between ependymal cells (granular ependymitis)

52
Q

chief signs in Tabes Dorsalis

A

absent reflexes at knee and ankle

impaired vibratory and position sense

Romberg sign

major symptoms lightning pains ataxia urinary incontinence

53
Q

T/F There is some ptosis and some degree of ophthalmoplegia in Tabes Dorsalis

A

True

54
Q

Pathologic findings in Tabes Dorsalis

A

striking thinness and grayness of posterior roots, principally, lumbosacral

thinning of spinal cord

peripheral nerves E/N

55
Q

T/F In Tabes Dorsalis, if the CSF is positive the patient should be treated with penicillin

A

True

56
Q

T/F Tabes Dorsalis If there is no pleocytosis, the CSF protein content is normal,and there is no evidence of cardiovascular or other typesof syphilis, antisyphilitic treatment is STILL necessary.

A

False

57
Q

Prognosis in Syphilitic Optic Atrophy

A

The prognosis is poor if vision in both eyes is greatly reduced. If only one eye is badly affected, sight in the other eye can usually be saved. In exceptional cases, visual impairment may progress, even after the CSF becomes negative.

58
Q

Pathologic Changes in Syphilitic Optic Atrophy

A

perioptic meningitis with subpial gliosis and fibrosis replacing degenerated optic nerve fibers vascular lesions with infarction of central parts of the nerve

59
Q

other types of Spinal Syphilis other than Tabes

A

Syphilitic Meningomyelitis (Erb spastic paraplegia)

Spinal meningovascular syphilis (form of anterior spinal artery syndrome) Syphilitic amyotrophy

Syphilitic amyotrophy with spastic-ataxic paraparesis

60
Q

Treatment of Neurosyphilis

A

Pen G given IV 18-24 million units daily (3-4 million units q4) for 10-14 days alternative procaine penicillin probenecid ceftriaxone

61
Q

Followup for neurosyphilis

A

reexamined every 3 - 6 months after tc CSF should retested after 6-mo interval If after 6 months, free of symptoms and CSF abnormalities have been reversed, no further treatment clinical exam at 12mo and another lumbar puncture If pleocytosis remains, another procedure should be repeated after 6 months At the end of 6 months, if there are still an increased number of cells and elevated protein, another full course of penicillin should be given

62
Q

True/False Neurosyphilis A persistent weakly positive serologic (VDRL) test after the cells and protein levels have returned to normal is an indication for additional treatment

A

False

63
Q

causative spirochete in Lyme Disease

A

Borrelia burgdorferi

64
Q

Bannwarth syndrome

A

painful lymphocytic meningoradiculitis

65
Q

striking feature of nearly all types of subacute and chronic infection of the meninges but most notably of tuberculous and syphilitic meningitis

A

Heubener arteritis subintimal fibrosis

66
Q

The isolation of ______________ from the CSF should suggest the possibility of a brain abscess with an associated meningitis

A

anaerobic streptococci, Bacteroides, Actinomyces, or a mixture of organisms

67
Q

True or False H. influenza meningitis usually follows upper respiratory and ear infections.

A

Trure

68
Q

Meningitis in the presence of furunculosis or following a neurosurgical procedure directs attention to the possibility of a ______________

A

coagulase-positive staphylococcal infection

69
Q

Ventricular shunts or drains inserted for the relief of hydrocephalus are particularly prone to infection with

A

coagulase-negative staphylococci and Propionibacterium acnes and diphteroids

70
Q

conditions with substantial red cells in CSF

A

anthrax meningitis viral infections: Hantavirus, dengue virus, ebola virus some cases of amebic meningoencephalitis

71
Q

bacteria reach the cochlea via the __________, which connects the subarachnoid space to the scala tympani

A

cochlear aqueduct

72
Q

causative organism in Catscratch fever

A

Bartonella henselae

gram-negative bacillus

formerly Rochalimaea henselae

73
Q

treatment for Catscratch Fever

A

firts line azithromycin or doxycycline

rifampicin in recalcitrant cases

74
Q

causative organism in Whipple Disease

A

Tropheryma whipplei

75
Q

diagnosis in Whipple Disease

A

PAS staining of an intestinal (jejunal) biopsy

supplemented by PCR testing of teh bowel tissue or biopsy material from brain or lymph node

76
Q

treatment in Whipple Disease

A

course of induction by penicillin or ceftriaone for 2 weeks followed by TMP-SMX or doxycylcine continued for 1 year

77
Q

treatment in subdural empyema

A

3rd gen cephalosphorin and metronidazole

78
Q

accounts for the largest number of brain abscess in the modern era

A

purulent pulmonary infections and bacterial endocarditis

79
Q

imaging findings in brain abscess

A

T1 - capsule nehances and the interior of abscess is hypotintense

T2 - surrounding edema is apparent, capsule is hypointense,

varaible diffusion reaction within the lesion

abscess capsule tends to be thinner on the side directed to the lateral ventricle

80
Q

single most effective anti-Koch’s

A

isoniazid

adults 5mg/kg

children 10mg/kg

should be given with pyridoxine 50 mg daily

most common SE: neuropathy, hepatitis

81
Q

treatment for TB Meningitis

A

Isoniazid 5mg/kg/day adults; 10mg/kg in children

Rifampicin 10mg/kg/d in adults; 15mg/kg in children

Ethambutol 15mg/kg/d

Pyrazinamide 20-35mg/kg

Ethionamide (added for resistant cases) 15-25 mg/kg

82
Q

True or False

The essential lesion in sarcoidosis consists of focal collections of epithelioid cells surrounded by a rim of lymphocytes; frequently there are giant cells and there is caseation.

A

False

caseation is lacking

83
Q

Main therapy for neurosarcoidosis

A

Corticosteroids

84
Q

most common time of occurrence of meningovascular syphilis is

A

6-7 years after the original infection

early as 9 months or as late as 12 years

Termed secondary syphilis

85
Q

Most common pathogenic organisms in unvaccinated children

A

Listeria monocytogenes

staphylococcus

86
Q

Most common pathogenic organism in an infant and unvaccinated child

A

H. influenzae

87
Q

From the earliest stages of meningitis, changes are also found in the small and medium-sized subarachnoid arteries. The endothelial cells swell, multiply, and crowd into the lumen.

This reaction appears within _____ to ____ hrs

A

48 to 72 hrs and increases in the days that follow

88
Q

T/F

Bacterial Meningitis

The unusual prominence of the vascular changes may be related to their anatomic peculiarities. Thrombosis in infectious vasculitis is more frequently seen in the arteries.

A

False

p698

The adventitia of the subarachnoid vessels, both of arterioles and venules, is actually formed by an investment of the arachnoid membrane, which is invariably involved by the infectious process. Thus, in a sense, the outer vessel wall is affected from the beginning by the inflammatory process-an infectious vasculitis.

The much more frequentoccurrence of thrombosis in veins than in arteries is probably accounted for by the thinner walls and the slower current of blood flow in the former.

89
Q

When macrophages are exposed to endotoxins, they synthesize and released cytokines, among which are

A

Interleukin-1

Tumor necrosis factor

90
Q

Bacterial meningtis

the presence of _____ was the only independent predictor of later seizures

A

persistent neurologic deficit

91
Q

______________ meningitis should be suspected when the evolution is extremely rapid (delirium and stupor may supervene in a matter of hours), when the onset is attended by a petechial or purpuric rash or by large ecchymoses and lividity of the skin of the lower parts of the body, when there is circulatory shock, and especially during local outbreaks of meningitis.

A

Meningococcal

92
Q

T/F

Meningococcal meningitis

Because a petechial rash accompanies approximately 50 percent of meningococcal infections, its presence dictates immediate institution of antibiotic therapy, even though a similar rash may be observed with certain viral (echovirus serotype 9 and some other enteroviruses), as well as S. aureus infections, and, rarely, with other bacterial meningitides.

A

True

p700

93
Q

______ meningitis is ususally preceded by an infection in the lungs, ears, sinuses or heart valves.

A

Pneumococcal

94
Q

_______ meningitis usually follows upper respiratory and ear infections in uninoculated child.

A

H. influenzae meningitis

95
Q

Cultures of the spinal fluid, which prove to be positive ______ percent of cases of bacterial meningitis

A

70 to 90 %

96
Q

Cranial nerve abnormalities are particularly frequent in ______ meningitis

A

pneumococcal

97
Q

begins as unilateral or cervicla adenopathy occurring after a seemingly innocuous scratch from an infected cat

high fever, encephalopathy, seizures, status epilepticus

A

Catscratch Fever

98
Q

pathogenesis of menigitis

the infection in both mother and infant is most often caused by

A

gram negative enterobacterua - E. coli

Group B strep

less often pseudomonas, listerua, S. aureus or epidermidis,

group A strep

99
Q

middle-aged woman

fever, weight loss, anemia, steatorrhea, abdominal pain, distention, athralgia, lymphadenopathy, hyperpigmentation

neuro: slowly progressive memory loss/dementia, supranuclear opthalmoplegia, ataxia, seizures, myoclonus, nystagmus, highly characteristic oculomasticatory movement described as myorhythmia
diagnosis: PAS-staining of jejunal biopsy

A

Whipple Disease

100
Q

source of infection cannot be ascertained in how many percent of brain abscess cases

A

20%

101
Q

T/F Brain Abscess

Endocarditis from the implantation in the brain of streptococci of low virulence (alpha and gamma streptococci) or similar organisms on valves previously damaged by rheumatic fever seldom gives rise to a brain abscess.

A

True

p714

In contrast, organisms such as S. aureus and gram-negative bacteria have a propensity to cause abscesse

102
Q

How many percent of patients with congenital heart disease are complicated by brain abscess?

A

5%

p715

103
Q

T/F

The capsule of an abscess is uniform in thickness.

A

False

NOT uniform in thickness, frequently being thinner on its medial (paraventricular) aspect

-earlier restrricted diffusion on MRI

104
Q

Brain Abscess

type of organisms tends to vary with source

accidental or surgical trauma

drug addicts who inject themselves

endocarditis

otitic infections

lung and paransal sinuses

A

accidental or surgical trauma - staphylococcal

drug addicts who inject themselves - staphylococcal

endocarditis - staphylococcla

otitic infections - enteric

lung and paransal sinuses - anaerobic streptococci

105
Q

Cryptococcous is a common soil fungus found in

A

roosting sites of brids, especially pigeons

106
Q

portal of entry for cryptococcus

A

respiratory,

less often skin and mucous membranes

107
Q

T/F

Crypto CFS studies

The gluose is reduced in 3/4 of cases and may reach high levels.

A

Treu

p732

108
Q

rate of positive tests for India ink CSF

A

75%

p732

109
Q

CALAS - if negative, excludes cryptococcal meningitis in ____

A

90% reliability in AIDS patients and slightly less in others

p732

110
Q

culture medium crypto

A

Saboraud’s agar

111
Q

Treatment for Crypto Men in pts without AIDS

A

Amphotericin B 0.7-1.0mg/kg/d

addition of Flucytosine 100mg/kg/d results in fewer failures or relapses, more rapid sterilization of CSF ad less nephrotoxicity, permits reduction of Ampro dose 0.3-0.5mg/kg/f

success rate 75-85% in immunocompetentq

112
Q

frequent complication for Ampho B

A

renal tubular acidosis

113
Q

Toxoplasmosis which is caused by Toxoplasma gondii is an obligate intracellular parasite readily recognized in ____

A

Wright- or Giemsa-stained preparations

114
Q

treatment for toxoplasmosis

A

Oral sulfadiazine 4g initially then 4-6 g daily and pyrimethamine 200mg intitialy then 50-100mg daily

leucovorin 15-20 mg daily to countreact antifolate effect of pyrimethamine

treatment for 6 weeks

115
Q

fatal disease characterized by headache, seizures, coma, with diffuse cerebral edema, and only rarely, focal features such as aphasia, hemiplegia, ataxia, hemianopia

retinopathy of macular whitening, orang or white discoloration of vessel, intraretinal blot type hemorrhages

neurologic symptoms appear 2nd-3rd week

A

Malaria

116
Q

treatment for Malaria

A

quinine

artesunate

once coma and convulsions supervene, 20-30% mortality

117
Q
  • begins with a chancre at the site of inoculation
  • localized lymphadenopathy, posterior cervical
  • parasitemia
  • 2nd year of infection: meningoencephalitis
  • chronic progressive syndrome consisting of reversal or disruption of circadian rhythm, vacant facial expression, ptosis, ophthalmoplegia, dysarthria, muteness, seizures, apathy, stupor, coma
A

Trypanosomiasis

Tx: melarsoprol

118
Q
  • infection from ingestion of uncooked infected pork
  • early symptoms: gastroenteritis
  • end of 1st week up to 4-6 weeks: fever, pain and tenderness of muscles, edema of conjunctivae, eyelids, fatigue
  • headache, stiff neck, mild confusional state, delirium, coma, hemiplegia, aphasia
  • heart is often involved
  • seldom fatal
A

Trichinosis, Trichinellosis

tx: albendazole and steroids

119
Q
  • infection with pork tapeworm Taenia solium
  • most often presents with seizures, although many are asymptomatic
  • only when the cyst degenerates many months or years after that an inflammatory and granunlomatous reaction is elicited
  • some, large subarachnoid or intraventricular cysts may obstruct CSF flow
  • tx: albendazole
A

Cysticercosis

120
Q

which of the ffg organisms has the tendency to localize to the ffg:

a. cerebral hemisphere
b. spinal cord

schistosoma hematobium, mansoni

A

a. cerebral hemisphere - japonicum
b. spinal cord - mansoni

121
Q

T/F

lesions of Schistosoma in the brain calcify

A

False

lesions DO NOT cakcify

p739

122
Q
  • seen in travelers who have bathed in lakes or rivers where the snail hosts of the parasite are plentiful
  • initial manifestation: local skin irritation at teh site of entry of the parasite (swimmer’s itch)
  • large serpiginous urticarial rash on the trunk
  • katayama fever
  • headaches, convulsions, papilledema, simulates brain tumor
A

Schistosomiasis

123
Q

Schistosoma infections mainly mansoni tend to localize in the spinal cord causing an acute or subacute myelitis that is concentrated in

A

conus medullaris

124
Q

tx for schistosomiasis

A

praziquantel 20mg/kg tid

125
Q

clinical features of nervous system involvement

biosy evidence of granulomas in other tissues: lymph nodes, lung, bones, uvea, skin, muscle

imaging: meningeal involvement, periventricular and white matter lesions, nodular or streak-like perivenular enhancement

A

Neurosarcoidosis

126
Q

Most certain indication for steroid therapy in neurosarcoidosis

A

recent onset of neurologic symptoms indicating an active phase

or a disabling syndrome such as myelopathy

127
Q
A

ADAMS (29 decks)

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