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Clin Med IV Exam II > CNS Infections > Flashcards

CNS Infections Flashcards

1
Q

Meningitis

A

-inflammation of the brain and/or spinal cord

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2
Q

What are the meninges comprised of

A

dura matter- outer layer
arachnoid matter- contains blood vessels
pia matter- covers brain

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3
Q

What is it called when the inflammation develops in the meninges and the brain parenchyma

A

meningoencephalitis

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4
Q

Most common causes of meningitis

A

bacterial (acute bacterial meningitis)

viral (aseptic meningitis)

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5
Q

Less common causes of meningitis

A
  • fungal
  • bacterial aseptic
  • parasitic
  • non infectious causes (drug induced, systemic disease)
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6
Q

Cardinal symptoms of acute bacterial meningitis

A
  • headache (unlike any other HA)
  • fever
  • neck stiffness
  • altered mental status
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7
Q

Things that cause drug induced meningitis

A
  • bactrim
  • cipro
  • flagyl
  • amox/penicillin
  • keflex
  • NSAIDs
  • ranitidine
  • tegretol
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8
Q

Other signs and symptoms of meningitis

A
  • nausea/vomiting
  • photophobia
  • focal neurologic deficits
  • seizures
  • dermatologic findings (petechial, purpuric rash)
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9
Q

What nerves are typically affected if pt has a focal neurologic deficit with acute bacterial meningitis

A

III, VI, VII, VIII

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10
Q

What type of meningitis presents with focal neurological findings

A

acute bacterial!

secondary to ischemia and infarction d/t cerebral infectious thrombophlebitis

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11
Q

Seizures=

A

more encephalitis

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12
Q

first place you typically see petechiae

A

palate

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13
Q

Risk factors for meningitis

A
  • > 50
  • URI, otitis media, sinusitis, mastioditis
  • head trauma, recent neurosurgery
  • crowded living conditions
  • immunocompromised
  • lack of immunization
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14
Q

What is the typical etiology for ABM

A

encapsulated bacteria colonized in the naso-oropharynx that penetrates the intravascular space

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15
Q

Most common pathogens of ABM

A
  • strep pneumo
  • neisseria meningitidis
  • H flu type B
  • group B strep
  • listeria monocytogenes
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16
Q

Other causes of ABM (less common)

A
  • secondary to bacteremia in remote focus (endocarditis, pneumonia)
  • neurosurgery (CSF shunt revision or insertion)
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17
Q

Presentation of aseptic meningitis

A

similar to ABM but usually benign course which resolves on its own or without specific therapy

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18
Q

Aseptic meningitis is most commonly what

A

viral

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19
Q

Most common cause of viral meningitis

A

enterovirus (in summer/early fall)

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20
Q

Most common cause of fungal aseptic meningitis

A

cryptococcus

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21
Q

Causes of viral aseptic meningitis

A
  • enterovirus
  • HSV 1/2
  • lymphocytic choriomeningitis virus (mice)
  • VZV
  • CMV, EBV, HHV, HIV, polio, coxsackie
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22
Q

Causes of fungal aseptic meningitis

A
  • cryptococcus
  • histoplasma
  • candida
  • coccidioides
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23
Q

Parasitic causes of aseptic meningitis

A
  • toxoplasmosis

- cysticercosis

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24
Q

Bacterial causes of aseptic meningitis

A
  • partially treated meningitis
  • TB
  • Lyme
  • erlichia
  • syphillis
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25
Q

Systemic diseases that can cause aseptic meningitis

A
  • sarcoid
  • SLE
  • Wegners granulomatosis
  • MS
  • GBS
  • leukemia/lymphoma
  • Behcets
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26
Q

Diagnostic studies for meningitis

A
  • CBC
  • Chem 7
  • lactate (if really sick)
  • CRP,ESR
  • blood cultures
  • LP
  • Head CT
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27
Q

Definitive diagnostic test for meningitis

A

lumbar puncture

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28
Q

When do you do a head CT before doing an LP

A

if you are concerned your patient has elevated ICP

puts pt at risk for possible herniation

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29
Q

What types of things would make you want a head CT before doing an LP

A
  • AMS
  • seizure within 1 week
  • known CNS lesion
  • focal neuro findings on exam
  • papilledema
  • > 60
  • immunocompromised
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30
Q

IF you start IV abx how long do you have to do an LP

A

2-4 hrs or CSF sterilization can occur and may effect gram stain

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31
Q

CSF WBCs >500 –>

A

likely bacterial source

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32
Q

CSF findings in bacterial meningitis

A
  • WBCs 100 to 5000
  • PMNs
  • decreased glucose
  • increased protein
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33
Q

CSF findings for viral meningitis

A
  • WBC 10 to 500
  • lymphocytes
  • normal glucose
  • elevated protein
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34
Q

CSF findings for fungal meningitis

A
  • WBC 0 to 500
  • lymphocytic
  • glucose normal or decrease
  • elevated protein
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35
Q

Treatment for meningitis

A
  • abx
  • steriods, prior to or with first dose of abx (dexmethasone)
  • antivirals?
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36
Q

What would you use to treat elevated ICP in meningitis

A
  • mannitol
  • mild hyperventilation
  • neurosurg consult
  • ? hypertonic saline
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37
Q

ABX for pts 16-50 with meningitis

A

vanco + 3rd generation ceph

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38
Q

ABX for pts over 50 with meningitis

A

vanco + 3rd gen ceph +ampicillin

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39
Q

ABX for immunocompromised with meningitis

A

vanco + 3rd gen ceph + ampicillin

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40
Q

Neurosurg, head trauma, cerebrospinal trauma pts with meningitis ABX

A

vanco + 3rd gen ceph + anti pseudomonal or meropenem

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41
Q

Encephalitis

A

inflammation of the parenchyma of the brain

42
Q

What can cause encephalitis

A
  • direct viral invasion
  • hypersensitivity rxn
  • diffuse inflammatory response that disproportionally affects gray matter over white matter
  • rarely paraneoplastic and autoimmune causes
43
Q

Symptoms of encephalitis

A
  • fever
  • headache
  • altered mental status
  • often seizures of neurologic deficits
44
Q

Encephalomyelitis

A

inflammation of brain parenchyma and spinal cord

45
Q

Encephalomyeloradiculitis

A

inflammation of brain parenchyma and nerve roots

46
Q

Primary manifestation of encephalitis

A

epidemic: echo virus, coxsackie virus, arbovirus, polio

Sporadic: HSV, VZV, mumps, rabies

47
Q

Secondary manifestation of encephalitis

A

immunologic complication of viral infection or vaccine

48
Q

How do you diagnose secondary manifestation of encephalitis

A

CSF PCR data excluding acute primary illness (no viral proteins)

49
Q

Most common cause of viral enecephalitis

A

HSV and enterovirus

50
Q

Causes of encephalitis

A
  • HSV
  • enterovirus
  • adenovirus
  • HIV
  • MMR
  • arbovirus (west nile)
  • rabies
  • parasitic
  • tick borne
  • bacterial/fungal
51
Q

How do you diagnose west nile virus

A

CSF
or
IgM MAC-ELISA

52
Q

Treatment of west nile virus

A

just supportive, can use

  • ribavirin
  • polyclonal immunoglobulin
  • interferon alpha
  • steriods
53
Q

Animals that carry rabies

A

racoon, fox, skunk, coyote, bat

domestic animals if not given vaccine

54
Q

What cancers cause paraneoplastic encephalitis

A
  • SCLC
  • testicular
  • thymoma
  • breast
  • HL
55
Q

Paraneoplastic encephalitis is ___ mediated. What are they?

A

antibody mediated

Anti-Hu, Ma2-associated, anti-CRMP5

56
Q

Autoimmune encephalitis

A

antibodies to neuronal cell surface/synaptic proteins

57
Q

What is the main antibody present in autoimmune encephalitis? What symptoms does it cause?

A

Anti- NMDA

psychiatric manifestation, cognitive/speech dysfunction, seizures, autonomic instability, dyskinesias

58
Q

In females autoimmune encephalitis is often associated with what

A

teratomas

59
Q

Diagnostics for paraneoplastic and autoimmune encephalitis

A
  • MRI of the brain
  • EEG
  • LP/CSF w/ antibody testing on serum and CSF
60
Q

Treatment of paraneoplastic and autoimmune encephalitis

A
  • IV IG
  • IV methylprednisolone

*early tumor resection if necessary

61
Q

Classic symptoms in encephalitis

A
  • fever
  • headache
  • change in mental status
62
Q

“Typical” HPI for a patient with encephalitis

A

mild flu or febrile viral illness with some evidence for meningeal involvement

  • HA
  • fever
  • myalgias
  • fatigue/weakness
  • aonrexia
  • N/V
  • photophobia
63
Q

Risk factors for encephalitis

A
  • age (young children and elderly)
  • immunocompromised
  • geographic region and travel exposure
  • outdoor activities
  • seasons (summer and early fall)
  • immunization status
64
Q

CSF with encephalitis

A
  • typically indistinguishable from viral meningitis
  • slightly elevated protein
  • pleocytosis w/ lymphocytic predominance
  • normal glucose
  • absence of organisms on gram stain adn culture
  • opening pressure >20mmHg
65
Q

What should be checked with CSF if suspected encephalitis

A

PCR for HSV, VZV, CMV, enterovirus, EBV, arbovirus

66
Q

Imaging findings with HSV encephalitis

A

focal findings of edema in orbitofrontal and temporal areas

67
Q

Imaging findings with WNV and EEE encephalitis

A

demyelination in basal ganglia and thalamic areas

68
Q

EEG findings for encephalitis

A

focal spiking

69
Q

When do you preform a brain biopsy with suspected encephalitis

A

undiagnosed lesion with patients who are worsening despite therapy

70
Q

What is the treatment for encephalitis

A

everyone gets Acyclovir but only effective with HSV and possibly with VZV and EBV

if none of those are the cause, treat supportively (fever suppression, ICP monitoring, fluid restict)

benzos/anticonvulsants w/ seizure associated encephalitis

manitol or hypertonic saline if increased ICP

71
Q

Most common type of epidural abscess. Why?

A

spinal, epidural space is present posterioly throughout the spine so spread of infection is common

72
Q

What causes an epidural abscess

A
  • hematogenous seeding
  • direct extension
  • invasive procedure
73
Q

Symptoms of intracranial epidural abscess

A
  • fever
  • HA
  • malaise
  • lethargy
  • N/V
74
Q

Risk factors for intracranial epidural abscess

A
  • DM
  • ETOH
  • trauma/surgery
  • IVDA
  • CKD
  • immunosuppression
  • anesthesia/injections
  • pregnancy
75
Q

What can cause an intracranial epidural abscess

A
  • sinusitis
  • orbital cellulitis
  • skull fx
  • neurosurgery
76
Q

Approach to treating intracranial epidural abscess

A

Medical surgical approach

  • craniotomy
  • vanco + 3/4 gen ceph +/- metronidazole
77
Q

Where do most spinal epidural abscesses occur

A

thoracic >lumbar >cervical

78
Q

How do spinal epidural abscesses occur

A

-most through hematogenous spread (remote infections, IVDA)

direct spread: vertebral osteomyelitis, diskitis, decubitus ulcer, psoas abscess, penetrating trauma, surgery, epidural catheters

79
Q

Four clinical stages of spinal abscess

A
  1. fever and focal back pain
  2. nerve root compression
  3. spinal cord compression (cauda equina)
  4. paralysis
80
Q

Characteristic pattern of cauda equina syndrome

A

neuromuscular and urogenital symptoms

81
Q

What causes causa equina syndrome

A

simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris

82
Q

How does cauda equina syndrome present

A
  • low back pain
  • unilateral or bilateral sciatica
  • saddle and perineal hypoesthesia or anesthesia
  • bowel and bladder disturbances
  • lower extremity motor weakness and sensory deficits
  • reduced or absent lower extremity reflexes
83
Q

How do you diagnose a spinal epidural abscess

A
  • MRI (preferred) CT
  • gram stain C+S, fungal, mycobacteria assessment of abscess drainage
  • blood cultures
  • routine labs typically not helpful

DO NOT DO LP

84
Q

Treatment of a spinal epidural abscess

A
  • neurosurg, spine surg, infectious disease consult
  • surgical decompression/drainage w/ laminectomy
  • if pt has no neuro deficits, can attempt CT- guided drainage + abx

ABX–> vanco + 3rd and 4th gen ceph
tx for 4-6 weeks

85
Q

Cerebral edema

A

an excess accumulation of water in the intra and or extra cellular spaces of the brain

86
Q

Cerebral edema is a response to what

A

primary brain insult (trauma, SAH, CVA, neoplasms, inflammatory diseases, severe toxic metabolic derangements)

87
Q

Two major subtypes of cerebral edema

A
  • cytotoxic

- vasogenic

88
Q

What frequently ensues after cerebral edema

A

morbidity and mortality

  • herniation due to elevated ICP
  • cerebral ischemia due to compromised regional and global blood flow
89
Q

Vasogenic cerebral edema

A

breakdown of the BBB due to increased vascular permeability–> excess extra cellular fluid

90
Q

Cytotoxic cerebral edema

A

BBB stays intact w/ increased intracellular fluid/cellular swelling (failure of Na/K pumps at cell)

91
Q

Interstitial cerebral edema

A

BBB breakdown associated w/ obstructive hydrocephalus and rupture of CSF-brain barrier–> CSF spreads into extracellular spaces and white matter

92
Q

What causes vasogenic cerebral edema

A
  • trauma
  • inflammatory conditions
  • neoplasms
  • tissue hypoxia/ high altitude cerebral edema
  • hypertensive encephalopathy
93
Q

Vasogenic edema affacts mostly what

A

white matter

94
Q

Treatment of vasogenic edema

A
  • dexamethasone
  • mannitol
  • hypertonic saline
  • surgical decompression
95
Q

Cytotoxic edema affects what

A

grey adn white matter

96
Q

Cytotoxic edema typically occurs when

A

after ischemic stroke, DKA, hyponatremia, generalized hypoxis insult (cardiac arrest)

97
Q

Which two types of cerebral edema typically occur together

A

cytotoxic and vasogenic

98
Q

Type 2 cerebral herniation

A

Transtentorial:

brain transverses the tentorium cerebelli through notch d/t mass effecrt

99
Q

Type 1 cerebral herniation

A

Uncal:

uncus (medial temporal lobes) displaced into supracellar cistern

100
Q

Type 3 cerebral herniation

A

Subfalcine:

unilateral displacement, medial frontal lobe through falx cerebri (most common)

101
Q

Type 4 cerebral herniation

A

external herniation

102
Q

Type 6 cerebral herniation

A

tonsillar herniation:

cerebellar tonsils through foramen magnum causes pressure on brainstem

Clin Med IV Exam II (8 decks)

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