Ch 23 CNS infections Flashcards
(160 cards)
1
Q
Meningitis
A
infection or inflammation that is confined to the meninges
2
Q
common causes of meningitis
A
bacteria or virus
3
Q
which outcome is worse in meningitis? bacterial or virus?
A
bacteria etiology is worse than viral
4
Q
3 bacterial forms of meningitis (accounts for 95% of bacterial forms of meningitis)
A
haemopilus meningitis
meningococcal meningitis - 2nd most common cause
pneumococcal meningitis - most common cause
5
Q
how is bacteria spread to meninges
A
can be spread from an adjacent infected area (eg ears or sinuses), from the environment (e.g. congenital defect, penetrating injury) through the bloodstream
6
Q
primary cause of bacterial meningitis
A
inflammation
- leads to tissue and vascular injury, septic thrombosis, smaller infarcts
TB can also develop meningitis
7
Q
complications of bacterial meningitis
A
brain edema and increased ICP - hypoxic ischemic encephalopathy (HIE)
8
Q
what happens when there is bacterial meningitis in children
A
cranial nerve defects (reversible)
- mostly in children (5-11 % cases)
9
Q
which cranial nerve is most affected by bacterial meningitis?
A
cranial nerve 8 (auditory)
- results in sensorineural hearing loss
Cranial nerve 6 (abducens)
- longest intracranial route
- most vulnerable to compression
CN 3, 4, 7 may also be affected
10
Q
how does TB bacteria spread?
A
to brain and spine from lung
11
Q
rates of bacterial meningitis
A
0.6-4/100,000 annually
12
Q
rates of neonatal bacterial meningitis
A
0.25-1/1000
13
Q
rate of TB meningitis?
A
rare, only in poor regions
14
Q
bacterial meningitis mortality rate
A
5-10%
significantly improved
highest in 1st year of life, decline mid life, then increase in older adults
15
Q
mortality rate highest in which type of meningitis?
A
pneumococcal (10-30%)
TB (15-30%)
16
Q
mortality rate lowest in which type of meningitist?
A
meningococcal (4-5%)
17
Q
% of people with long term consequences of bacterial meningitis
A
15-25%
18
Q
common consequences of bacterial meningitis
A
hearing loss 11%
ID 4%
spasticity 4%
seizure disorders 4%
cognitive impairment/ADHD in 50% of childhood survivors
19
Q
determinants of severity - age
A
most cases happen in children <5 years or > 60 years
20
Q
medical risk factor for bacterial meningitis
A
immunosuppression - increased risk for infections
e.g. HIV, autoimmune etiology, cystic fibroids, DM, hypoarathyroidism
21
Q
SES risk factors
A
resources
22
Q
Types of bacterial meningitis and NP outcomes
A
pneumococal meningitis show greater cognitive impairments than meningococcal meningitis
23
Q
viral or bacterial meningitis have better outcomes?
A
viral
24
Q
other medical risk factors for bacterial meningitis
A
complications (prolonged seizures, hemiparesis, b/l hearing loss)
Low CSF glucose level
strep pneumonia infection
younger age - worse language outcome
25
male or female worse behavioral outcome for bacterial meningitis
MALES
26
acute vs gradual presentation
acute:
sudden fever
severe HA
stiff neck
gradual:
non specific flu like symptoms
27
common presenting sx in children of bacterial meningitis
```
hyperthermia
lethargy
anorexia
vomiting
respiratory distress
convulsion
irritability
jaundice
diarrhea
stiff neck
```
28
assessment of bacterial meningitis
lumbar puncture - diagnostic, check CSF to see if there's blood or white blood cells, protein levels, low glucose
brain imaging - CT/MRI do NOT help with diagnosis!
even if scans do not show meningeal enhancement, it does not r/o diagnosis
MRI is used for TB meningitis
29
treatment for bacterial meningitis
```
antibiotics
vaccine
corticosteroids
- inflammation and swelling,
- prevents hearing loss
```
TB meningitis
- anti TB drugs
30
NP outcomes overall in bacterial meningitis
MORE cognitive impairments than physical impairments
31
NP IQ in bacterial meningitis
adults - average IQ
| peds - low average to average IQ
32
NP academic in bacterial meningitis
2x more likely to need special ed, grade retention
| no consistent academic deficit in certain domains
33
NP attention in bacterial meningitis
adults - trails B and stroop
| peds - ADHD rates higher than average
34
NP processing speed in bacterial meningitis
adults - simple reaction time slower
| *MAIN DEFICIT*
35
NP language in bacterial meningitis
adults - no problem
| peds - kids dx before age 1 have impairment
36
NP visuospatial in bacterial meningitis
no consistent finding
37
NP memory in bacterial meningitis
adults - mixed
38
NP Executive function in bacterial meningitis
adults - problems more common
| peds - not severe impaired but below expectation
39
NP sensorimotor in bacterial meningitis
hearing loss - consistent finding (usually in pneumococcal than meningococcal)
hemiparesis
cortical blindness
ataxia
spasticity
40
Meningitis is the cause of ?% of deaf and hard of hearing in youth in USA?
3-6%
41
NP mood in bacterial meningitis
peds - ADHD, behavioral changes and other MH issues in adolescence
42
NP work in bacterial meningitis
adults - can work normally
| peds - in peds onset, lower economic sufficiency in adulthood
43
Aseptic Forms of meningitis - aseptic means?
non bacterial forms of bacterial meningitis
44
Cause of aseptic meningitis?
virus
fungi
parasite
enterovirus (through intestine)
45
most common cause of aseptic meningitis
enterovirus
46
examples of fungi that can cause aseptic meningitis
```
crytococcus
histoplasma
blastomyces
coccidioides
candida - acquired usually in hospital
```
47
which one is more common? viral or bacterial forms of meningitis
viral forms
48
how many cases of viral aseptic meningitis
10,000 reported
| possibly 75,000
49
fungal meningitis happens in which population?
rare
| usually in immunocompromised eg HIV positive
50
most common form of fungal meningitis
crytococcus
51
mortality of viral meningitis
< 1%
52
morbidity of viral meningitis
less common long term neurological consequences than bacterial meningitis, usually benign outcomes
53
recovery of viral meningitis?
7-10 days
no residual effects
persistent effects are mild
54
presenting problem in viral meningitis?
headache - most common sx
```
fever
irritability
nausea and vomiting
stiff neck
rash
fatigue
```
55
assessment and dx of viral meningitis
lumbar puncture - examine blood and CSF to isolate viral pathogen
CT, MRI, EEG - clarify dx
56
treatment of viral meningitis
antibiotics - USELESS
mostly supportive - rest, fluids, anti inflammatory meds
some antiviral meds
57
treatment of fungal meningitis
antifungal meds
58
NP in fungal meningitis
mostly mild
| but long lasting deficits can be seen in motor speed, gross motor, and EF
59
Definition of Encephalitis
infection of the brain tissue/parenchyma
60
most common cause of Encephalitis
virus
61
other causes of Encephalitis
(besides virus #1)
bacteria, fungi, parasites
autoimmune
62
two types of Encephalitis
primary Encephalitis = acute viral Encephalitis
| secondary Encephalitis = post-infective Encephalitis
63
what is primary Encephalitis / acute viral Encephalitis
direct infection of brain through direct invasion of pathogen
64
what is secondary Encephalitis/post-infective Encephalitis
results from previous viral infection (e.g. chickenpox, mumps, measles) or immunization (measles vaccine)
65
how many viruses are these associated with Encephalitis?
>100
66
most common Encephalitis?
```
herpes simplex virus
varicella zoster virus
epstein barr virus
adenovirus
enterovirus
arbovirus
```
67
how does virus work to lead to Encephalitis?
most virus reach CNS via bloodstream
| some virus travel to CNS along cranial nerves
68
how does herpes simplex virus travel and reach the brain?
it is dormant in trigeminal ganglia
| when activated, it travels along trigeminal nerve into brain
69
rates of Encephalitis
7.3/100,000
70
incidence of Encephalitis per year
20,000 cases per year, mostly mild
71
highest incidence rate of Encephalitis in which age group?
children < 1 year
72
most common cause of Encephalitis in children?
Herpes simplex Encephalitis
73
did incidence rate increase or decrease in children?
increase
74
mortality rate for Encephalitis
5% overall (3% in children)
75
factors predicting mortality rate of Encephalitis
age (some types have higher mortality rates in elderly)
| type (rabies virus Encephalitis and untreated HSV)
76
morbidity
1/3 have some form of neuro and cog difficulties when discharged
6-12 mos full recovery
77
age and severity of Encephalitis
most severe in infants and elderly
78
risk factors for Encephalitis and NP
HSV Encephalitis has the most impairments compared to other types of Encephalitis (2-4x)
bilateral temporal lesions have worse outcomes than unilateral lesions
79
what predicts severity in children
length of hospital stay
neuroimaging
HSV type Encephalitis
80
risk of seizure in Encephalitis
20% for those with early seizures
| 10% without early seizures
81
presentation of Encephalitis
```
acute (hours to days)
- severe HA and fever
altered consciousness
disorientation
behavioral and speech disturbances
neurological signs
```
subacute (weeks)
seizures
speech disturbances
chronic
occasional acute sx (as in HIV orl lyme disease)
82
behavioral presentation of Encephalitis
behavior or psychotic disorder in HSV
- delusion, hallucination, mood disorder
some develop Kluver Bucy syndrome with b/l damage to amygdala
83
Kluver Bucy syndrome
related to amygdala
| inappropriate sexual behaviors and mouthing of objects.
84
Assessment of Encephalitis
lumbar puncture/blood work
EEG - to detect seizures (usually non specific)
CT MRI - edema, localized infection, mass, inflammatory
85
Treatment of Encephalitis
antiviral drugs
anticonvulsant
corticosteroid
hemispherectomy - for Rasmussen Encephalitis
86
IQ and Encephalitis
adults - low average to average
| peds - low average to average, learning problems
87
attention and Encephalitis
higher prevalence in kids
88
processing speed in Encephalitis
affected in all
89
language in Encephalitis
unaffected
| some naming problems in HSV Encephalitis
90
visuospatial in Encephalitis
no consistent findings
91
memory in Encephalitis
HSV Encephalitis has memory problems
92
EF in Encephalitis
common problem
| 40% EF problems in HSV Encephalitis
93
sensorimotor in Encephalitis
no consistent findings
| west nile Encephalitis - motor problems
94
mood in Encephalitis
behavior, mood, attention (kids)
| HSV with more personality changes
95
work in Encephalitis
can work with good outcomes
| HSV Encephalitis has more difficulty
96
NP impact of Chronic Herpes simplex complex (HSV)
lower IQ
lower overall cognitive scores
increased risk for AD
97
Autoimmune and paraneoplastic Encephalitis definition?
autoimmune syndrome associated with attack of antibodies on neuronal cell surface or synaptic receptors with or without cancer associated
98
paraneoplastic Encephalitis disorder (PND)
cancer related
99
2 groups of Autoimmune Encephalitis
intracellular antibody disorders (PND)
| synpatic and neuronal surface autoantibody disorders
100
intracellular antibody disorders
PND falls in this group
autoimmune reaction initiated in response to tumor, which expresses neuronal antigens, mediated by cytotoxic t cell responses
paraneoplastic limbic encephalitis (PLE)
- inflammatory process related to cancer (small cell lung)
- localized to limbic system
101
synaptic and neuronal surface autoantibody disorders
antibodies disrupt the neuronal receptor or synaptic protein
| prevents post synaptic electrical impulse causing nerve cell and brain to stop working
102
most common form of autoimmune encephalitis
Anti NMDA receptor encephalitis( anti NMDARE)
#2 is ADEM
103
what is NMDARE - anti NMDA receptor encephalitis?
involves antibodies that decrease number of cell surface NMDA receptors and NMDA receptor clusters in postsynaptic dendrites
104
where are NMDA receptors located or concentrated?
hippocampus
forebrain
limbic system
play a primary role in synaptic excitatory transmission of glutamate
105
anti NMDARE associated with
tumors
106
Classic PND
rare
| usually in older adults
107
anti NMDARE age?
23 mos - 76 years
| median age 19 years
108
autoimmune encephalitis gender ratio?
females more in NMDARE
109
race of NMDARE
blacks more than whites
110
mortality rates of Autoimmune encephalitis and Paraneoplastic encephalitis
paraneoplastic higher than autoimmune
autoimmune encephalitis is at 6%
111
morbidity PND and Autoimmune encephalitis
PND and AE both have significant morbidity
- seizures
- infection
- cog deficits
112
IQ and anti NMDARE
adults - IQ generally average long term
| kids - improves over time, poor academic performance in 36%
113
attention and anti NMDARE
deficits in attention and working memory
114
processing speed in anti NMDARE
improves over time
| deficits in some
115
language anti NMDARE
no consistent impairment in adults
| some verbal fluency problems in small % of kids
116
visuospatial and anti NMDARE
adults - worse than average but improves
| kids - visuomotor integration impaired in 1/3, but improves
117
memory and anti NMDARE
episodic memory core deficit
cannot consolidate
verbal memory more affected, visual memory bad too
118
EF and anti NMDARE
persistent deficits in 50% of people
119
mood in anti NMDARE
anxiety but not depression
| behavioral changes in kids, but improves
120
social of PND and Auto immune encephalitis
impaired social cognition and relationships in some groups
121
what affects outcome in anti NMDARE
delayed initiation of immunotherapy
age or gender or seizure do NOT correlate with outcomes
removal of tumor - better outcome
122
what affects outcome in paraneoplastic limbic encephalitis
sleep disturbance
impairment of cognition
psych sx ( depression, anxiety, agitation, hallucination)
123
paraneoplastic limbic encephalitis presentation?
subacute onset of up to 12 weeks
124
paraneoplastic syndromes presentation
```
altered consciousness
behavior and mood disturbance
sensory changes
cranial nerve palsy
ridigity
cerebellar dysfunction
```
125
Anti NMDARE phases in symptom presentation
prodromal phase
- flu like sx with fever, malaise, HA, fatigue
psychotic phase
- acute psychosis or schizophrenia
unresponsiveness phase
- stop responding toverbal commands
- mute, akinetic, fixed gaze, sterotyped athetotic movement
hyperkinetic phase
- autonomic instability (hypo/hypertension, cardiac arrhythmia)
126
anti NMDARE in children presentation
```
behavioral problems
irritability
agitation
hyperactivity
temper tantrums
```
127
assessment of autoimmune and paraneoplastic encephalitis
lumbar puncture
- look for antibodies in blood, CSF can confirm autoimmune or cancer related (CSF better sensitivity), inflammatory markers
neuroimaging
- CT MRI (T2 flair in anti NMDARE)
EEG
- slowing and epileptoform activity in anti NMDARE although normal in a few months after onset
128
treatment Anti NMDARE
cancer treatment - removal of tumor, chemo, steroid, immunotherapy
target anti bodies
129
recovery in paraneoplastic limbic encephalitis PLE
seizure and behavior problem improve with tx
persistent deficit in memory and learning
anti nMDARE
- recovery is slow, hospitalized for few months than rehab
- most show residual cognitive deficits
- some with relapse (those without tumor or immunotherapy more at risk)
130
other infection and causes of encephalitis
intracranial abscess
intrauterine and intranatal infection
HIV
progressive multifocal leukoencephalopathy (PML)
cerebral toxoplasmosis
acute disseminated encephalomyelitis (ADEM)
131
intracranial abscess
infectious pus collections in the brain or surrounding area
can originate in nearby area and spread through blood
can occur after depressed skull fracture, penetrating brain injury, neurosurgery, meningitis
cause brain damage by increasing ICP and mass effect on brain
132
two types of intracranial abscess
subdural or epidural empyema
| brain abscess
133
intracranial abscess
| - subdural or epidural empyema
found between inner surface of dura and outer surface of arachnoid (subarachnoid) or in space between dura and skull (epidural)
epidural abscesses more common in spinal cord than brain
134
intracranial abscess
| - brain abscess
cavity filled with pus in brain parenchyma
135
Intrauterine and intranatal infections
TORCH!
```
toxoplasmosis
other infection
rubella
cytomegalovirus
herpes simplex virus 2
```
Prion disease
136
prion disease
caused by infectious proteins called prions
137
examples of prion dieases
CJD,
Gerstmann Straussler Scheinker syndrome,(GSS)
fatal familial insomnia (FFI)
138
CJD
belongs to transmissible spongiform encephalopathy
brain tissue develops holes that gives it sponge like appearance
rapidly progressive and fatal
rapidly progressive dementia (memory issues, personality changes, hallucinations, physical problems)
139
Human Immunodeficiency Virus (HIV)
neurons NOT directly impacted by HIV infection
| infection leads macrophages and microglia to cause gradual destruction of neuronal integrity
140
MRI findings of HIV
small areas of bilateral, subcortical signal hyperintensity
volume loss and metabolic changes in basal ganglia
large hyperintensity (showing lesions)
global and diffuse atrophy
ventricular enlargement
reduced white matter
isolated focal lesions
141
2 key syndromes in HIV
HIV associated neurocognitive disorder (HAND)
- common in up to 50% of people
- deficits in attention, EF, fluency, memory, psychomotor speed
- decreases in brain activation, L frontal attentional networks
142
HIV1 AIDS dementia complex
| HIV associated dementia
```
severe form of cog impairment
subcortical dementia
- mimics parkinsons
- disruption of cortical connection (fronto-striatal-thalamo cortico loop) leads to attention deficits, working memory, EF, learning
- memory impairment
- psychomotor slowing, motor impairment
```
143
HIV 1 associated minor cognitive/motor disorder
less severe of cog impairment
- similar subcortical profile as HIV dementia
2% in people with HIV
0.5-1 SD below mean on cog impairment at least 2 domains
- deficits in processing speed, attention, psychomotor functioning
144
perinatally acquired HIV infection
children and adolescents
- poor working memory, slow processing, EF
- poor VS skills, VS memory, language
- conductive hearing problems 20-30%
- mental health problems 25%
145
treatment of HIV associated dementia
ART - antiretroviral treatment
- decreased prevalence of HIV assoicated dementia
- only 28% of children have started it
146
problems with not being treated for HIV?
access to care
| not disclosing to doctors
147
Progressive multifocal leukoencephalopathy (PML)
rare and fatal viral disease
causes progressive and multifocal damage of white matter
affects people who are immunocompromised (e.g. transplant, HIV)
148
what causes PML
JC virus
149
Cerebral Toxoplasmosis
infection in brain caused by parasite called toxoplasma
| leads to brain abscess in HIV patients
150
acute disseminated encephalomyelitis (ADEM)
inflammatory demyelinating condition of CNS (brain and spinal cord)
looks like MS
single occurrence or multiphasic (MDEM)
151
cause of ADEM
postinfectious or post vaccination (1-2 weeks after)
152
highest incidence of ADEM
early childhood 5-8 years
153
presentation of ADEM
confusion
cog impairment
neurological deficits
psyc sx - mood lability, agitation, personality, delusion, hallucination (can appear before neurological signs)
154
what does brain MRI show for ADEM
```
white matter hyperintensities in
both hemispheres
subcortical region,
cerebellum,
spinal cord
```
155
MRI used to differentiate between ADEM and what?
MS
156
some people have ADEM later being reclassified as having
MS
157
treatment of ADEM
high dose steroids
| plasmapheresis
158
mortality of ADEM
rare - most recover with treatment
159
NP of ADEM
better than pediatric MS
| some subtle deficits in attention, processing, EF
160
rasumussen encephalitis
frequent and severe seizure
loss of speech and motor skills
hemiparesis
cog deficits
