Chap 32-33: Infection of the CNS Flashcards
(298 cards)
1
Q
Two pathways by which infection reaches intracranial structures.
A
1) Hematogenous spread
2) Contiguous spread
2
Q
Two pathways by w/c infection from ear or sinuses causes intracranial CNSi
A
1) infected thrombi form in diploic vein spread thru dural sinuses
2) osteomyeletic focus
3
Q
In adult most common pathogenic organism:
A
1) Streptococcus pneumoniae
2) Neisseria meningitidis
3) Haemophilus influenzae (unvaccinated)
4) Listeria monocytogenesis
5) Staphylococcus
4
Q
In neonate, pathogenic organism to consider
A
1) E. coli
2) group B streptococcus
5
Q
To determine likely organism one must consider the ff:
A
1) age
2) clinical setting (community-acquired, nosocomial, post-surgical)
3) Immune status
4) Systemic and local cranial disease
6
Q
First reaction to bacteria or toxin in the brain
A
Hyperemia of the meningeal venules and capillaries w/ inc permeability of vessels
7
Q
Predominant cells in bac men during the first few days
A
Neutrophils w/ phagocytosed bacteria
8
Q
After few days after the neutrophils inc the following occurs
A
Inc of lymphocytes and histiocytes
Exudation of fibrinogen then become fibrin
9
Q
T/F. Process of resolution, inflammatory cells disappear in almost reverse order as they had appear.
A
TRUE
10
Q
Hydrocephalus from meningeal reaction occurs due to
A
First purulent exudate around the base
Later by meningeal fibrosis
11
Q
Three most common bacteria causing meningitis
A
1) S. pneumoniae
2) N. meningitides
3) H. influenzae
4) Listeria
12
Q
Bacterial organism due to LP, spinal anesthesia, or shunting.
A
Pseudomonas
Enterobacteriaceae
13
Q
Should be suspected in extremely rapid evolution w/ assoc petechial or purpuric rash and circulatory shock
A
Meningococcal meningitis
14
Q
Rapid decline of the incidence of the bacterial organism due to vaccination
A
H. influenzae
15
Q
Meningitis often preceded by infection in the lungs, ears or heart valves.
A
Pneumococcal meningitis
16
Q
Meningitis follows URTI and ear infection in unvaccinated child
A
H. influenzae
17
Q
Focal cerebral signs in early stages occur most frequently in
A
Pneumococcal
H. influenzae
18
Q
Seizures in bac men is mostly encountered in
A
H. influenzae meningitis
19
Q
Persistent focal cerebral lesion or intractable sz develops in 2nd week of infection due to
A
infectious vasculitis
20
Q
In infants and neonates this may suggest presence of meningeal infection
A
fever, irritability, dec sensorium, vomiting, convulsions, bulging fontanels
21
Q
Keys to early diagnosis of bac men
A
High index of suspicion
Liberal use of LP
22
Q
Most significant factor in pathogenesis of meningitis in neonates
A
Maternal infection (UTI or peurperal fever)
23
Q
In infants w/ meningitis, one must consider to find
A
Subdural effusion
24
Q
T/F. Aspirated subdural effusions after bacterial meningitis are proven to be sterile
A
TRUE
25
Indespensible part of the examination of patients w/ symptoms and signs of meningitis due to high index of suspicion
Lumbar puncture
26
T/F. Tonsillar herniation may occur in fulminant meningitis independent of LP
TRUE
27
Pressures over ____mm H20 suggest presence of brain swelling and potential for cerebellar herniation
350
28
CSF w/ cell counts more than 50,000/mm3 raise the possibility of
brain abscess rupturing in the ventricles
29
Hemorrhagic CSF may occur in meningitis of
```
Anthrax meningitis
Hantavirus
Dengue
Ebola
Amebic meningoencephalitis
```
30
Caveat in interpreting glucose CSF/serum ratio of less than 40%
Serum glucose should be less than 250mg/dL
31
Nigrovic criteria that may predict likely of low risk of bac men if the ff are absent
1) positive CSF gram stain
2) CSF absolute PMN count of >1000 cell/mL
3) CSF protein >80m/dL
4) Blood count PMN of >10,000
5) hx of sz at or after time of presentation
32
Cultures of the spinal fluid prove to be positive by how may percent in bac men
70-90%
33
Particularly useful in dx px w/ partially tx bac men by detecting bacterial antigens
CIE
| Latex-particle agglutination test
34
Infrequently used in testing bac men but can be diagnostic and prognostic
LDH
LDH fractions 4 and 5 (high in meningitis produced by granulocytes)
LDH fractions 1 and 2 (high if there is neurologic sequelae or later die)
35
Positive in 40-60% of patients w/ H. influenzae, meningococcal, pneumococcal meningitis and provide clue as to the causative agent
Blood cultures
36
One should suspect in a patient w/ recurrent bacterial meningitis
Fistula / Sinus tracts
| CSF rhinorrhea
37
Most specific and sensitive test for CSF leak
Beta2-transferrin test
38
T/F. Viral meningitis is far common than bacterial meningitis
TRUE
39
Nonbacterial meningitis when cultures are negative but may have reduction of glucose conc
EBV infection
Bechet disease
Mollaret meningitis
Vogt-Koyanagi-Harada Syndrome (iridocyclitis, psoriasis)
40
Empiric therapy for bac men in 0-4 weeks old
Cefotaxime plus ampicillin
41
Empiric therapy for bac men in 4-12 weeks old
3rd gen cephalosporin plus ampicillin (plus dexa)
42
Empiric therapy for bac men in 3mos - 50 y/o
3rd gen cephalosporin plus vancomycin (+/- ampicillin)
43
Empiric therapy for bac men in >50 y/o
3rd gen cephalosporin plus vancomycin plus ampicillin
44
Empiric therapy for bac men in immunocomporomised state
Vanco plus ampicillin plus ceftazidime
45
Empiric therapy for bac men in basilar skull fracture
3rd gen cephalosporin plus vancomycin
46
Empiric therapy for bac men in head trauma, neurosurgery CSF shunt
Vanco plus ceftazidime
47
Reason why ampicillin is added in immunocompromised state
Cover for Listeria
48
Duration of bac men treatment
10-14 days
49
Persistence of fever, or late appearance of neurologic deficits should raise the suspicion of
```
subdural effusion
mastoiditis
venous sinus thrombosis
cortical vein phlebitis
brain abscess
```
50
In children particularly w/ H influenzae, use of dexamethasone results to
Less sensorineural deafness or neurologic sequelae BUT mortality NOT affected
51
Dose/ administration of dexamethasone in bac men for children
0.15mg/kg qid x 4 days
52
In adults, esp w/ pneumococcal meningitis, use of dexamethasone results to
Mortality REDUCTION and improved overall outcome
53
Dose/ administration of dexamethasone in bac men for adults
Dexa 10mg QID x 4 days, first dose prior to antibiotics
54
Value of repeat lumbar puncture
if px is worsening w/o explanation
55
Meningococcal prophylaxis
Ciprofloxacin single dose
Rifampin 600mh q12h (adults) or 10mg/kg q12h (children) for 2 days
NO PROPHYLAXIS if >2 weeks has elapsed since exposure
56
Rate of mortality for meningitis of :
H. influenzae
Meningococcal
Pneumococcal
5% (H. influenzae, Meningococcal)
| 15% Pneumococcal
57
One to consider if w/ meningococcemia w/ shock
Waterhouse-Friderichsen syndrome
58
Osler triad
Pneumococcal meningitis, pnuemonia, endocarditis
59
Neurologic sequelae occurs in ____ % in H. influenzae and ____ % in pneumococcal meningitis
25%
30%
60
In bacterial meningitis, the independent predictor of later sz is
presence of neurologic deficit
61
Deafness in meningitis is a result of
Suppurative cochlear destruction
62
Three common pathogens causing BACTERIAL ENCEPHALITIS
Mycoplasma pneumoniae
L. monocytogenes
Legionnaires disease
63
This bacterial encephalitis may present as rhombencephalitis
L. monocytogenes
64
Treatment of L. monocytogenes
Ampicillin (2g q4h) plus gentamicin (15mk TID)
65
Similar to Listeria but seen in India ans SEA, prone among diabetics, w/ chances of relapse
Melioidosis (Burkholderia pseudomallei)
66
Bacterial encephalitis w/ severe diffuse involvement of cerebrum, cerebellar or brainstem. CSF and CT seems normal. w/ tx using fluroquinolones.
Legionella
67
Exceptional feature of Anthrax meningoencephalitis
Hemorrhagic and inflammatory spinal fluid formula
68
Encephalitis presenting as slowly progressing memory or dementia assoc w/ wt loss, fever, anemia, steatorrhea, abdominal pain, athralgia, lymphadenopathy, hyperpigmentation.
Whipple disease
69
During the height of systemic bacterial or viral infection, the child sink to dec sensorium w/ neck supple, and CSF no changes, term is used for obscure cause
Acute toxic encephalopathy
70
Usual accompaniment of subdural empyema
Thrombosis of underlying cortical veins or sinuses
71
Usual origin of infection of subdural empyema
Frontal or ethmoid sinuses; hardly ever as bacteremia or septicemia
72
Tx of subdural empyema
Surgery plus antibiotics (ceftazidime plus metronidazole)
73
Focal sz or may involve 5th and 6th CN due infection of petrous part of temporal bone
Gradenigo syndrome
74
Usual involvement in intracranial septic thrombophlebitis
Transverse sinus
Cavernous sinus
Petrous sinus
75
Pathogens incriminated for intracranial septic thrombophlebitis
Streptococci and staphylococci
76
Brain abscess is always usually secondary to bacteremia particularly
Purulent pulmonary infections
Bacterial endocarditis
Ear infections
77
Children more than ___% of cerebral abscess are assoc w/ CHD
while ___% of CHD are complicated w/ brain abscess
60%
5%
78
Most common CHD implicated for brain abscess
Tetralogy of Fallot
79
Most common organism causing cerebral abscess
Virulent streptococci
80
In brain abscess, pus and proliferation of adventitia of blood vessels, evident in DWI of MRI occur by
2 weeks
81
T/F. Abscess is not uniform in thickness, it has thinner lateral aspect
FALSE. Medial aspect is thinner
82
Size of abscess that may produce positive scan
>1cm
83
Brain abscess in MRI
T1: capsule enhances, hypointense interior w/ restricted diffusion
T2: surrounding edema, hypointense capsule
84
Surgical approach for brain abscess if:
solitary, superficial and encapsulated
Deep abscess
Total excision (superficial)
Aspiration (deep)
85
Percent Mortality in brain abscess if px is
Comatose
Alert
50% (Comatose)
5-10% (Alert)
86
Neurologic sequelae in brain abscess occurs by
30%
87
Two stages of TB men
1) Bacterial seeding in meninges and subpial region forming tubercles
2) Rupture of tubercles and discharge of bacteria
88
Early manifestation of TB men in
50% of cases
75% of cases
50% of cases: fever, malaise, headache
| 75% of cases: lethargy, confusion, stiff neck
89
Approximately, ____ of TB men have active TB in other parts
2/3
90
When to start HIV meds upon onset of anti-Kochs medication?
W/in 2 weeks
91
TB PCR of CSF have sensitivity of
80% w/ 10% false positive rate
92
Self-limiting form of meningitis in prevalent tuberculosis countries showing modest pleocytosis, normal or elevated protein, normal glucose
Tuberculous Serous Meningitis
93
Most frequent intracranial tumors among children in tropical countries
Cerebellar tuberculomas
94
Treatment meds and durations of TB men
HRZE x 2 mos
| HR x 9-12 mos
95
Anti-Kochs drugs w/ highest to penetrate the BBB
INH
| PZA
96
Treatment dose of Anti-Kochs in TB men
INH: 5mg/kg
RMP: 10mg/kg
EMB: 15mg/kg
PZA: 20mg/kg
97
Important adverse effects of INH
Hepatitis
| Neuropathy
98
Important adverse effects of EMB
Optic neuropathy
99
Important adverse effects of PZA
Rash, GI disturbance, hepatits
100
In Vietnam study on corticosteroids and TB men, the outcome showed
Reduced mortality BUT no effect on disability
101
Dose of Dexamethasone in TB men
0.4mkd for a week then taper slowly from 3-6 weeks
102
Overall mortality of TB men is ____%
w/ HIV infected px higher around ____%
when Coma supervenes ____ %
10%
21%
50%
103
Neurologic sequelae occurs in TB men by
20-30%
104
Essential lesion in sarcoidosis
focal collections of epitheloid cells surrounded by lymphocytes and giant cells BUT caseation is LACKING found in all organs
105
Cranial nerve most frequently involved in sarcoidosis
Facial nerve
106
Diagnosis of neurosarcoidosis is based on
Clinical features
| Biopsy evidence in other organs
107
Serum levels of this is increased in sarcoidosis
Angiotensin-converting enzyme
108
Main therapy of sarcoidosis
Corticosteroids (Prednisone 40mg x 2weeks, then 5mg tapering q 2weeks until reaching 10-15mg/d then maintain for several months)
109
Initial event in neurosyphilitic infection is ____ in 25% of all cases
Meningitis
110
Treponeme invades the CNS w/in ____ of inoculation w/ organism
3-18 mos
111
If CSF is negative by:
2nd yr chances are ____ to have neurosyphillis
5th yr chances are ____ to have neurosyphillis
5%
| 1%
112
All forms of neurosyphillis begin as
meningitis
113
Clinical forms of Neurosyphillis
Early clinical syndrome
Secondary syndrome
Tertiary syndrome
Early clinical syndrome: Aseptic meningitis & meningovascular
Secondary syndrome: Vascular syphillis (1-12 yrs)
Tertiary syndrome: General paresis, tabes dorsalis, optic atrophy, subacute myelitis
114
Clinical standpoint the most impt form of neurosyphilis
asymptomatic form, hence all px w/ syphilis should have as spinal fluid exam
115
T/F. Neurosyphilis clinical syndromes mostly exist in pure form of each
FALSE. Mostly are combination w/ one predominating
116
T/F. The clinical syndromes and pathologic reactions of congenital syphilis are similar to those late-acquired type
TRUE, they only vary by age
117
Sensitive indicator of the presence of active neurosyphilitic infection
CSF exam
118
CSF formula of Neurosyphilis
1) pleocytosis up to 100cell/m3, mostly lymphocytes (lower for AIDS px)
2) elevation of TP 40-100mg/dL
3) inc IgG w/ oligoclonal banding
4) positve serologic test
119
Gamma globulin represents in neurosyphilis as
specific antibody response to the organism
120
CSF changes once remission of neurosyphillis occurs in order
1) cells disappear first
2) TP returns to normal
3) Gamma globulin reduced
4) Serologic test last to revert to normal
121
CSF changes that precedes or accompanies clnical relapse in neurosyphilis
Return of cells and elevation of protein
122
T/F. Reagin tests (Kolmer or VDRL), if positive in CSF is virtually diagnostic of neurosyphilis
TRUE
123
Serum reactivity alone for reagin tests w/o CSF means
Past exposure of syphilis but does not imply neurosyphilis
124
T/F. Serum reagin tests are always positive in late syphilis or those w/ neurosyphilis
FALSE. Negative in majority
125
If suspected false positive for reagin test, FTA-ABS if positive in serum means
practically have neurosyphilis
126
Most reliable but expensive difficult to perform and available in few labs to diagnose syphilis
TPI (T. pallidum immobilization)
127
Abnormal pupils that are unreactive to light but constricts w/ accomodation seen in asymptomatic neurosyphilis
Argyll Robertson pupils
128
Meningeal syphilis occurs typically when
First 2 years
129
The most common form of neurosyphilis nowadays, main manifestation for secondary syphilis
Meningovascular form
130
Meningovascular syphilis typically occurs around
6-7 yrs, but can be early as 9 mos
131
Pathologic changes of meningeal infiltration AND inflammation and fibrosis of small arteries known as
Heubner arteritis
132
Paretic neurosyphilis occurs around ____ from original infection
15-20 yrs
133
Form of neurosyphilis presenting as progressive dementia, dysarthria, myoclonic jerks, action tremors, sz, UMN signs, Argyll robertson pupils
General paresis
134
Pathologic changes in general paresis form of neurosyphilis
Meningeal thickening
Brain atrophy
Secondary ventricular enlargement
Granular ependymitis
135
Expected mental decline and death occurs in general paresis
3-4 yrs
136
Major symptoms of tabes dorsalis
Lightning pain, ataxia, urinary incontinence, absent DTRs of lower ext, impaired position and vibration sense, romberg sign.
Argyll Robertson pupils in 90% of cases & optic atrophy
137
Pathologic changes in the tabes dorsalis
Thinness and grayness of posterior roots in lumbosacral and thinning of spinal cord due to degeneration of posterior column
138
Tx of Neurosyphilis
Pen G 3-4 MU q4h x 10-14 days
| Alternatives: procaine penicillin, probenecid, ceftriaxone
139
Lightning pains for neurosyphilis respond to
Gabapentin and CBZ
140
Monitoring of pxs w/ neurosyphilis
Px re-examined q3-6 mos
CSF retested q 6 mos interval
ONCE cleared, another follow up after 12 mos w/ LP
141
T/F. A weakly positive serologic VDRL test after cells and protein levels return to normal constitutes re-treatment
FALSE.
142
Erythema chronicum migricans (migrating skin lesion) followed by acute radicular pain, chronic lymphocytic meningitis, peripheral or cranial neuropathies
Lyme disease (Borrelia burgdorferi)
143
Lyme disease involves the ff organs
Skin
Nervous system
Heart (myocarditis, pericarditis, AV block)
Joints
144
Most frequent cranial neuropathy in Lyme disease
Facial palsy
145
Severe painful meningoradiculitis of cauda equina paraticulary characteristic of Lyme infection in Europe
Banwarth syndrome
146
Most valuable screening for Lyme disease
ELISA
147
Pragmatic diagnostic criteria for Neuroborreliosis
present in 4 of 5:
1) no past hx of neuroborreliosis
2) active CSF ELISA serology
3) anti-Borrelia antibody index greater than 2
4) favorable outcome after antibiotic tx
5) no alternative dx
148
Treatment of Lyme disease
Doxycycline (100mg BID) x 14 days (rashes, CN palsy alone)
| Ceftriaxone (2g OD) x 14 days, (CNS involvement)
149
Type of meningitis in Leptospirosis
Aseptic meningitis
150
The dx of fungal infection lies on two lines of clincal info
1) evidence of infection in other organs
| 2) subacute meningeal or multifocal encephalitic d/o
151
Fungal infections tend to occur in px w/
Leukopenia
T-lymphocyte inadequate
Insufficient antibodies
152
T/F. CSF formula for fungal meningitis among AIDS px maybe normal or minimal pleocytosis
TRUE
153
CSF exam should include this aside from fungal studies
TB meningitis, leukemia/ lymphoma (as they may concur)
154
Usual portal of entry for cyptococcosis
Respiratory tract
155
Cryptococcosis occurs in AIDS px by
6-12%
156
Test for cryptococcosis that is distinctive and diagnostic esp in AIDS px since CSF maybe normal
India Ink (positive in 75% of cases)
157
Test for cryptococcosis when negative excludes it in AIDS px.
CALAS
158
Medium where cyptococcus is grown
Sabouraud glucose agar
159
Tx of Cryptococcal meningitis
Amphotericin B (0.7-1 mg/k/d) X 6 weeks until CSF culture is negative
160
Addition of this drug to Ampho B results to fewer relapse
Flucytosine x 6 weeks until CSF culture is negative
161
Drug regimen for crypto in AIDS px
Ampho B plus flucytosine x 2 weeks
| Fluconazole x 1 yr to prevent relapse
162
Fungal infection presenting as chronic sinusitis (sphenoidal), w/ base of skull osteomyelitis affecting adjacent intracranial structures resulting to infectious vasculitis
Aspergilosis
163
Malignant infection of cerebral vessels occuring in diabetic pxs. drug addicts, hematologic malignancy presenting similar to Cavernous sinus thrombosis
Mucormycosis
164
Most common cause of focal cerebral lesion among AIDS pxs
Toxoplasmosis
165
Diagnostic criteria of Toxoplasmosis
Clinical syndrome
Radiographic feature
Elevated IgG titers of Toxo
166
Tx of Toxoplasmosis
Co-trimoxazole x 6 weeks
| Prophylaxis also with it among AIDS until CD4 count exceeds 250 x 6 mos
167
Amoebic meningoencephalitis usual pathogen
Naegleria
168
Cerebral malaria is typically caused by
Falciparum malaria
169
Neurologic symptoms occur in malaria around____
AND the ones susceptible to it are ____
2nd-3rd week
Children in hyperendemic areas
170
Leading cause of epilepsy and other neurologic problem in South America and India
Cysticercosis
171
Cysticercosis is caused by
larval or intermediate stage of Taenia solium (pork tapeworm)
172
Most common schistosoma involving nervous system
S.japonicum
173
Organism for schistosoma w. tendency to localize in
Cerebrum
Spinal cord
Cerebrum: S. japonicum
| Spinal cord: S. mansoni
174
Tx of neuroschistosoma
Praziquantel plus corticosteroids
175
Route of entry of viruses:
Mumps, measles, VZV:
Polioviruses / Enterovirus:
HSV :
Mumps, measles, VZV: Respiratory
Polioviruses / Enterovirus: oral-intestinal
HSV : mucosa / genital
176
HSV, VZV and rabies, through peripheral nerve through what mechanism
Retrograde axoplasmic transport system
177
Clinical syndrome of viruses
1) Acute aseptic meningitis
2) Recurrent meningitis
3) Acute encephalitis / meningoencephalitis
4) Ganglionitis
5) Chronic nervous tissue invasion by retrovirus
6) Poliomyelitis
7) PML or SSPE
8) Prions
178
Bacterial causes of aseptic meningitis
Mycoplasma
Q fever (Ricketts)
Leptospirosis
179
Clinical syndrome of aseptic meningitis
Headache, fever, meningeal signs, Lymphocyte pleocytosis w/ normal glucose
180
Causes of aseptic meningitis in decreasing frequency
1) Enterovirus
2) HSV-2
3) Varicella`
181
Virus associated w/ Mollaret meningitis
HSV-1 (more common) & HSV-2
182
Fifth disease in children is caused by
Parvovirus
183
Nonviral causes of aseptic meningitis and recurrent meningitis
1) Parameningeal infection (epidural abscess)
2) Partially tx bac men
3) Difficult to isolate organisms (TB / fungal/ syphilis)
4) Neoplastic invasion
5) Granulomatous, vasculitic, inflammatory dz
6) Chemical / allergic meningitis
184
Associated w/ chronic neutrophilic meningitis
Fungal (Nocardia, Aspergillus, Actinomyces)
| Mycobacterium
185
Aseptic meningitis, bladder failure, vaginal or vulvar pain associated w/ HSV2
Elsberg syndrome
186
Acute recurrent inflammatory CNS disease of small blood vessels assoc w/ ulcers in Middle Eastern origin
Bechet disease
187
Core syndromes of Encephalitis syndrome
Seizures, alteration of sensorium, aphasia, hemiparesis, UMN signs, abn movt
188
HSV encephalitis has selective damage in
Inferomedial temporal lobe
| Frontal lobe
189
T/F. Diffrentiation between viral and ADEM is NOT possible in clinical grounds
TRUE
190
T/F. Postexanthematous and post-vaccinal are essentially forms of ADEM
TRUE
191
Most common sporadic cause of encephalitis w/ no seasonal or geographic predeliction
HSV encephalitis
192
Age distribution of HSV encephalitis
Skewed and biphasic
Between 5-30 y/o
Older than 50 y/o
193
The most common encephalitis outside North America
Jap B encephalitis
194
Most common viral infection among AIDS px
CMV
195
Usual histopathologic hallmarks of viral encephalitis
1) Perivascular cuffing of lymphocytes and mononuclear cells
| 2) Patchy infiltration of meninges
196
Most common viral cause of Herpes Simplex Encephalitis in
Adults
Neonates
Adults: HSV-1
Neonates: HSV-2
197
Characteristic pathologic findings in HSV encephalitis
Intense hemorrhagic necrosis of inferomedial temporal lobe and medioorbital frontal lobe
198
Characteristic localization of lesion in HSV encephalitis is explained by
Route of entry where reactivation in trigeminal nerve then spreads along fibers supplying the anterior and middle cranial fossae
199
EEG finding highly suggestive of HSV encephalitis
Lateralized periodic discharges in temporal regions and slow-wave complexes at 2-3/sec interval
200
T/F. CT scan can show hypodensity in temporal lobes in HSV encephalitis in 2/3 of cases
TRUE. MRI very sensitive
201
Useful test in diagnosis of HSV encephalitis while virus is replicating in the first few days w/ 98 % sensitivity
PCR
202
T/F. Antiviral treatment does not appear to affect HSV PCR results
TRUE
203
False negative test likely occurs in first ____ hrs of febrile infection
48
204
Tx for HSV encephalitis
Acyclovir (30mkd) x 10-14 days
205
Relapse of HSV after acyclovir tx is seen among
Children, rarely in adults
206
Mortality and morbidity in HSV encephalitis is governed by
1) Age
2) State of consciousness
3) Time of institution of acyclovir
207
90% survival w/ acyclovir tx in alert px was seen upon giving it w/in
4 days
208
Duration of AED in HSV encephalitis
One year or more then judge risk upon d/c:
Further sz
EEG abn
Exposure to danger situations (eg driving)
209
Most common rabid species in USA
Wild:
Domestic:
Wild: racoons, skunks, foxes, bats
Domestic: Dogs, cats
210
Incubation period of rabies virus
20-60 days (shorter as 14 days)
211
Characteristic initial manifestation of rabies
Tingling or numbness at site of bite (inflammatory response once reaches sensory ganglion)
212
Characteristic pathologic finding in rabies
Negri bodies prominent in pyramidal cells of hippocampus and purkinje cells
213
Focal collections of microglia in rabies is called
Babes nodules
214
After a bite of a healthy animal, surveillance of animal for ____ days is necessary
10
215
Tx of Rabies bite
Post-exposure prophylaxis of HRIG 20u/kg around bite and half via IM and active immunization
216
Two forms of active immunization of Rabies and difference
DEV (allergic encephalomyelitis and 23 doses)
| HDCV (less allergic rxn w/ 5 doses at 0-3-7-14-28 days)
217
Acute cerebillitis in children is commonly associated w/
VZV
218
Common agent of shingles / herpes zoster
VZV
219
Pathologic changes assoc w/ VZV
1) Inflammatory rxn of sensory ganglia
2) Inflammatory rxn in spinal roots and contiguous peripheral nerve
3) Poliomyelitis (rare)
4) Mild leptomeningitis
220
Pathogenesis of herpes zoster
Spontaneous reactivation of VZV that was latent in the sensory ganglia due to waning immunity
221
VZV primarily localized in
Trigeminal and thoracic ganglion cells
222
Vesicular eruption is preceded by
Itching, tingling, or burning sensation of dermatome
223
Usual duration of:
Vesicles
Pain and dysesthesia
Vesicles: 5-10 days
| Pain and dysesthesia: 1-4 weeks
224
Characteristic herpetic nature of skin eruption showing multinucleated giant cells in base of early vesicles
Tzanck smear
225
Most common site of shingles in 2/3 of cases
T5-T10 dermatome
226
Complication of VZV, histologically similar to granulomatous angitis and Wegener granulomatosis, presenting as focal neurologic sign after ophthalmic zoster
Zoster angitis
227
Important inception of shingles
Attenuated live vaccine for adults >60 y/o
228
Antiviral agents that shortens duration of pain and speeds healing of vesicles
Famciclovir (500mg TID x 7 days)
Valacyclovir (2g QID)
Acyclovir
229
Drug of choice for preventing postherpetic pain
TCA drugs
230
Drug of choice for postherpetic pain
Amitriptyline 50mg ODHS
| Capsaicin ointment
231
HIV infection result to reduction of what cell
CD4 cells (T-helper cells)
232
Later stages of HIV, most common neurologic complication is
Subacute or chronic HIV encephalitis (dementia)
233
Survival after onset of dementia in HIV
3-6 mos
234
Most sensitive test in early stages of dementia in HIV
Psychomotor Speed Test (trail making, pegboard, symbol digit test)
235
MRI changes in HIV encephalitis
Widening of sulci
Ventricular enlargement
Patchy white matter changes, ill-defined margins
236
Form of HIV myelopathy
Vacuolar degeneration
237
Anti-AIDS drug that causes myopathy due to its effect on mitochondria
Zidovudine
238
Most common focal infection in AIDS
Toxoplasomosis
239
Important differentials for Toxoplasmosis among AIDS px
CNS Lymphoma, hence a trial of tx of Toxoplasmosis first then if not work-up for lymphoma by biopsy
240
Most common nonfocal neurologic infection of AIDS
CMV
| Cryptococcus
241
Shingles occur in AIDS if CD4 count is below
500
242
T/F. Presence of HIV, accelerates transition of syphilis to late stages
TRUE
243
Neurologic complication of IRIS in HIV
Progressive multifocal leukoencephalopathy
244
Tropical spastic paraparesis is assoc w/ virus
HTLV-1 infection
245
Delayed progression of muscle weakness that appears many years after acute paralytic illness
Postpolio syndrome
246
Main reservoir and main route of polio virus
Human intestine; fecal-oral route
247
Incubation period of polio
1-3 weeks
248
Inapparent infections which are mild systemic symptoms w/pharyngitis or gastroenteritis
Abortive poliomyelitis
249
Form of poliomyelitis presenting as aseptic meningitis, tenderness of muscles and pain in neck and back
Nonparalytic poliomyelitis
250
Weakness manifest at the height of fever, w/ no progression after temp is normal for 48 hrs.
Paralytic poliomyelitis
251
Atrophy of muscles in polio is detected in ____, maximal in _____ and is permanent
3 weeks of onset of weakness
| 12-15 weeks
252
Common occurrence as well in early phase of paralytic poliomyelitis
Urinary retention
253
Most frequently involved cranial muscle:
| Due to affectation of:
Deglutition
| Nucleus ambiguous
254
Earliest histopathologic changes in anterior horns of cords
Central chromatolysis of nerve cells w/ inflammatory rxn
255
Preventive measure for poliomyelitis
Attenuated live vaccine orally, two doses, 8 weeks apart
256
Return of muscle strength occurs mainly in ____ months due to restitution of partially damaged nerve cells
3-4 mos
257
Other main causes of sporadic poliomyelitic syndrome
RNA viruses - Echoviruses
258
Also known as inclusion body encephalitis
SSPE
259
Age group mostly affected by SSPE
Children and adolescent rarely beyond age 10
260
Usual duration of asymptomatic period of measles infection to SSPE
6-8 years
261
Clinical manifestation of SSPE
Personality and behavioral changes
Intellectual detoriation
Focal or generalized sz
Myoclonus, ataxia, visual disturbance
262
Death occurs in SSPE w/in _____ years
1-3 years
263
Characteristic EEG pattern for SSPE
Periodic discharges 2-3/s followed by flat pattern w/ 5-8 s interval between discharges
264
CSF formula for SSPE
Minimal to absent cells
Inc protein
IgG high
265
MRI findings of SSPE
Changes of subcortical white matter and periventricular region
266
Histopathologic hallmark of SSPE
Eosinophilic inclusions in nuclei of neurons and glia cells
267
Pathogenesis of SSPE
Delay or inadequate immune response hence incapable to clear suppressed infection
268
Diagnosis of SSPE
Periodic complexes in EEG
Elevated IgG CSF
Elevated antibody titers in serum and CSF
269
Drugs to improve and prolong survival in SSPE
Amantadine
| Inosine pranobex
270
Progressive rubella panencephalitis presents as
Congenital rubella (remember the tetrad) then decade later detoriation in behavior and cognition then seizures then becoming demented
271
Characterized by widespread demyelinating lesion mainly in cerebral hemispheres w/ varied size and severity of lesion
Progressive Multifocal Leukoencephalopathy
272
The incidence of PML in AIDS is ___
| In contrast, the incidence of AIDS in PML is ____
5%
75%
273
PML is usually associated w/ what medical conditions
Neoplasm
| Chronic immunodeficiency state
274
PML is associated w/ what virus
JC virus (human polyovirus)
275
Poor prognostic sign for recovery from PML
CD4 count less than 100
276
Approach to slow progression of PML or remission in AIDS px
Aggressive antiretroviral drug tx
277
PML is associated with this syndrome when antiretroviral tx started
IRIS
278
Viral encephalitis showing depigmentation of SN and locus ceruleus due to nerve cell destruction hence presenting w/ parkinsonism
Van Economo Disease
279
Encephalitis presenting as intractable focal seizures and progressive hemiparesis due to presence of ____
Rasmussen encephalitis
Autoantibodies on glutamate receptors
280
Prion protein (PrP) is normally encoded in
Chrom 20q
281
Current theory of prion disease
Abnormal prion protein folding acts as template to convert PrP to PrPsc
282
Profound dementia, diffuse myoclonic jerks, w/ visual or cerebellar signs
CJD (Subacute Spongiform Encephalopathy)
283
Major neuropathologic changes in CJD
Neuronal loss and gliosis w/ vacuolation in cerebral and cerebellar cortices
284
Only clearly demonstrated mechanism of spread of CJD
Iatrogenic
285
Younger onset, w/psychiatric and sensory symptoms w/o usual EEG findings, due to transmission via infected meat
Variant CJD (Bovine spongiform encephalopathy)
286
Most common isoform of CJD
MM Type 1 (Most common is MM while VV is least common; Type 1 is more frequent than Type 2)
287
Typical EEG finding of CJD is seen in isoform
Type 1 cases
288
Isoform assoc w/ MRI changes
MV2
289
Isoform presenting as ataxia, psychiatric, lack of EEG changes, prolonged duration of illness
MV2
290
CJD w/ cerebellar ataxia
Brownell-Oppenheimer variant
291
CJD w/ visual disturbance
Heidenhain variant
292
Typical EEG pattern seen in CJD
Diffuse non-specific slowing or high voltage slow-sharp wave complex in slow low voltage background; pseudoperiodic
293
MRI seen CJD
Hockey-stick sign (hyperintense lenticular nuclei in T2
294
MRI pattern of CJD is similar to what disease entity
Diffuse cerebral anoxia
295
Immunoassay to test for CJD w/ 98% sensi and 80% specificity. Three repeated testing more likely to be positive
14-3-3
296
Strong familial in AD inheritance, begins insidiously as cerebellar ataxia, corticospinal tract sign, nystagmus, mild dementia,
Mutation of prion protein gene
Gerstmann-Straussler-Scheinker Syndrome
297
Rare familial disease, presenting as intractable insomnia, sympathetic overacitivity, and dementia, due to gliosis of medial thalamic nuclei. Assoc mutation w/ prion gene
Fatal insomnia
298
Prion disease but exclusive to Fore linguist of New Guniea highlands, by eating infected brain tissue of the dead
Kuru
