CNS infections Flashcards Preview

CSI > CNS infections > Flashcards

Flashcards in CNS infections Deck (62):
1

meningitis def

Inflammation of the arachnoid and pia mater in addition to the interposed CSF in the subarachnoid space

Extends throughout the subarachnoid space around the brain, spinal cord, and ventricles

med. emergency

2

clinical manifestations

ha, fever, menigismus + AMS

elderly may only present with lethargy, consider LP

insidious onset of symps >1 - several days

acute fulminant over sev. hrs -petechia over whole body

3

+ meningitis signs

Kernig

Brudzinski

CSF abnormalities

4

see slide 5
meningitis levels

bac: >1000 cells, PMNs, low glucose

5

presentation

neck pain, photophobia
+ Kernig's, Brudzinski's
-faint rash on lower legs
-close eyes, speech slurred: inc. CSF, inc. pressure on brain, at risk for herniation
*get CT before LP

-what to do next?
CT first, LP, blood Cx (i.e. pneumococcus meningitis)

6

abx?

ceftriaxone: high dose to penetrate CSF

+ vancomycin: empirical, slightly resistant org.

7

if suspect viral meningitis: tx

ADD acyclovir IV

8

meningococcal meningitis

Purulent CSF with G- IC and EC diplococci

Petechial or non-blanchable purpuric rash

*Terminal complement deficiency (C5-C9), @ risk for encap. org infections (gon, streph inf) asplenia, predispose patients to infection

Waterhouse - Friderichsen Syndrome: overwhelming sepsis-->intravasc. collapse-DIC

9

Kernig

lift knee up
+ if pain and opp. leg flexes up

10

Brudzinski

lift neck up
+ if pain and knees bend

11

Neisseria meningitis strains (meningococcal meningitis)

Groups A, B, C, Y, W-135

Vaccine does NOT cover serogroup B

40% of healthy hosts are nasopharyngeal carriers of meningococci
*most serious life-threatening form of bac meningitis

12

what to do with pt

Blood cultures, CT/MRI of brain, lumbar puncture
Do not delay IV antibiotics!
-ceftriaxone, vancomycin

Continue IV dosing until patient is afebrile for 4-5 days

13

steroids?

should be given early if given at all
-controversial
dec. ototoxicity

14

ppx?

close contacts
roommates, family in same house, HC workers w. intimate close contact
*droplet zone, i.e. person who intubated infected person

Rifampin x4
*Ciprofloxacin
Certriaxone IM (preggos)
if preg think ceph!

15

fever, ha, neck pain
vomited 2x this morning
Z-pack for CAP (think Strep pneumo)
CT brain, LP
empiric abx

2700 WBCs (94% segmented neutrophils)

Protein 220 mg/dL *high*
Glucose 18mg/dL (serum is 130mg/dL) *low*
Gram stain reveals Gram positive diplococci

bacterial
pneumococcal meningitis

Most common bacterial agent of meningitis in adults;
if + blood culture consider HIV testing
Gram positive diplococci
No rash, though purpura fulminans in overwhelming sepsis


16

extremes for pneumococcal meningitis

Extremes of age, CSF leaks, sinusitis/otitis (bac spreads), alcoholism, splenectomy, multiple myeloma patients

17

tx

Ceftriaxone 2gm IV q12h
Vancomycin 15mg/kg IV load
Steroids?

dexamethaxone
1st 4 days

18

listeria meningitis

G+ rod


Extremes of age, patients with cell mediated immunosuppression
Hodgkin’s disease, HIV, PREGNANCY

19

listeria preceding FBI

Pregnant patients are occasionally advised to avoid lunchmeats and soft cheeses due to the risk of listeria

20

tx for listeria men.

IV ampicillin or IV meropenem
*include AMP empirically if listeria extremes*

21

G+ coccus that causes meningitis

Streptococcus pneumoniae (pneumococcus). This bacterium is the most common cause of bacterial meningitis in infants, young children and adults in the United States


22

G- coccus that causes meningitis

Neisseria meningitidis (meningococcus)

23

Cryptococcal meningitis

india ink stain, "bubbly"

Subacute headache in HIV+ patient
Buzz words: Pigeon droppings, construction
Few lymphocytes in CSF
+ India ink
+ Cryptococcal Ag in CSF, serum, urine

24

Cryptococcal meningitis tx

Amphotericin B, +/- flucytosine; fluconazole (HIV+: on for rest of life if have mening. 2x!)

25

Shunt Associated Meningitis

Be suspicious of skin flora in aspiration of shunt

Coagulase negative staph
Propionibacterium species
Corynebacterium species

Do not presume “contaminants” as you may conclude if these organisms were seen in blood cultures

26

G- rod that causes meningitis

Haemophilus influenzae (haemophilus)

27

Gram Negative Meningitis

Neurosurgical patients - including insertion of pressure monitors, drains

Head trauma/skull fracture-->open portal

Remote focus (diverticulitis?)-->smolders (i.e. E. coli)-->enter blood-->enters CSF
(may not just be UTI if bac in blood-Gall bladder)

Extremes of age

Following prophylaxis for CSF leak
**Gram positives empirically covered, select out for gram negative infections***

28

G+ rod that causes meningitis

Listeria monocytogenes (listeria)

29

recurrent memingitis: mollaret's

women 40-60

HSV 1?, HSV 2?, epidermoid cyst?

30

recurrent meningitis

Parameningeal focus - infection, epidermoid cyst, craniopharyngioma
CSF leak, often following trauma
Pneumococcus most common

31

recurrent meningitis: terminal ??

complement deficiencies

32

recurrent meningitis other presentations

SLE, migraines

33

med-caused "aseptic" meningitis

NSAID’s, azathioprine trimethoprim/sulfa, fluconazole

34

non-inf. etiology "aseptic" meningitis

Ca, AI

35

“Aseptic” Meningitis: VIRAL

Viral, difficult to culture organisms
R/O primary HIV infection (part of acute retroviral syndrome)
R/O primary genital herpes

36

Usual Aseptic culprits

Enteroviruses (Echo, coxsackie, polio, etc.)
Herpes (HSV, VZV, EBV, CMV)
Arboviruses (West Nile)
Lyme disease
Adenovirus
Lymphocytic choriomeningitis virus
Possible spirochetes? (leptospira, neurosyphilis, borrelia, etc.)

37

Acute Retroviral Syndrome

Fever, chills, myalgias
Lymphadenopathy
Rash - maculopapular
Pharyngitis
N/V, diarrhea
-looks like mono

*Headache (if LP -> mild pleocytosis)

Elevated LFT’s
**HIV 1/2 Ab may be +/- or indeterminate

38

what's missing in acute retroviral syndrome?

upper resp. symptoms

39

West nile virus

2-15 day incubation period
Most of the illness is the fever component

Fever/headache (~3/4)
Muscle weakness and/or pain (~2/3)
Rash (~3/4)
Adenopathy
Joint pain
N/V, diarrhea (which may be severe, prolonged)
Eye pain

40

west nile dx

Serologies for WNV IgM, IgG in the blood

“Summer surveillance” panels available seasonally

41

west nile risks

West coast, standing water

42

Neurologic west nile virus

Meningitis – fever, nuchal rigidity, CSF pleocytosis
Encephalitis – mental status changes
(Meningo-encephalitis)

waxing-waning

Acute flaccid paralysis (polio-like), seizures, other neurologic syndromes
CNS involvement within 24-48 hours of fever onset

43

Neurologic West Nile Virus
Greatest predictor of severe disease ?

is advanced age – mortality higher if patient >75yo
Dx: CSF IgM antibody for WNV

44

WNV tx

None known to be effective, including ribavirin, interferon or steroids-still given!
No vaccine yet available
IVIG with high titers of WNV antibody??

45

WNV assoc.

Transplantation
Transfusion
Breastfeeding
Transplacental transmission
Occupational exposure

46

Most common tick borne infection in the United States

Borrelia burgdorferi (Lyme)

target, erythema migraines

flu-like, fever, ha, aches

47

dx HSV encephalitis

by CSF HSV PCR

classically HSV-1

Neurologic status at time of treatment predicts prognosis

48

HSV encephalitis

acyclovir

49

HSV encephalitis

Fever, bizarre behavior, focal TEMPORAL lobe findings including seizure and MRI abnormalities

50

focal CNS disease in HIV: toxoplasmosis

Acute onset, fever, +serology, multiple contrast + lesions with mass effect

51

focal CNS disease in HIV: lymphoma EBV PCR+

Subacute onset, no fever, SINGLE contrast + lesion with mass effect

52

Progressive Multifocal Leukoencephalopathy

JC virus with +PCR
Indolent, no fever, contrast negative lesions WITHOUT mass effect

53

PRION diseases

Buzz word “slow virus”
Transmissible agent is a prion – devoid of nucleic acid

Creutzfeld-Jacob Disease
Classic, Familial (14-3-3 protein found in CSF)
Bovine Spongiform Encephalopathy (vCJD)
Diagnosis by brain biopsy
Kuru
Scrapie
Fatal Familial Insomnia

54

additional ddx

Botulism: diploplia, descending paralysis
Use of “black tar” heroin
Home-canned foods; toxin is heat labile

Polio - mutant strains of oral vaccine, biowarfare

Bell’s palsy – associated with HSV-1, also consider Lyme, HIV

Tick paralysis
Treatment? pull off

55

neuro lyme disease: early dissem. inf

Days to weeks later – facial palsy, meningitis, headache, encephalitis, cardiac manifestations (AV block)
LP + Lyme Ab – treated with 4 weeks of IV ceftriaxone 2gm q24h

56

neuro lyme disease: Late disseminated infection

Months later – severe, chronic polyneuropathy, chronic encephalomyelitis, somatoform delusions

57

“Chronic Lyme Disease”

Poorly understood, symptomatically managed

58

HSV encephalitis LP

LP may be initially normal
CLASSICALLY with high RBCs
"bloody tap"

59

causes of chronic meningitis

Tuberculosis
Fungal (candida, cryptococcus, aspergillus)
Lyme disease
Spirochete (syphilis, leptospirosis)
Toxoplasma
Non-infective (leukemia, SLE, tumor cells)

60

brain abscess

Classically with headache, high fever

Think Strep viridans species (poor dentition?)
Anaerobes
Staph aureus (including MRSA) with trauma, IVDA patients

Think fungal, yeast in diabetics, IVDA, neutropenic hosts
Mucormycosis
Candida
Aspergillus

61

epidural abscess

Fever
Back pain
Neurological deficit (if absent – consider vertebral osteomyelitis, discitis)

*S. aureus including MRSA most common
High ESR/CRP -monitor for normalization

At surgery, granulation tissue common
Epidural phlegmon-sticky material

62

primary amebic encephalitis:

change in smelling things after water skiing

Think Naegleria fowleri
Following swimming in warm, fresh water

Migration via olfactory nerve
Suspect if change in taste or smell
Tx: Amphotericin B (+ azithromycin?)
Almost universally fatal