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Clin Med IV Exam II > CNS Infections > Flashcards

CNS Infections Flashcards

(102 cards)

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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
Systemic diseases that can cause aseptic meningitis
- sarcoid - SLE - Wegners granulomatosis - MS - GBS - leukemia/lymphoma - Behcets
26
Diagnostic studies for meningitis
- CBC - Chem 7 - lactate (if really sick) - CRP,ESR - blood cultures - LP - Head CT
27
Definitive diagnostic test for meningitis
lumbar puncture
28
When do you do a head CT before doing an LP
if you are concerned your patient has elevated ICP puts pt at risk for possible herniation
29
What types of things would make you want a head CT before doing an LP
- AMS - seizure within 1 week - known CNS lesion - focal neuro findings on exam - papilledema - >60 - immunocompromised
30
IF you start IV abx how long do you have to do an LP
2-4 hrs or CSF sterilization can occur and may effect gram stain
31
CSF WBCs >500 -->
likely bacterial source
32
CSF findings in bacterial meningitis
- WBCs 100 to 5000 - PMNs - decreased glucose - increased protein
33
CSF findings for viral meningitis
- WBC 10 to 500 - lymphocytes - normal glucose - elevated protein
34
CSF findings for fungal meningitis
- WBC 0 to 500 - lymphocytic - glucose normal or decrease - elevated protein
35
Treatment for meningitis
- abx - steriods, prior to or with first dose of abx (dexmethasone) - antivirals?
36
What would you use to treat elevated ICP in meningitis
- mannitol - mild hyperventilation - neurosurg consult - ? hypertonic saline
37
ABX for pts 16-50 with meningitis
vanco + 3rd generation ceph
38
ABX for pts over 50 with meningitis
vanco + 3rd gen ceph +ampicillin
39
ABX for immunocompromised with meningitis
vanco + 3rd gen ceph + ampicillin
40
Neurosurg, head trauma, cerebrospinal trauma pts with meningitis ABX
vanco + 3rd gen ceph + anti pseudomonal or meropenem
41
Encephalitis
inflammation of the parenchyma of the brain
42
What can cause encephalitis
- direct viral invasion - hypersensitivity rxn - diffuse inflammatory response that disproportionally affects gray matter over white matter - rarely paraneoplastic and autoimmune causes
43
Symptoms of encephalitis
- fever - headache - altered mental status - often seizures of neurologic deficits
44
Encephalomyelitis
inflammation of brain parenchyma and spinal cord
45
Encephalomyeloradiculitis
inflammation of brain parenchyma and nerve roots
46
Primary manifestation of encephalitis
epidemic: echo virus, coxsackie virus, arbovirus, polio Sporadic: HSV, VZV, mumps, rabies
47
Secondary manifestation of encephalitis
immunologic complication of viral infection or vaccine
48
How do you diagnose secondary manifestation of encephalitis
CSF PCR data excluding acute primary illness (no viral proteins)
49
Most common cause of viral enecephalitis
HSV and enterovirus
50
Causes of encephalitis
- HSV - enterovirus - adenovirus - HIV - MMR - arbovirus (west nile) - rabies - parasitic - tick borne - bacterial/fungal
51
How do you diagnose west nile virus
CSF or IgM MAC-ELISA
52
Treatment of west nile virus
just supportive, can use - ribavirin - polyclonal immunoglobulin - interferon alpha - steriods
53
Animals that carry rabies
racoon, fox, skunk, coyote, bat domestic animals if not given vaccine
54
What cancers cause paraneoplastic encephalitis
- SCLC - testicular - thymoma - breast - HL
55
Paraneoplastic encephalitis is ___ mediated. What are they?
antibody mediated Anti-Hu, Ma2-associated, anti-CRMP5
56
Autoimmune encephalitis
antibodies to neuronal cell surface/synaptic proteins
57
What is the main antibody present in autoimmune encephalitis? What symptoms does it cause?
Anti- NMDA psychiatric manifestation, cognitive/speech dysfunction, seizures, autonomic instability, dyskinesias
58
In females autoimmune encephalitis is often associated with what
teratomas
59
Diagnostics for paraneoplastic and autoimmune encephalitis
- MRI of the brain - EEG - LP/CSF w/ antibody testing on serum and CSF
60
Treatment of paraneoplastic and autoimmune encephalitis
- IV IG - IV methylprednisolone *early tumor resection if necessary
61
Classic symptoms in encephalitis
- fever - headache - change in mental status
62
"Typical" HPI for a patient with encephalitis
mild flu or febrile viral illness with some evidence for meningeal involvement - HA - fever - myalgias - fatigue/weakness - aonrexia - N/V - photophobia
63
Risk factors for encephalitis
- age (young children and elderly) - immunocompromised - geographic region and travel exposure - outdoor activities - seasons (summer and early fall) - immunization status
64
CSF with encephalitis
- 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
What should be checked with CSF if suspected encephalitis
PCR for HSV, VZV, CMV, enterovirus, EBV, arbovirus
66
Imaging findings with HSV encephalitis
focal findings of edema in orbitofrontal and temporal areas
67
Imaging findings with WNV and EEE encephalitis
demyelination in basal ganglia and thalamic areas
68
EEG findings for encephalitis
focal spiking
69
When do you preform a brain biopsy with suspected encephalitis
undiagnosed lesion with patients who are worsening despite therapy
70
What is the treatment for encephalitis
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
Most common type of epidural abscess. Why?
spinal, epidural space is present posterioly throughout the spine so spread of infection is common
72
What causes an epidural abscess
- hematogenous seeding - direct extension - invasive procedure
73
Symptoms of intracranial epidural abscess
- fever - HA - malaise - lethargy - N/V
74
Risk factors for intracranial epidural abscess
- DM - ETOH - trauma/surgery - IVDA - CKD - immunosuppression - anesthesia/injections - pregnancy
75
What can cause an intracranial epidural abscess
- sinusitis - orbital cellulitis - skull fx - neurosurgery
76
Approach to treating intracranial epidural abscess
Medical surgical approach - craniotomy - vanco + 3/4 gen ceph +/- metronidazole
77
Where do most spinal epidural abscesses occur
thoracic >lumbar >cervical
78
How do spinal epidural abscesses occur
-most through hematogenous spread (remote infections, IVDA) direct spread: vertebral osteomyelitis, diskitis, decubitus ulcer, psoas abscess, penetrating trauma, surgery, epidural catheters
79
Four clinical stages of spinal abscess
1. fever and focal back pain 2. nerve root compression 3. spinal cord compression (cauda equina) 4. paralysis
80
Characteristic pattern of cauda equina syndrome
neuromuscular and urogenital symptoms
81
What causes causa equina syndrome
simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris
82
How does cauda equina syndrome present
- 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
How do you diagnose a spinal epidural abscess
- 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
Treatment of a spinal epidural abscess
- 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
Cerebral edema
an excess accumulation of water in the intra and or extra cellular spaces of the brain
86
Cerebral edema is a response to what
primary brain insult (trauma, SAH, CVA, neoplasms, inflammatory diseases, severe toxic metabolic derangements)
87
Two major subtypes of cerebral edema
- cytotoxic | - vasogenic
88
What frequently ensues after cerebral edema
morbidity and mortality - herniation due to elevated ICP - cerebral ischemia due to compromised regional and global blood flow
89
Vasogenic cerebral edema
breakdown of the BBB due to increased vascular permeability--> excess extra cellular fluid
90
Cytotoxic cerebral edema
BBB stays intact w/ increased intracellular fluid/cellular swelling (failure of Na/K pumps at cell)
91
Interstitial cerebral edema
BBB breakdown associated w/ obstructive hydrocephalus and rupture of CSF-brain barrier--> CSF spreads into extracellular spaces and white matter
92
What causes vasogenic cerebral edema
- trauma - inflammatory conditions - neoplasms - tissue hypoxia/ high altitude cerebral edema - hypertensive encephalopathy
93
Vasogenic edema affacts mostly what
white matter
94
Treatment of vasogenic edema
- dexamethasone - mannitol - hypertonic saline - surgical decompression
95
Cytotoxic edema affects what
grey adn white matter
96
Cytotoxic edema typically occurs when
after ischemic stroke, DKA, hyponatremia, generalized hypoxis insult (cardiac arrest)
97
Which two types of cerebral edema typically occur together
cytotoxic and vasogenic
98
Type 2 cerebral herniation
Transtentorial: | brain transverses the tentorium cerebelli through notch d/t mass effecrt
99
Type 1 cerebral herniation
Uncal: | uncus (medial temporal lobes) displaced into supracellar cistern
100
Type 3 cerebral herniation
Subfalcine: | unilateral displacement, medial frontal lobe through falx cerebri (most common)
101
Type 4 cerebral herniation
external herniation
102
Type 6 cerebral herniation
tonsillar herniation: | cerebellar tonsils through foramen magnum causes pressure on brainstem

Clin Med IV Exam II (8 decks)

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