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Infections in the CNS Flashcards

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1
Q

define meningitis

A

infection/inflammation of the meninges

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2
Q

define encephalitis

A

infection/inflammation of the brain substance

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3
Q

define myelitis

A

inflammation/infection of the spinal cord

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4
Q

what is the classical triad of meningitis?

A

> fever
neck stiffness
altered mental status

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5
Q

what are the clinical features of meningitis?

A 
> short history of progressive headache
> petechial skin rash (non-blanching)
> cranial nerve palsy
> seizures
> focal neurological deficit
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6
Q

what is the differential diagnosis for meningitis?

A

> infective: bacterial, viral and fungal
inflammatory: sarcoidosis
drug induced: NSAIDs, IVIG
malignant: metastatic, haematological

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7
Q

what are the bacterial causes of meningitis?

A

> Neisseria meningitidis : meningococcus

> streptococcus pneumonia : pneumococcus

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8
Q

what are the viral causes of meningitis?

A

enteroviruses

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9
Q

what are the clinical features of encephalitis?

A 
> flu like prodrome
> progressive headache with associated fever
> progressive cerebral dysfunction
> seizures
> focal symptoms/signs
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10
Q

what is the difference between viral encephalitis and bacterial meningitis?

A

viral encephalitis is generally slower and cerebral dysfunction is a more prominent feature

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11
Q

what is the differential diagnosis for encephalitis?

A 
> infective: viral
> inflammatory: limbic encephalitis
> metabolic: hepatic, uraemic, hyperglycaemic
> malignant: metastatic, paraneoplastic
> migraine
> post ictal
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12
Q

what are the two antibodies involved in autoimmune encephalitis?

A

> anti-VGKC (voltage gated potassium channel)

> anti-NMDA receptor

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13
Q

describe the clinical features of Anti-VGKC encephalitis

A

> frequent seizures
amnesia (not able to retain new memories)
altered mental state

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14
Q

describe the clinical features of anti-NMDA receptor

A

> flue like prodrome
prominent psychiatric features
altered mental state and seizures
progressing to a movement disorder and coma

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15
Q

what investigations would you carry out for meningitis?

A

> blood cultures
lumbar puncture
there is no need to image if there are no contraindications to lumbar puncture

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16
Q

what investigations would you carry out for encephalitis?

A

> blood cultures
CT (+/- MRI)
lumbar puncture
EEG

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17
Q

what are the contraindications for a lumbar puncture?

A

> focal symptoms or signs suggesting a focal brain mass
reduced conscious level suggesting raised intracranial pressure
in the immunocompromised you should image first as some features can be lost

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18
Q

what CSF findings would you find in bacterial meningitis?

A

> increased opening pressure
high neutrophillic cell count
reduced glucose (as bacteria consume glucose)
high protein

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19
Q

describe the CSF findings in viral meningitis and encephalitis

A

> normal/increased opening pressure
high mainly lymphocytic cell count
normal glucose
slightly increased protein

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20
Q

what is the commonest cause on encephalitis in Europe?

A

herpes simplex encephalitis

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21
Q

what is the lab diagnosis for herpes simplex encephalitis?

A

PCR of CSF for viral DNA

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22
Q

how do you treat herpes simplex encephalitis?

A

aciclovir in clinical suspicion

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23
Q

where does the herpes simplex virus remain latent?

A

in the trigeminal ganglion or sacral ganglion

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24
Q

how are enterovirses spread?

A

by the faecal-oral route

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25
what can cause non-paralytic meningitis?
enteroviruses
26
do enteroviruses causes gastroenteritis?
no
27
how are arbovirus encephalitides transmitted?
by vector (mosquito or tick) from non-human host
28
give some examples of arbovirus encephalitides?
> west nile virus > st louis encephalitis > western equine encephalitis > Japanese b encephalitis
29
define a brain abscess
localised area of pus within the brain
30
what is a subdural empyema?
thin layer of pus between the dura and arachnoid membrane over the surface of the brain
31
what are the clinical features of brain abscesses and empyema?
``` > fever > headache > focal symptoms and signs (depressed conscious level) > meningism (particularly in empyema) > features of the underlying source ```
32
name some causes of brain abscesses and empyema
> penetrating head injury > spread form adjacent infection (dental, sinusitis, otitis media) > blood borne infection > neurosurgical procedure
33
how would you diagnose a brain abscess and empyema?
> imaging: CT or MRI > investigate source > blood cultures > biopsy (drainage of pus)
34
what streptococci group are often present in brain abscesses?
penicillin sensitive strep-milleri group (strep. anginosus, strep intermedius, strep constellatus)
35
in a brain abscess is there more likely to be one organism present of a mixture of organisms present?
a mixture of organisms
36
how would you manage a brain abscess?
> surgical drainage if possible | > high dose antibiotics (culture and sensitivity tests on aspirate provide useful guide)
37
what antibiotics could you give to cover strep infection in a brain abscess?
> penicillin | > ceftriaxone
38
what treatment would you give for an anaerobic brain abscess?
metronidazole
39
name HIV indicator illnesses
``` > cerebral toxoplasmosis > aseptic meningitis/encephalitis > primary cerebral lymphoma > cerebral abscess > cryptococcal meningitis > space occupying lesion of unknown cause > dementia > leucoencephalopathy ```
40
what brain infections could you see in HIV patients with low CD4 counts?
``` > Cryptococcus neoformans > toxoplasma gondii > progressive multifocal leukoencephalopathy > crytomegalovirus > HIV encephalopathy ```
41
what tests could you carry out to differentiate the causative organisms in HIV low CD4 count brain infections?
``` > india ink, cryptococcal antigen > toxoplasmosis serology > JC virus PCR > CMV PCR > HIV PCR ```
42
what do cryptococcal antigens loos like in an indian ink stain?
as a capsule organism in double circles
43
what spirochaetes infections involve the CNS?
> lyme disease > syphilis > leptospirosis
44
how is lyme disease transmitted?
vector borne, tick
45
describe stage one in lyme disease?
> early localised infection > erythema migrans: characteristic expanding rash at site of tick bite > 50% flue like symptoms
46
describe stage 2 lyme disease
> early disseminated infection (weeks-months) > one or more organ system involvement > musculoskeletal and neurological involvement
47
what neurological involvement is there in stage 2 lyme disease if the patient is untreated?
``` > mononeuropathy > mononeuritis multiplex > painful radiculoneuropathy > cranial neuropathy > myelitis > meningo-encephalitis ```
48
describe stage 3 lyme disease
> chronic infection occurring after a period of latency | > musculoskeletal and neurological involvement is the most common
49
what are the investigations for lyme disease?
``` > serological tests > CSF lymphocytosis > PCR of CSF > MRI brain/spine > nerve condition studies ```
50
what is the treatment for lyme disease?
> intravenous ceftriaxone | > oral doxycycline
51
when does tertiary syphilis (neurosyphilis)occur?
years/decades after primary disease
52
what tests are carried out for neurosyphilis?
> treponema specific antibody test > non-treponemal specific antibody test > CSF PCR
53
how does the CSF change in neurosyphilis?
> CSF lymphocytes increase | > there is evidence of intrathecal antibody production
54
what is the treatment for neurosyphilis?
high dose penicillin
55
what causes poliomyelitis?
poliovirus type 1,2 or 3 (enterovirus)
56
what part of the central nervous system does paralytic poliomyelitis affect?
the anterior horns of the lower motor neurons
57
describe the paralysis seen in poliomyelitis
> asymmetric > flaccid paralysis > no sensory features
58
in the uk what polio types does the vaccine contain?
all three types
59
rabies is described as neurotropic. what does this mean?
the virus enters the peripheral nerves and migrates to CNS
60
what is there at the site of the initial lesion in rabies?
paraesthesiae
61
what is the affect of rabies infection?
> ascending paralysis | > encephalitis
62
how would you diagnose rabies encephalitis?
> culture (detection or serology)
63
who is given the rabies pre-exposure prevention?
> bat handlers > regular handlers of imported animals > selected travellers to enzootic areas
64
what is the rabies post exposure treatment?
> wash wound > active rabies immunisation > human rabies immunoglobulin (passive immunisation) if high risk
65
what is the bacteria involved in tetanus infection?
clostridium tetani: anaerobic gram positive bacillus spore forming
66
describe the pathology of tetanus
toxin acts on the neuro-muscular junction blocking inhibition of motor neurons causing rigidity or spasm
67
describe the prevention of tetanus
> immunisation (toxoid) combined with other antigens | > penicillin and immunoglobulin for high risk wounds/patients
68
describe the bacteria involved in botulism
clostridium botulinum | > anaerobic spore producing gram positive bacillus
69
describe the effect of the neurotoxin in botulism
> binds irreversibly to the presynaptic membranes of peripheral neuromuscular and autonomic nerve junctions > toxin binding blocks acetylcholine release
70
what is the recovery form botulism neurotoxin?
sprouting new axons
71
where is clostridium botulism naturally present?
> soil > dust > aquatic environments
72
what are the three modes of infection of botulism?
> infantile (intestinal colonisation) > food-borne > wound (drug abuse)
73
what is the clinical presentation of botulism?
``` > incubation period (4-14 days) > descending symmetrical flaccid paralysis > pure motor > respiratory failure > autonomic dysfunction ```
74
how do you diagnose botulism?
> nerve conducting studies > mouse neutralisation bioassay for toxin in blood > culture from debrided wound
75
what is the treatment for botulism?
> anti-toxin > penicillin/metronidazole > radical would debridement
76
name a post infective inflammatory syndrome affecting the central nervous system
acute disseminated encephalomyelitis
77
name a post infective inflammatory syndrome affecting the peripheral nervous system
guillain barre syndrome
78
what is the aetiology of Creutzfeldt-Jakob disease?
> sporadic > new variant > familial > acquired (cadaveric growth hormone, dura matter grafts, blood transfusion)
79
what should you consider in any rapidly progressing dementia?
sporadic CJD
80
what are the clinical features of sporadic CJD?
``` > insidious onset > early behavioural abnormalities > rapidly progressing dementia > myoclonus > progressing global neurological decline > motor abnormalities > cortical blindness > seizures (sometimes) ```
81
what is the differential diagnosis for sporadic CJD?
> Alzheimer's disease my myoclonus > subacute sclerosing panencephalitis > CNS vasculitis > inflammatory encephalopathies
82
what is the prognosis of sporadic CJD?
> rapid progression | > death within 6 months
83
what is new variant CJD linked to?
bovine spongiform encephalopathy in cattle
84
what is the difference in the clinical features of new variant CJD compared to sporadic CJD?
> early behavioural changes are more important | > longer course (average 13 months)
85
what is the investigation for Creutzfeldt-Jakob disease?
> MRI (pulvinar signs in variant) > EEG (generalised periodic complexes typical though often normal) > CSF (normal or raised protein. immunoassay 14-3-3-brain protein)

Nervous System (45 decks)

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