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Infections of the Nervous System Flashcards

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1
Q

What is meningitis?

A

Inflammation/ infection of the meninges

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2
Q

What is encephalitis?

A

Inflammation/ infection of brain substance

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3
Q

What is myelitis?

A

Inflammation/ infection of the spinal cord

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4
Q

What is the clinical features of meningitis?

A

Fever, neck stiffness and altered mental state
Short history of progressive headache and meningism
Can also have cerebral dysfunction (confusion or delirium), CN palsy, seizers, petechial skin rash

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5
Q

What symptoms are included in meningism?

A

Neck stiffness, photophobia, nausea and vomiting

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6
Q

What are some differential diagnosis for meningitis?

A

Bacterial, viral, fugal
Inflammatory - sarcoidosis
Drug induced - NSAIDs and IVIG
Malignant - metastatic and haematological

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7
Q

What are the bacterial and viral causes of meningitis?

A

Bacterial - Neisseria meningitidis (meningococcus) + Streptococcus pneumoniae (pneumococcus)
Viral - Enteroviruses

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8
Q

What are the clinical features of encephalitis?

A

Flu like prodrome (4-10days)
Progressive headache with fever, meningism, progressive cerebral dysfunction (confusion, memory disturbance, abnormal behaviour), seizers

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9
Q

What is the difference between viral encephalitis and bacterial meningitis?

A

Viral encephalitis has slower onset and more prominent cerebral dysfunction features

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10
Q

What are the differential diagnosis for encephalitis?

A

Viral (HSV)
Inflammatory - limbic encephalitis, ADEM
Metabolic - hepatic, uremic, hyperglycaemic
Malignant - metastatic, paraneoplastic
Migraine, post ictal (seizer)

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11
Q

What are the 2 important antibodies for auto-immune encephalitis?

A

Anti-VGKC (voltage gated potassium channel)
Anti-NMDA receptor

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12
Q

What are the symptoms of anti-VGKC auto-immune encephalitis?

A

Frequent seizers, amnesia and altered mental state

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13
Q

What are the symptoms of anti-NMDA receptor auto-immune encephalitis?

A

Flu like prodrome, prominent psychiatric features, altered mental state and seizers, progressing to movement disorder and coma

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14
Q

What investigations are used for meningitis?

A

Blood cultures, lumbar puncture and no need for imaging if no contraindications to LP

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15
Q

What investigations are used for encephalitis?

A

Blood cultures, imaging (CT and maybe MRI), lumbar puncture and EEG

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16
Q

What are some contraindications for a lumbar puncture?

A

Focal symptoms and signs suggest focal brain mass
Reduced consciousness suggests raised ICP
New onset seizers
Papilledema

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17
Q

What are the CSF findings for bacterial meningitis?

A

Increased opening pressure
High WCC - mainly neutrophils
Reduced glucose compared to blood
High protein

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18
Q

What are the CSF findings for viral meningitis and encephalitis?

A

Normal or increased opening pressure
High WCC - mainly lymphocytes
Normal glucose
Slightly increased protein

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19
Q

What is culture streptococcus pneumoniae sensitive to?

A

Penicillin

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20
Q

Describe HSV encephalitis

A

Commonest cause in Europe
Lab diagnosis by PCR of CSF for viral DNA
Treat with aciclovir on clinical suspicion

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21
Q

Describe herpes simplex

A

Types 1 and 2 cause cold sores and genital herpes
Virus remain latent in trigeminal or sacral ganglion after primary infection
Encephalitis is rare complication of HSV

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22
Q

Describe enteroviruses

A

Spread by faecal oral route
Tendency to cause CNS infections, human infection and not animal
Do not cause gastroenteritis
Included poliovirus, coxsackieviruses and echoviruses

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23
Q

Describe Arbovirus encephalitis

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A

Common in other parts of the world
Transmitted by vector from non-human host - arthropod borne
Relevant to travel

24
Q

What are brain abscesses and empyema?

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A

Brain abscess - localised area of pus within brain
Empyema - thin layer of pus between dura and arachnoid membrane over surface of brain

25
What are the clinical features of brain abscess and empyema?
Fever, headache, focal symptoms (seizers, dysphagia, hemiparesis) Signs of raised ICP - depressed conscious state and papilledema Meningism with empyema Features of underlying source
26
What are the cause for brain abscess and empyema?
Penetrating head injury, spread from adjacent infection, blood borne infection, or neurosurgical procedure
27
How is brain abscess or empyema diagnosed?
CT or MRI, investigate source, blood cultures and biopsy (drainage of pus)
28
What organisms can cause brain abscess?
Polymicrobial Streptococci in most - esp. in penicillin sensitive strep milleri group Anaerobes in most
29
Describe the management for brain abscesses
Surgical drainage if possible Penicillin or ceftriaxone to cover strep Metronidazole for anaerobes Culture and sensitivity tests High mortality without treatment
30
What are some HIV indicator illnesses of the brain?
Cerebral toxoplasmosis, aseptic meningitis/ encephalitis, primary cerebral lymphoma, cerebral abscess, cryptococcal meningitis, dementia and leukoencephalopathy
31
What infections can be seen in HIV patients with low CD4 counts?
Cryptococcus neoformans, toxoplasma gondii, HIV-encephalopathy
32
What diagnostics are used for HIV indicator illnesses?
Cryptococcal antigen, toxoplasmosis serology, CMV PCR and HIV PCR
33
What spirochaetes could be in the CNS?
Lyme disease Syphilis Leptospirosis
34
Describe Lyme disease
Vector borne - tick Borrelia burgdorferi Has 3 stages and is multisystem
35
What is stage 1 of Lyme disease?
Early localised infection - characteristic expanding rash at site of bite (erythema migrans) Mainly flu like symptoms
36
What is stage 2 of Lyme disease?
Early disseminated infection weeks or months after Musculoskeletal and neurological involvement most common More PNS than CNS
37
What is stage 3 of Lyme disease?
Chronic infection months to years after Musculoskeletal and neurological involvement common Subacute encephalopathy and encephalomyelitis
38
What is the investigation and treatment of Lyme disease?
Range of serological tests, CSF lymphocytosis, MRI brain, nerve conduction studies Prolonged antibiotic treatment - IV ceftriaxone or oral doxycycline
39
Describe neurosyphilis
3 stage presentation - primary, secondary and latent Tertiary disease is years or decades after primary Treponema specific and non treponemal specific antibody tests CSF lymphocytes increased High dose penicillin
40
Describe poliomyelitis
Caused by poliovirus type 1,2 or 3 - all enteroviruses Paralytic disease in 1% - anterior horn cells of LMN affected Asymptomatic, flaccid paralysis esp. legs
41
Describe rabies
Acute infectious disease of CNS affecting almost all mammals Transmitted to human by bite or salivary communication Neurotropic Paraesthesia at site Ascending paralysis and encephalitis
42
Describe rabies encephalitis
No clinical diagnostic test before disease apparent Diagnosis by PCR and serology Sedation, intensive care needed and possible death
43
What is used for pre-exposure prevention?
Active immunisation with killed vaccine In UK - bat handlers, imported animal handlers and selected travellers
44
What is rabies post-exposure treatment?
Wash wound, give active rabies immunisation, and give rabies immunoglobin
45
Describe tetanus
Infection with clostridium tetani Anaerobic gram positive bacillus and spore forming Toxin acts at NMJ Blocks inhibition of motor neurons Rigidity and spasm
46
Describe the prevention of tetanus
Immunisation Give combined with other antigens Penicillin and immunoglobulin for high risk wounds/ patients
47
Describe botulism
Clostridium botulinum - anaerobic spore producing gram positive bacillus Neurotoxin Naturally presents in soil, dust and aquatic environments Modes of infection - infantile, food, wound
48
What is the presentation of botulism?
Incubation period 4-14 days, descending symmetrical flaccid paralysis, pure motor, respiratory failure and autonomic dysfunction
49
What is the diagnosis and treatment of botulism?
Nerve conduction studies, mouse neutralisation bioassay for toxin in blood and culture Treatment is antitoxin, penicillin/ metronidazole and radical wound debridement
50
What are some post infective inflammatory syndromes?
CNS - acute disseminated encephalomyelitis PNS - Guillain Barre syndrome Preceding infection or immunisation - molecular mimicry, latency and autoimmune
51
Describe Creutzfeldt-Jacob disease
Transmissible proteinaceous particle - prion Aetiology - sporadic CJD, new variant, familial and acquired
52
What are the clinical features of sporadic CJD?
Rapidly progressive dementia Insidious onset, early behavioural abnormalities, myoclonus, progressive neurological decline, motor abnormalities and seizers
53
What are the differential diagnosis for sporadic CJD?
Alzheimer's disease Subacute sclerosing pan encephalitis CNS vasculitis Inflammatory encephalitis
54
What is the prognosis of sporadic CJD?
Rapid progression and death often within 6 months
54
Describe new onset variant CJD
Younger onset <40 linked to bovine spongiform encephalopathy in cattle Early behavioural changes are common Longer course
55
What are the investigations for CJD?
MRI - pulvinar sign in variant but usually no specific changes in sporadic EEG - generalised periodic complexes typical CSF - normal or raised protein, immunoassay 14-3-3 brain protein

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