Cm Neuro 8: Cns Infection

Front 1

Meningitis

Encephalitis

Meningoencephalitis

Cerebritis

Abscess

Empyema

Back 1

1. Localized to Subarachnoid space

2. Brain tissue infection by virus

3. Meningiits + encephalitis

4. Diffuse bacterial, fungal, parasitic infection of brain tissue

5. Local bacterial, fungal, parasitic infection of brain tissue (acute, active infection)

6. Infection localized to space btwn dura and arachnoid (subtle, chronic presentation)

Front 2

RED FLAGS

Back 2

EMERGENT:

1. Bacterial (purulent) meningitis: N. Meningitieds, organ failure.

2. Herpetic encephalitis (steroid, DM, immunocompromised)

3. epidural abscess

4. Subdural empyema

5. High opening pressures on LP

6. Opportunistic infections

Front 3

GENERAL S/S (6)

Back 3

TRIAD: Headache, fever, neck stiffness (all 3 not always present)

Photophobia (nerve palsy), confusion/altered LOC, localized pain = epidural abscess

Front 4

GENERAL PE findings (7)

Back 4

Nuchal rigidity (Brudzinski's, Kernig's)

Maculopapular, bumpy rash (menningocoocal meningitis - RMSF on diff), papilledema, altered mental state, nerve palsy, focal neuro, posturing (decorticate, decerebrate)

Front 5

Approach to bacterial meningitis

Back 5

1. PE: Level of alertness, focal neuro signs, papilledema, rash, posturing

2. Lab: CSF/LP*, Blood culture, CBC, drug tox, BMP (chem profile)

*Contraindicated in head trauma, loss of consciousness, papilledema, focal deficit

Front 6

Bacterial meningitis red flags

Back 6

1. Hx: Older than 60; immunocompromised, history of CNS dx; seizure

2. PE: LOC (commands, answer questions), gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, abnormal language = ischemia, edema, mass lesions - GET AN MRI or CT

Front 7

Bacterial meningitis tx

Back 7

START THERAPY ASAP:

18-50 = S. Pneumonia, N. Meningitides = VANC CEFOTAXIME + CEFTRIAXONE

50+ also consider Listeria, group B strep: ADD AMPICILIN

Refine treatment after lab results. May add steroids.

Front 8

LP: What are signs/#s of bacterial men.

Back 8

Normal = 70-180

CSF studies:

1. Normal = 0-5 lymphocyte. 200-20K = meningitis.

2. Gram stain >60%

3. Culture >90%

4. Fungal mycobacterium/AFB

5. Decreased glucose

.6 CSF/Serum ratio <.4

7. Protein increased

8. PCR - bacterial DNA*

9. Latex agglutination-antibody/antigen response testing.

Front 9

5 most important causes of bacterial meningitis

Back 9

1. Group B strep: Neonatal strep.

2. Listeria (older/infants): Gram+ rod, bimodal peak, food borne

3. Strep pneumonia (most common)*

4. N. Meningitis*

5. H. Flu: children receive vaccine*

*=vaccine available (pneumococcal/meningococcal)

Front 10

S. pneumonia predisposing factors

Back 10

Pneumonia, Sinusitis, Immunocompromised (splenectomy, complement deficient, hypogammaglobulinemia, head trauma, CSF leak, skull fracture.

MOST COMMON CAUSE (50%)

20% mortality

Vaccine available

Front 11

N. Meningitidis

Back 11

1. 20% of cases

2. Epidemic/endemic outbreak, exposure prophylaxis needed.

3. Fulminant presentation - petechial/purpuric rash, immunocompromised pt.

4. Vaccine available

Front 12

Other causes

Back 12

S. aureus, S. epidermitis, Gram neg. /Pseudomonas aueriginosa

Front 13

Chemoprophylaxis

Back 13

1. M. Menigitis - at risk for droplet contact, 1+ hour intimate contact. RIFAMPIN, CEFTRIOXONE, CIPRO.

2. Group B strep: treat carrier mother

3. HIB: Unimmunized, RIFAMPIN

Front 14

Acute viral/aseptic meningitis: presentation on LP; 2 causes

Back 14

1. Viruses can cause encephalitis

2. Aseptic on LP (inflammation w/o agent)

3. SYPHILIS as spirochete phase can cause

4. Erhilchiosis = TICK BORNE

Front 15

Acute viral/aseptic meningitis: S/S

Back 15

S/S: Acute onset severe headache, fever, photophobia, meningismus. NO PERSONALITY change.

Front 16

Acute viral aseptic meningitis: Dx

Back 16

1. CSF PCR for enterovirus, HSV, ZVZ

2. IgM for west nile virus

3. CSF for fungus, mycobacterium

4. Viral culture: CSF, throat

5. Serology: Viral Ab, IgM, Titer rise in IgG, HIV

DDX: Bacterial meningitis, parameningeal focus of infection, slow/non-culturable organism, chronic/subacute meningitis, neoplastic meningitis.

Front 17

Acute viral meningitis LP findings

Back 17

1. Opening pressure increased

2. WBC 25-2K (normal 0-5)

3. Protein 50+

4. Normal-low glucose

5. No organism on grain stain

Front 18

Acute viral meningitis treatment

Back 18

1. Managed as outpatient

2. No IV antibiotic

3. Consider antiviral agents

4. Supportive/symptomatic care: Rest, fluid, analgestic/antipyretic, atiemetic

Front 19

Chronic Meningitis presentation

Back 19

S/S:

1. Chronic headache

2. Neck pains

3. Double vision, hearing loss

4. Sphincter dysfunction

5. Falling

PE:
1. Papilledema

2. CN defect

3. Delerium

5. Myelopathy, radiculopathy

Front 20

Causes of chronic meningitis

Back 20

1. Mycobacterium

2. Bacterial: Syphillis, Lyme dx

3. Helminthic- tapeworm

4. Fungal - cryptoccus, coccidiodes, histoplasma

*Mollaret's: Benign, recurrent, aseptic meningitis. Repeated fever 104+, meningismus, severe headache. HSV1/2, EBV possibly?

Front 21

Viral encephalitis - what is encephalitis

Back 21

1. Infection of tissue of brain due to virus

3. Meningitis may also be present - meningoencephalitis

4. If spinal cord also: Encephalomyelitis

Front 22

Encephalitis presentation

Back 22

1. Confusion, altered state of consciousness

2. Fever, headache, stiff neck, focal neuro, SEIZURE, change in MOOD/PERSONALITY

Front 23

Encephalitis cause

Back 23

1. Common = herpes viruses: HSV, VZ, EBV.

Arthropod (La crosse, WNV, St Louis)

2. Zeka, Rabies, Equine, Powassan, CMV, enterovirus, mumps, tick fever

Front 24

HSV in encephalitis; S/S, Dx, Tx

Back 24

1. MOST COMMON

70% mortality, but treatable if early, mental deficit if not.

2. S/S: 1-7 days upper resp symptoms, sudden onset headache, fever, delirium, behavior changes,

*SEIZURE, EEG, MRI.

3. Dx: CSF PCR, culture, IgG, IgM titers for WNV, HSV. PCR, MRI, EEG.

4. Tx: Acyclovir IV

Front 25

Brain abscess: S/S, cause, Tx

Back 25

1. Blood borne from distant sites of infection (lung, endocarditis)

2. Sinusitis/Otitis media

3. Similar to other space occupying lesions

4. ENCAPSULATED on MRI

Cause: Multiple organisms. Anaerobes, Microaerobic strep, staph, candida, aspergillius.

Tx: ABX, drainage

Front 26

Subdural empyema

Back 26

1. EMERGENCY

2. Infection in space btwn dura and arachnoid

3. 20% of intracranial infection

4. Complication of sinusitis, otitis media

5. MRI

6. Treatment: Surgical drainage, IV ABX

Front 27

CNS opportunistic infections

Back 27

1. HIV/Mass lesion

2. Toxoplasmosis

3. Primary CNS/lymphoma

4. Crypto

5. TB

6. PML

7. Neutropenia

8. Mold

9. Bacterial brain abscess

10. VZV

Front 28

Cranial epidural abscess

Back 28

1. INVOLVES INNER SKULL TABLE, btwn that and dura.

2. Complication of fracture/craniotomy

3. From sinus, ear, mastoid, orbit infection

4. Fever, headache, nuchal rigidity, seizure, focal deficit. Insidious

5. Cranial MRI with enhancement

6. Neurosugical drainage + ABx by drainage