M2.neu Distinctive Neurologic Infections

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Syphillis - clinical features

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1mary: chancre (no neuro)
2ndary: can be aSx or flu-like, rash, lymphadenopathy, mucosal lesions; aseptic meningitis with CN involved
3iary: 10-30% untreated pts, after long latent period

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Tertiary Syphillis features

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meningovascular syphillis: stroke, HA, apathy, irritability, insomnia; with lymphocytes in meninges and blood vessels

general paresis: dementia, psych manifestations, seizures, myoclonus, abnormal pupils, dysarthria, UMN findings, incontinence, death; with thickened fibrotic meninges, loss of cortical neurons, gliosis, prolif of rod-shaped microglia

Tabes dorsalis: chronic inflamm of dorsal roots and ganglia with degen of posterior columns; decreased proprio, lightning-like pain (L'Hermitte's), profound ataxia

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Syphilis diagnosis

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-specific antibodies (FTA): present in blood throughout life of pts with previous syphilis infection

-non-specific serologic tests (RPR, VDRL): represent active infection, can be assayed in LP

Front 4

Lyme disease

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-Neuroborreliosis
-Primary, secondary, tertiary
-Neuro Sx: subacute/chronic meningitis, CN involvement (esp. facial n.)

Front 5

Herpes varicella-zoster (VZV)

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-primary infection: chickenpox
-virus latent in neurons of sensory ganglia, reactivated years later; more common in immunocompromised or elderly
-sharp burning pain in dermatome
-vesicular rash in dermatome
-post-herpetic neuralgia (pain > 4 weeks)
-spread to spinal cord: transverse myelitis
-spread to motor branches of roots: weakness
-spread to neighbor nerves
-spread to blood vessels: stroke

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VZV Diagnosis

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-primarily clinical
-can do cultures, micro on vesicular scrapings
-can culture and PCR from CSF

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VZV Treatment

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-early acyclovir reduce duration of rash and post-herpetic neuralgia if started early
-steroids may also help

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Neurologic Manifestations of HIV

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1. HIV itself affects all levels of nervous system
-encephalopathy, vacuolar myelopathy, direct peripheral neuropathy

2. Auto-inflamm rxn: immune peripheral neuropathy

3. Immune suppression: opportunistic infections, e.g. toxo, crypto, EBV causing CNS lymphoma, PML (can be confused with MS), VZV, CMV (polyradiculopathy)

4. Toxicity of medications

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Progressive multifocal leukoencephalopathy - path

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Giant, bizarre astrocytes

Oligodendrocytes with enlarged nuclei and viral inclusions

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Approach to mass lesions in HIV

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-solitary: Bx

-multiple: think toxo; serum titer (+) implies empiric Tx with pyrimethamine, titer (-) implies Bx

-if PML or CNS lymphoma Dx: treat with anti-retrovirals

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Cysticercosis - life cycle

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Organism in human intestine produces eggs.
Eggs passed in feces.
Pig or human eats eggs: cysts develop (neuro Sx)
Humans eat pork: organism colonizes gut

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Cysticercosis - clinical features

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-multiple brain cysts on imaging: degenerate, partially calcified; common near ventricles (hydrocephalus)

-often aSx
-Sx onset 1-35 years after exposure
-seizures are most common manifestation
-stroke (if in right place), encephalitis (multiple cysts plus immune rxn)

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Cysticercosis treatment

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-albendazole
-anti-epileptic drugs
-shunt/resection (hydrocephalus)