25 Central nervous system infections 2 Flashcards
Facial nerve palsy
How to UMN/ LMN differ clinically?
LMN - cannot wrinkle forehead. As facial nerve supplying this is damaged
UMN - can wrinkle forehead. Alternative pathways allow activation of facial muscle
Unilateral facial palsy
What is differential diagnosis?
LMN lesion
Idiopathic- Bell’s
Iatrogenic - local anaesthetic
Mononeuropathy - DM/ sarcoidosis/ AI
Neoplasia facial nerve
Infective - HSV VZV - Ramsay Hunt - usually painful face/ may have vesicles in ear EBV CMV HIV Lyme GBS
Unilateral facial palsy
What is differential diagnosis?
UMN lesion
Cerebrovascular disease
Vasculitis
MS
Infective -
Syphilis
HIV
What are investigations for unilateral facial palsy?
Examine eyes/ ears for Ramsay Hunt
Swab lesions for HSV/ VZV
Serology for lyme, VZV, EBV, CMV, HIV
If all other causes of facial nerve paralysis excluded, then it is idiopathic - Bell’s palsy.
What is management of Bell’s palsy?
- Eye care/ lubrication
- Prednisolone within 72 hours
25 mg bd for 10 days.
60 mg od for 5 days then reducing by 10 mg each day - Some evidence of benefits of aciclovir, though not routinely prescribed. This effect is likely due to aciclovir treating mis-diagnosed Ramsay Hunt
- Refer patient to ENT if worsening facial palsy, and no improvement on treatment
- Refer patient to ophthalmology if any eye symptoms - pain/ itch/ irritation
CUH guidelines
What is empirical treatment for bacterial meningitis?
Ceftriaxone 2g BD
dexamethasone 7.6mg IV QDS
add amoxicillin 2g 6x for pregnant/ >60
vancomycin if penicillin allergy/ penicillin resistant organism suspected
chloramphenicol 25mg/kg QDS
suspect penicillin resistant organism if been to country with high prevalence in last 6 months
CUH guidelines
Bacterial meningitis
When to stop dexamethasone?
give for 4 days if pneumococcal meningitis confirmed
stop otherwise
CUH guidelines
Bacterial meningitis
Pregnant patient, who is allergic to penicillin. What are options for listeria cover?
co-trimoxazole 30mg/ kg IV TDS
CUH guidelines
Patient with altered behaviour, fever. Suspect viral encephalitis.
LP done 24 hours after symptom onset, viral PCR negative
Can aciclovir be stopped?
Consider repeating LP 72 hours after symptom onset, as LP can sometimes be performed too early
CUH guidelines
What is duration of aciclovir for encephalitis, positive by PCR?
14 days if immunocompetent adult
21 days if aged <12, or immunocompromised
What is treatment duration for these forms of bacterial meningitis?
Meningococcus Haemophilus Pneumococcus GBS Listeria E. coli/ gram negs
Meningococcus - 7 days Haemophilus - 10 days Pneumococcus - 14 days GBS - 14 days Listeria - 21 days E. coli/ gram negs - 21 days
GP phones, and is referring patient in with suspected meningitis.
Asks for advice about prophylaxis for contacts.
What classifies as a contact?
Contacts should be limited to household members, or other close contacts e.g share dormitory, share kitchen, boyfriend/ girlfriend
had exposure within past 7 days
GP phones, and is referring patient in with suspected meningitis.
Asks for advice about prophylaxis for contacts.
What are options?
- Ciprofloxacin
Can be used in children >2, with caution, due to tendinopathy. Can be used in pregnancy - Ceftriaxone - IM injection
- Rifampicin - do not give in pregnancy
Ensure patients have had routine vaccinations - Hib/ Men C/ Pneumococcus
PHE will organise contact tracing
Meningitis prophylaxis
What is dosage?
Ciprofloxacin
Rifampicin
Ciprofloxacin 500mg single dose
Rifampicin 600mg BD 2 days
Neurosurgical infection
Which organisms are associated with infection in trauma/ neurosurgery?
Staph aureus
Gram neg - E. coli, Klebsiella
Neurosurgical infection
Which organisms are associated with infection in shunts/ drains/ implants?
Coagulase negative staph
Staph aureus
Dipetheroids
Proprionibacterium (cutibacterium)
Neurosurgical infection
What is treatment and duration?
Brain abscess - trauma/ sinus/ dental source
Brain abscess - post-operative
Brain abscess - trauma/ sinus/ dental source
- ceftriaxone 2g BD plus
- metronidazole 400mg PO
6 weeks
Brain abscess - post-operative
- vancomycin 15-20mg/l plus
- meropenem 2g TDS
6 weeks
Neurosurgical infection
What is treatment of CSF shunt infection?
Shunt needs to be removed, and external ventricular drain (EVD) needs to be inserted
- vancomycin 15-20mg/l plus
- meropenem 2g TDS
6 weeks - gram pos - intrathecal vancomycin 20mg OD 5 days
- gram neg - intrathecal gentamicin 5mg OD 5 days
Neurosurgical infection
What is treatment and duration?
Post-operative meningitis (no abscess)
- vancomycin 15-20mg/l plus
- meropenem 2g TDS
14 days
Neurosurgical infection
EVD related ventriculitis
What is treatment and duration?
- vancomycin 15-20mg/l plus
- meropenem 2g TDS
2 weeks - gram pos - intrathecal vancomycin 20mg OD 5 days
- gram neg - intrathecal gentamicin 5mg OD 5 days
Shorter duration than shunt infection, as external drain can be changed, and is allowing infected material to leave ventricles to external environment
Neurosurgical infection
What is treatment and duration?
Post neurosurgical wound infection - not involving skull bone/ bone flap
Flucloxacillin 14 days
Neurosurgical infection
What is treatment and duration?
Post neurosurgical wound infection - involving skull bone/ bone flap
- vancomycin 15-20mg/l plus
- ceftriaxone 2g OD
6 weeks
Neurosurgical infection
Implantable electronic stimulator device infections
What is treatment and duration?
generator pocket/ lead infection - cellulitis, purulent exudate, wound dehiscence
Vancomycin/ teicoplanin/ daptomycin plus
meropenem if septic
6 weeks if device remains in situ
14 days if device removed
Neurosurgical infection
What is treatment and duration?
epidural abscess
discitis
Vancomyin plus
ceftriaxone plus
metronidazole
empirical therapy. Rationalise once culture results known
6 weeks therapy
