25 Central nervous system infections 2 Flashcards

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1
Q

Facial nerve palsy

How to UMN/ LMN differ clinically?

A

LMN - cannot wrinkle forehead. As facial nerve supplying this is damaged

UMN - can wrinkle forehead. Alternative pathways allow activation of facial muscle

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2
Q

Unilateral facial palsy

What is differential diagnosis?

LMN lesion

A

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
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3
Q

Unilateral facial palsy

What is differential diagnosis?

UMN lesion

A

Cerebrovascular disease

Vasculitis

MS

Infective -
Syphilis

HIV

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4
Q

What are investigations for unilateral facial palsy?

A

Examine eyes/ ears for Ramsay Hunt

Swab lesions for HSV/ VZV

Serology for lyme, VZV, EBV, CMV, HIV

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5
Q

If all other causes of facial nerve paralysis excluded, then it is idiopathic - Bell’s palsy.

What is management of Bell’s palsy?

A
  • 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
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6
Q

CUH guidelines

What is empirical treatment for bacterial meningitis?

A

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

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7
Q

CUH guidelines

Bacterial meningitis

When to stop dexamethasone?

A

give for 4 days if pneumococcal meningitis confirmed

stop otherwise

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8
Q

CUH guidelines

Bacterial meningitis

Pregnant patient, who is allergic to penicillin. What are options for listeria cover?

A

co-trimoxazole 30mg/ kg IV TDS

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9
Q

CUH guidelines

Patient with altered behaviour, fever. Suspect viral encephalitis.

LP done 24 hours after symptom onset, viral PCR negative

Can aciclovir be stopped?

A

Consider repeating LP 72 hours after symptom onset, as LP can sometimes be performed too early

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10
Q

CUH guidelines

What is duration of aciclovir for encephalitis, positive by PCR?

A

14 days if immunocompetent adult

21 days if aged <12, or immunocompromised

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11
Q

What is treatment duration for these forms of bacterial meningitis?

Meningococcus 
Haemophilus 
Pneumococcus 
GBS 
Listeria 
E. coli/ gram negs
A
Meningococcus - 7 days
Haemophilus - 10 days
Pneumococcus - 14 days
GBS - 14 days
Listeria - 21 days
E. coli/ gram negs - 21 days
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12
Q

GP phones, and is referring patient in with suspected meningitis.

Asks for advice about prophylaxis for contacts.

What classifies as a contact?

A

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

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13
Q

GP phones, and is referring patient in with suspected meningitis.

Asks for advice about prophylaxis for contacts.

What are options?

A
  • 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

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14
Q

Meningitis prophylaxis

What is dosage?

Ciprofloxacin
Rifampicin

A

Ciprofloxacin 500mg single dose

Rifampicin 600mg BD 2 days

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15
Q

Neurosurgical infection

Which organisms are associated with infection in trauma/ neurosurgery?

A

Staph aureus

Gram neg - E. coli, Klebsiella

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16
Q

Neurosurgical infection

Which organisms are associated with infection in shunts/ drains/ implants?

A

Coagulase negative staph
Staph aureus
Dipetheroids
Proprionibacterium (cutibacterium)

17
Q

Neurosurgical infection

What is treatment and duration?

Brain abscess - trauma/ sinus/ dental source

Brain abscess - post-operative

A

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

18
Q

Neurosurgical infection

What is treatment of CSF shunt infection?

A

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
19
Q

Neurosurgical infection

What is treatment and duration?

Post-operative meningitis (no abscess)

A
  • vancomycin 15-20mg/l plus
  • meropenem 2g TDS
    14 days
20
Q

Neurosurgical infection

EVD related ventriculitis

What is treatment and duration?

A
  • 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

21
Q

Neurosurgical infection

What is treatment and duration?

Post neurosurgical wound infection - not involving skull bone/ bone flap

A

Flucloxacillin 14 days

22
Q

Neurosurgical infection

What is treatment and duration?

Post neurosurgical wound infection - involving skull bone/ bone flap

A
  • vancomycin 15-20mg/l plus
  • ceftriaxone 2g OD

6 weeks

23
Q

Neurosurgical infection

Implantable electronic stimulator device infections

What is treatment and duration?

generator pocket/ lead infection - cellulitis, purulent exudate, wound dehiscence

A

Vancomycin/ teicoplanin/ daptomycin plus
meropenem if septic

6 weeks if device remains in situ
14 days if device removed

24
Q

Neurosurgical infection

What is treatment and duration?

epidural abscess

discitis

A

Vancomyin plus
ceftriaxone plus
metronidazole

empirical therapy. Rationalise once culture results known

6 weeks therapy