32. Central Nervous System Infections Flashcards
CT scan shows a nodular lesion in the right temporal lobe, the MRI showed the lesion as being 3x3 cm with vasogenic edema and no midline shift, leptomenngeal enhancement was reported, chest x ray was normal, subsequent work up showerd that the patient was with advanced HIV disease and had a viral load of >1,000,000, CSF was cloudy, gram stain showed many lymphocytes but no organism WBC 860 RBC 200, neutrophils at 6%, lymphocytes at 75%, glucose at 27 mg/dL, protein at 466 mg/dL, gram stain was negative, CSF film array was negative, major goals to cure the individual patient, minimize risk of death and disability, is reportable, patient needs to take the prescribed medication, medications are rifampin, isoniazid, ithambutol, a 6 month treatment regiment is generally recommended for patients with extrapulmonary TB ***
tuberculosis meninigitis
85 year old white male with no past medical history developed nausea and vomiitng for two days with fevers of up to 102F, thereafre he began to experience rapidly worsening confusion and weakness, CSF was yellow, occassionl PMNS, WBC at 180, RBC at 30, crenated RBC at 0, neutrophils at 2%, glucose at 52 mg/dL,
85 year old white male with no past medical history developed nausea and vomiitng for two days with fevers of up to 102F, thereafre he began to experience rapidly worsening confusion and weakness, CSF was yellow, occassionl PMNS, WBC at 180, RBC at 30, crenated RBC at 0, neutrophils at 2%, glucose at 52 mg/dL,
39 year old white male with no past medical history ** WBC 759 and lymphocytes at 93%, testing for CSF fluids includes **
CSF polymerase chain reaction testing for herpes simplex virus, HSV-2, VZV and enteroviruses, additional testing should be considered based on geographic considerations, clinial presentation, and exposure history ***
encephalitis testing
e coli, haemophilus influenzae ***
biofire meningitis/encephalitis panel menu
typically reveals mild mononuclear pleocytosis although a polymorphonuclear cell predominance may initially be seen if the sample is obtained early in the course of illness; persistent neutrophilic pleuocytosis has been obsergved in patients with west nile virus encephalitis
CSF analysis for viral encephalitis
CSF analysis is essential unless contraindicated in all patients with encephalitis , MSRI is the most sensitive neuroimaging test, ***
viral encephalitis general considerations
HSV-1 and 2 account for 5-10% of all cases of encephalitis, one of the most common causes of identified sporadic encephalitis worldwide, affets all age groups and is seen during all seasons, HSV-1 infection is more common in adults, HSV-2 infection is more common in neonates
typical magnetic resonance imaging changes associated with viral encephalitis
43 year old white male with a history of alcohol abuse present in a 1 week history of fever, chills, cough, hemoptysis, ***, CXR shows a cavitary lesion in the lingula, **, underwent emergency craniotomy with the removal of purulent material, gram stain revealed many gram positive cocci and few gram variable organisms, conditions predisposing to brain abscesses are otitis media or mastoiditis, sinusitis, dental infection, pentrating trauma or post neurosurgical, lung abscesses, empyeme, bronchiectasis, bacterial endocarditis, congenital heart disease, initial approach is to perform contrast CT or MRI, start empirical antimicrobial therapy when abscess materal has been obtained for microbiologic and histopathologic therapy, can be complications of other infectious processes, broad antibiotic coverage due to polymicrobial etiology, consult neurology
a 75 year old male had been having a cough productive of greenish sputum for about 3 weeks, 3 days prior to his admission an outside hospital, he developed acute severe neck pain, that he thought began after he went over a road bump, he then began to have increased neck stiffness with global headaches, 7-8/10 in intensity, 1 day prior to admission he became confused, kernig sign and brudzinzki signs, petechiae, maculopapular rash, facial nerve palsy, freshwater, pulmonary infiltrates, lymphadeonopathy, personality changes, mosquito bites
bacterial meningitis
if symptoms are present, blood cultures STAT, then dexamethasone with antimicrobial therapy, perform CT scan of the head, if contraindication for lumbar punctures not present like abscess, vasogenic edema or midline shift, perform lumbar puncture
bacterial meningitis algorithim
immunocompromised state with HIV infection or AIDS, history of CNS disrease, new onset seizure, papilledema, abnormal level of consciousness, focal neurologic deficit
recommended criteria for adult patients with suspected bacterial meningitis who should undergo CT prior to LP
he was afebrile, CT scans shows sphenoid, ethmoid, and maxillary sinusitis, cell count and RBCs, CSF shows elevated WBC, high neutrophils, low glucose, high protein
case 1 continued
elevated opening pressure, high PMNs, high protein, low glucose
bacterial infection
