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NMSP > Cerebrovascular Disease and Infections > Flashcards

Cerebrovascular Disease and Infections Flashcards

1
Q

what is the most common route of infection in the CNS

A

hematogenous-arterial

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2
Q

hematogenous spread of infections in the CNS is most common arterially BUT, retrograde venous spread via anastomosis with _ _ is possible

A

facial veins

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3
Q

what are the 4 routes of infection spread in the CNS?

A
  1. hematogenous
  2. direct implantation
  3. local extension
  4. periopheral nervous system
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4
Q

how does direct implantation occur in CNS infection spread?

A

from trauma or congenital malformations (like a meningomylocele-both the cord and meninges are protruding)

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5
Q

how does local extension of CNS infections spread?

A

through the sinuses, teeth, cranial or spinal osteomyelitis

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6
Q

how do CNS infections spread through the PNS

A

via viruses
-examples: Rabies, Herpes

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7
Q

what are the parts of the meninges?

A

dura mater, arachnoid, pia (innermost)

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8
Q

what produces the meninges, where is CSF located

A

85%- produced by choroid plexus of the lateral third and fourth ventricles

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9
Q

there is a complete exhange of CSF every _ hrs because the brain is bathed in bacteria

A

3-4 hrs

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10
Q

CSF circulates to the arachnoid space and is absorbed by arachnoid villi along the _ _ sinus

A

superior sagital

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11
Q

tuberculus meningitis develops by seeding _ from _ or _ granulomas

A

CSF

subepidural or submeningeal

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12
Q

CSF has no _; however _ are in the epidural space

A

lymphatics

lymphatics are in the epidural space

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13
Q

infections from the retropharyngeal, posterior mediastinal, or retroperitoneal spaces may produce _

A

spinal epidural abscesses

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14
Q

herpes simplex and zoster produces _ infection of _ ganglia. They replicate in _ cells and _ to the CNS within _ nerves.

A

latent infection

sensory ganglia

schwaann cells

ascend to the CNS within SENSORY nerves

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15
Q

Rabies virus binds at or near _ receptors and the _ and ascends to the CNS via _ nerves

A

Acetylcholine receptors

NMJ

Motor

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16
Q

Capillaries do not have _ they are surrounded by _ processes of adjacent astrocytes. Molecules move across capillaries mainly by active transport and _ solubility. There is relative impermeability to immunoglobulins, complement and _ *this is an important factor in the pathogenesis of CNS infections and in slection of antibiotic therapy

capillaries are a part of the blood brain barier

A

fenestrations

foot processes

lipid

antibiotics

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17
Q

what is meningoencephalitis

A

meningo- meninges
encephalitis- brain parenchyma
itis- inflammation

**inflamation of the meninges and brain parenchyma

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18
Q

what is chemical meningitis

A

non-bacterial irritant in the subarachnoid space from a ruputred cyst or a chemical irritant

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19
Q

what is acute pyogenic meningitis

A

inflammation of the meninges due to bacteria

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20
Q

what is aseptic meningitis

A

inflammation of the meninges due to a virus

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21
Q

what is chronic meningitis

A

inflammation of the meninges due to tuberculosis, spirochestes, or cryptpcoccus

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22
Q

pyogenic meningitis has _ _ covering the brainstem and cerebellum (base of the brain) it has _ leptomeninges

A

supprative exudate

thickened

papilledema also due to the increased ICP

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23
Q

TB and neurosyphyllis have a predilection for the?

A

base of the brain

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24
Q

inflammation and infection of the brain cause loss of _ integrity and therefore loss of the BBB and with this comes transudation of _ fluid into the brain or spinal cord creating cerebral edema

(CNS response to infection)

A

capillary

intravascular

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25
Q

cerebral edema is accelerated by products released by both living and antibiotic lysed _

A

bacteria

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26
Q

Cerebral edema due to bateria is slowed and reversed by _

A

corticosteroids

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27
Q

symptoms of acute meningitis ? (suppurative)

A

headahce, meningeal irritation signs, high fever, confusion (coma)

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28
Q

the full syndrome of meningitis usually develops with several _ but it can develop over a few hours with a _ course

A

fulminant

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29
Q

pneumococcal meningitis is often found where?

A

convexities near the sagital sinus

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30
Q

h. influenzae meningitis is usually found where

A

basal location

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31
Q

acute pyogenic meningitis can lead to ?

A

ventriculitis: inflammation into the ventricles

focal cerbritis: inflammation into the walls of the veins and brain substance

phlebitis: venous thrmobosi and hemorrhagic infarction

leptomeningeal fibrosis and hydroephalous (chronic)- impede CSF circulation

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32
Q

acute meningitis follos the _ vasculature

A

leptomeningeal

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33
Q

pneumococcal meningitis has capsular polysaccharides tha tlead to a particularly gelatinous esudate that encourages

A

chronic adhesive arachnoiditis

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34
Q

in acute suppurative meningitis _ fill the subarachnoid space and inflammatory cells infiltrate the walls of the veins and extend into the brain substance, this is known as _

A

neutrophils

focal cerebritis

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35
Q

what are the complications of bacterial meningitis

A

Meningogoccemia with a rash leading to waterhouse-friederischsen syndrome (b/l adrenal hemorrhage and death)

other complications: seziures, encephalitis, hearing loss, blindness, paralysis

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36
Q

in a lumbar puncture we get a _ _ of the CSF and cultures te CSF and blood. There is also means to do PCR techniques and antigen detection in urine and CSF

A

gram stain

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37
Q

lumbar puncture gram stain vs. presumptive ID

gram negative diplococci:
gram positive diplococci:
gram negative pleomorphic:
gram positive cocci:
gram negative bacilli:

A

gram negative diplococci: N. meningitidis

gram positive diplococci: s. pneumoniae

gram negative pleomorphic: H. Influenzae

gram positive cocci: S. aureus or S. epi streptococci

gram negative bacilli: E. Coli or other gram negative

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38
Q

how is a lumbar puncture taken

A

a spinal needle is inserted between the 3rd and 4th vertebrae

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39
Q

in a lumbar puncture there is _ contamination thus utilize the _ tube collected for the most accurate cell count. RBCs will utilize _ out of sample if not processed quickly and _ will increase if not processed quickly.

A

blood

last

glucose

bacteria

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40
Q

turbid=

A

chunky

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41
Q

Bacterial Menigitis CSF results

Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:

A

Opening pressure: elevated

Apperance: cloudy/turbid
WBC: greater than 1,000
Cell type: neutrophils
Protein: increased
Glucose: markedly decreased

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42
Q

Viral Menigitis CSF Lab values

Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:

A

Opening pressure: normal
Apperance: clear/colorless
WBC: less than 100
Cell type: lymphocytes
Protein: normal to elevated
Glucose: normal to elevated

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43
Q

Fungal/TB meningitis CSF values

Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:

A

Opening pressure: variable
Apperance: variable
WBC: variable
Cell type: lymphocytes
Protein: elevated
Glucose: decreased

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44
Q

who has a an increased rosk of meningitis

A

less than 5
older than 60
diabetes mellitus
immunosuppresion
sinusitis
IV drug use/bacterial endocarditis
Sickle cell anemia patients

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45
Q

what is the most common cause of meningitis in newborns (0-6months)

A

group B strep
E Coli
Listeria

GEL

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46
Q

what is the most common cause of menigitis in a child (6mo-6yo)

A

Strep pneumoniae
H. influenza (in the unvaccinated)
Neisseria menigitdis
group B strep

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47
Q

what is th emost common cause of meningitis in adolescents/young adults

A

N. Meningitidis

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48
Q

what is the most common cause of meningitis in the elderly

A

s. pneumoniae and listeria

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49
Q

immunosuppressed individuals with purulent meningitis may be due to?

A

Klebsiella/ anaerobic organisms

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50
Q

brain abcess has the same route as?

A

meningitis (follows the leptomeninge vessels)

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51
Q

acute bacerial endocarditis exposed you to _ abcesses

A

multiple brain

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52
Q

congential heart disease like a R to L shunt will cause brain abcesses to form how?

A

they remove the pulmonary filtration of organisms

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53
Q

non immunosuppresed brain absess are usually caused by?

A

strep or staph

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54
Q

presentation of a patient with a brain abcess

A

the patient will present with progressive focal neurologial deficits and signs on increased intracranial pressure

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55
Q

CSF of a brain abcess

A

high WBC count
high protein
normal glucose

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56
Q

complications of a brain abcess

A

herniation from ICP

rupture with spreading into the ventricles

meningitis

venous sinus thrombosis (patient can die)

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57
Q

how do we treat a brain abcess?

A

drainage and antibiotics

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58
Q

what does a brain abcess look like

A

liquefactive necrosis in the middle surrounded by edema and fibrosis

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59
Q

what is a subdural empyema

A

bacteria or fungus infedction of skull bones or sinuses that spreads to the subdural space

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60
Q

subdural empyemas can lead to thrmbophlebitis of the _ vessels

A

bridging leading to an infarct

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61
Q

signs and symptoms of a subdural empyema

A

similar to an abcess: focal neurological signs, lethargy, coma

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62
Q

what is usuallt the residual evidene of a subdual empeyema

A

thickened dura

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63
Q

treatment of a subdrual empyema

A

drainage

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64
Q

extra dural abcesses is usually associated with?

what is it?

A

associated with osteomyelitis

**abcess in the extradural space: may cause cord compression

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65
Q

osteomyelitis often arises from an adjacent focus of _

A

infection such as sinusitis or following a surgical procedure

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66
Q

neisseria meningitdis colonizes the _ and _ of asymptomatic arriers and is spread by direct contact with _ secretions

A

oropharynx and rhinopharynx

respiratory

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67
Q

colonization of neisseria meningitidis has a higher proportion in _ populations

A

crowded (dorms, prisons)

68
Q

microbiology of neisseria meningitidis

A

gram negative diplococci with intracellular and extracellular neutrophils

69
Q

what medium does neisseria meningitis grow on?

A

chocolate agar/chocolate blood agar

70
Q

n. meningitidis is a rapidly progressive _ with a fever, _ and _ with petechial and _ lesions

A

septicemia

hypotension

purpuric lesions

71
Q

outcome of N. meningitidis

A

purpura fulminans: hermorrhagic skin lesions

b/l hemorrhage of adrenal glands

72
Q

chronic meningitis symptoms

A

4+ weeks duration

fever, headache, lethargy, confusions, stiff neck

73
Q

chronic meningitis CSF

A

elevated proteins (lympocytic)

low glucose level (variable)

74
Q

again what are the causes of chronic menigitis

A

tuberculosis, Neuroborreliosis, Neurosyhphilis

75
Q

mycobacterium tuberculosis produes a _ meninoencephalitis within the _ space with a gelatnous or fibrinous exudate

A

diffuse

subarachnoid

76
Q

outcomes of tuberculosis meningitis

A

obliterative endarteritis

encases cranial nerves and blocks CSF flow - hydrocephalus

tuberculoma

77
Q

what is obliterative endarteritis ?

A

this is inflammation infiltration in the vessel walls/intemal thickening leading to arterial occlusion and infarction

78
Q

tuberculosis meningitis has predilection for?

A

base of the brain (arachnoiditis)

79
Q

what is a tuberculoma

A

intraparenchymal mass that has central caseous necrosis and calcifications

80
Q

in order to test for tuberculosis menigitis you must perform what?

A

CSF smear- 15% positive
CSF culture-90% positive

a tuberculin test is typically negative

81
Q

chronic meningiis can also be caused by borrelia burdorferi aka neuroborreliosis aka _ _ that has _ symptoms followed by a characteristic _ in about 4 weeks

A

lyme disease

neurological

rash (bulls eye)

82
Q

what neurological symptoms are seen in lymes disease causing meningitis

A

cranial nerve palsies, peripheral neuropaties

83
Q

CSF of neuroborreliosis (lymes disease) meningitis

A

antibodies

84
Q

antibodies in the CSF of lymes disease chronic meningiti can cross react with what other diseases

A

mono, rhematoid arthritis, lupus, syphillis (can be misdiagnosed)

85
Q

neurosyphillis is the _ stage and only 10% of patients that are untreated will develop chronic meningitis people with _ are an increased risk due to imparied cell mediated immunity

A

tertiary

HIV

86
Q

what are the three types of neurosyphillis

A

meningovascular

paretic

tabes dorsalis

87
Q

what is meningovascular neurosyphillis

A

a chronic meningitis that involves the BASE of the brain and results in a communicating hydrocephalus

88
Q

complications of meninovascular neurosyphillis

A

obliterative endartitis/heubner arteritis

89
Q

what is paretic neurosyphillis

A

progressive/insidious mental defects with mood alterations known as delusions of grandeur

ends in severe dementia

90
Q

what deposts are in paretic neurosyphillis

A

iron deposits

91
Q

what is the outcome of paretic neurosyphhillis

A

granular ependymitis:

proliferation of subependymal glia under a damaged ependymal lining and a communicating hydrocephalus

92
Q

what is tabes dorsalis

A

damage to the sensory nerves in the dorsal roots that reslts in impaired joint position sense, atatacia, loss of pain sensation, joint damage, and absence of DTRs

93
Q

joint damage in tabes dorsalis is known as

A

charcot joints (lightening pains)

94
Q

terponema pallidum: neurosphyllis

immunoflourcense

A

spirochete

95
Q

aspectic or viral meningoencephalitis has the absence of a recognizable _ in a patient with meningeal irritaiton, fever, alterations of conciounsess.

80% of viral causes are caused by _

clinical course is less fulminant than pyogenic meningitis

CSF: _ pleocytosis and moderate increase in _ , normal levels of _

A

organism

enteroviruses

lymphocytic pleoytosis

protein

glucose

usually self limitis

96
Q

pathogenesis of viral meningitis

A

CNS infections may occur following hematogenous dissermiation of viruses

or viruses may reach the CNS through nerves like olfactory and trigeminal sensory or m otor nerves

97
Q

in viral meningitis the brain mounts an inflammatory response with a populaiton of _

A

lymphocytes

98
Q

most viral meningitis have a _ period

A

latency

this is important for many several viruses

99
Q

on histology viral encephalitis will show

A

perivascular lymphocytic cuffs

microglial nodules

100
Q

what is arhropod borne viral encephalitis

A

a virus in the west nile that causes encephalitis and invloves the spinal cord

101
Q

symptoms of arthropod borne viral encephalitis

A

spinal cord involvement- polio like syndrome with paralysis

neuro deficits like seziure/confusion

focal signs (occular palsies, reflex asymmetries)

102
Q

CSF of arthropod borne viral encephalitis

A

colorless

increase in pressure

increase in protein

normal glucose

at first a neutrophilic infiltrate but then a lymphocytic infiltrate (when you take csf collection will vary cell type)

103
Q

histology of arthropod borne viral encephalitis

A

foci of necrosis

neuronophagia

microglial nodules

104
Q

what is neuronophagia

A

single- cell neuronal necrosis with phagocytosis of the dbris

macrophages surround it

105
Q

what are micoglial nodules

A

small aggregates around foci of necrosis

lymphs and microglial cells

106
Q

HSV 1 is common in population?

A

children and young adults

107
Q

symptoms of HSV 1

A

alterations in mood memory and behavior with weakness lethargy, ataxia (this is uncommon)

NEcrotizing and hemorhaggic inferior and medial temporal lobes (they will be necrotic and missing)

108
Q

inclusions in HSV 1

A

cowdry type A

109
Q

HAV2 is common in

A

neonates born by vaginal delvery to women with active HSV

110
Q

in HSV1 encephalitis of the _ lobe and destruction of the _ _

A

temporal lobe

cingulate gyrus

111
Q

HSV has _ inclusions, _ of chromatin, and ground glass _ nuclei

A

intranucelar

margination

multinucelated

112
Q

herpes zoster (varicella) has a _ cutaneous infection. It has a _ phase in the _ neurons of the dorsal root or _ ganglia. It reactivates and causes _ which presents as a painful vesiclar skiin eruption limite to a single or limited dermatome

encephalitis

A

chickenpox

latent

trigeminal

shingles

113
Q

what is post neuralgia syndrome

A

persistant pain as well as painful sensation following non painful stimuli in a person with shingles (can cause encaphalitis)

114
Q

CMV usually affects _ and the _

it is an opportunistic infection with _

in utero there is _ necrosis and severe brain destruction that causes _cephaly and periventricaly _

A

infants

immunocompromised

AIDs

periventricular

MICROencephaly

calcification

115
Q

CMV encephalitis localised in the _ _ regions and causes seere heorrhagic necrotitzing _encephalitis and choroid plexitis.

A

paraventricular subependymal regions

ventriculoencephlitis

116
Q

CMV also also radiculoceritits which is ?

A

inflammation of the spinal nerve roots

117
Q

what kinds of inclusions are in CMV

A

intranuclear and intracytoplasmic

severe destruction of brain parenchyma

118
Q

most cases of Polio have been erradicated by _ but a novel strain of enterovirus _

A

vaccination

D68

119
Q

Polio is a _ virus that spreads through - contamination

A

RNA

fecal-oral

120
Q

what is the pathogenesis of poliomyeltitis

A

it attacks the anterior horn motor neurons of the spinal cord inducing flaccid paralysis with muscle wasting and hyporeflexia

it has mononuclear cell perivacular cuffs and neuronophagia

(may extend into the posterior horns and cause cavitations)

can cause encephalitis

121
Q

what is post polio syndrome

A

this is 25-30 years after an initial polio infection that presents with decreased muscle mass and pain

122
Q

rabies is a _virus from the rhabodovirdae family.

the incubation period is _ and is depends on the distance from the wound to the brain.

It ascends along _ _ from the wound site

there are local _ around the _ and this is dignostic

A

lyss

1-3 months

peripherial nerves

parathesias around the wound

123
Q

symptoms of rabies

A

flaccid paralysis leading to respiratory center failure

violent motor responses and convulsions due to essxtraordinary CNS excitability

hydrophobia ( foaming at the mouth)

pins and needles at the site of a bat bite

124
Q

what causes hydrophobia in rabies

A

contracture of the pharyngeal muscles that produces aversion to swallowing

125
Q

how would you describe the rabies virus

A

bullet proof shape

126
Q

histology of rabies virus (can lead to encephalitis)

A

negri bodies

in the purkinje cell (eosinophilic)

negri bodies are also seen in pyrimidal neruons of the hippocampus

127
Q

HIV causes a _ meningitis that can be acute or chronic describe

A

aseptic

acute: perivascular inflammation
Chronic: microglial nodules with multinucleated giant cells

128
Q

the vessels in HIV aseptic meningitis look?

A

abndomal with prominent endothelial cells and perivascular pigmented macrophages

129
Q

the white matter in HIV aspectic meningitis looks

A

has myelin pallor and axonal swelling and gliosis

130
Q

types of HIV aspectic meningitis

A

IRIS

HAND

131
Q

with is IRIS

A

immune reconstiution inflammatory syndrome

(paradoxical deterioraiation after starting antiviral medication)

HIV aseptic meningitis

132
Q

what is HAND

A

HIV associated neurocongitive disorders

which is HIV ssociated dementia with cognitive changes depsite treatment for HIV

133
Q

HIV also is associated with increased incidence of ?

A

Primary CNS lymphoma

(this is most commonly an EBV+ B cell tumor)

134
Q

histology of HIV encephalitis

A

a multinucleated giant cells WITHIN a microglial nodule

135
Q

JC polyomavirus is a primary infection that is asymptomatic and is reactivated during _

it differentally affects the _ cells and _ is the principle pathologic effect

it is alomst exculusively in _ indivudals like HIT+ and reactivated. It has irrgular ill-defined dstruction of white matter and _ area of demylination with _ _ macrophages in the center with a decreased number of _

A

immunosuppression

oligodentrocyte

demyelination

immunusuppressed

subcortical

lipid laden macrophages

axons

136
Q

immunosuppressive states

A

HIV, monocolonal antibody therapy, granulomatous diseases, chemotherapy

137
Q

what stain can be done on PML

A

Myelin stain

glassy viral inclusions

138
Q

what is subacute sclerosing panencephalitis (SSPE)

A

a paramyxovirus that is a progressive clinical syndrome of cognitive decline, spasticity of limbs, and seziures

it is in children that have not had their measles vaccine

139
Q

pathogenesis of SSPE

A

gliosis and myelin degeneratio nwith viral inclusions in the nuclei of oligodentrocytes and neurons there are also inflammation and neurfibrillary tangles

140
Q

measles spreads through

A

air respiratory droplets

viral symptoms- rash (flat red spots)- hairline and spread downward + fever

141
Q

fungal meningoencephalitis is primarily in _ patients and spreads _

A

immunocomprommised

hematogenously

142
Q

diabetes mellitus fenal meningoencephalitis _ with direct extension

A

mucormycosis

143
Q

what funcal meningoenceplitis can cause vasculitis

A

mucormycosis, asperiglliosis and candidia occasionally

vasculitis leads to thrmobosis of the vessels and infacrtion

144
Q

endomeic pathogens that cause funcal meningoencephalitis

A

histoplasma, coccidoioces, blastomyces

145
Q

fungal meningoencephalitis causes of parenchymal infection

A

candidia, and cryptococcus

146
Q

cyrptococcous meningitis is associated with

A

aids

can be fulminant and fatal

147
Q

causes of fungal meningoencephalitis

A

candida, mucor species, aspergillus fumigatus and cyrptococcous neoformans

148
Q

mucormycosis is known as _ fungus and spreads from the_

A

black fungus

sinuses (runny nose, ne sided facial swelling, headache, fever, blurred vision)

149
Q

cyrptococcus neofromas CSF findings

histology findings

A

CSF: india ink perparation with the cyrptococcal polysaccardie antigen

histologyL cyrptococcal soap bubbles

150
Q

cyrotococcus neoformans spreads to the

A

perivascualr spaces (virchow-ribin spaces)

cyrtococcous gatti is in immunocompetent individuals

151
Q

what stain can we do on tissue selection for cyptococcous neofromans

A

muscicarmine stain

152
Q

toxoplasmosis gondii is an opportunisitic infection in _ or the immunosuppressed

in pregnancy the fetus will develop multifocal necrotizing lesions that may calcify

a brain abcess can frm and it will be lacted near the _ -_ junction of the cerebral cortex and the _ _ nuclei

there are _ _ lesions

histology: central foci of necrosis with _ hemorrhages surrounded by inflammation, macrophage infiltration and vascular proliferations.

There are free _ and encysted _ at the periphery of necrotic zones

A

HIV

gray-white

deep gray nuclei

ring enhancing lesions

petechial hemorrhages

tachyzoites and encysted bradyzoites

153
Q

what protazoes cause central amebiasis

A

naegleria fowleri

acanthomeoba

154
Q

what protazoa causes cerbral malaria

A

plasmodium falciparum

155
Q

what is naefleria fowleri

A

a brain eating ameba that infects people through contaminated freshwater by entering the nose

156
Q

what is acanthamoeba

A

a chronic granulomatous meningoencephalitis

157
Q

what is plasmodium falciparum

A

this is a protazoa that results in long term congitivie defects and decreased blood flow

look up when this question comes up

158
Q

what causes a rash on the palms and soles

A

HFMD
Kawasaki dz
rocky mountain spotted fever

secondary syphillis

159
Q

what is creutzfeldt- jakob disease

A

abnormal forms of cellular proteins that results in a rapidly progressive neurodegenerative disorder

prion: PRP

has spongiform change in intracellular vaculoes

160
Q

pathogenesis of CJD

A

misfolding of the PrP protein allows for its acquisition of infectious characterisitcs

there is a conformational change from the normal alpha helix to an abnormal B helix, and PRPSC accumulated in neural tissue and is associated with amyloid deposition

161
Q

CJD usualy presents in the _ decade and is caused _

there is rapidly progressive dementia with _ and there is a _ month survicial rate. _ changes are microscopic

A

7th decade

ioatrogenic (corneal transplant, brain transpolant)

myoclonus
7 month survivial rate

spongiform

162
Q

what is VCJD?

A

this is a variant of CJD that presented in the UK with a slower progression and associated with bovine spongiform encephalopathy (from cows/ tranfusions)

mad cow disease

they have kuru plaques *aggregates of ABN protein

163
Q

CJD affects the cerebrellum but the _ also in VCJD

A

cortex

can see cortical plaques

164
Q

kuru plaque stain in vCJD

A

congo red and PAS+

  • amyloid
165
Q

what is the fatal familial insomnia variant of CJD

A

codon 129 substitution that results in ataxia, autonomic distubrances, stupor and sleep disturbances

survivial is less than a year

166
Q

what is myoclonus

A

involuntary jerking muscles contractions on sudden stimulation

167
Q

kuru plques are representative of what in CJD and its variants

A

PRPsc (amyloid)

NMSP (13 decks)

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