Cerebrovascular Disease and Infections Flashcards
1
Q
what is the most common route of infection in the CNS
A
hematogenous-arterial
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
3
Q
what are the 4 routes of infection spread in the CNS?
A
- hematogenous
- direct implantation
- local extension
- periopheral nervous system
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)
5
Q
how does local extension of CNS infections spread?
A
through the sinuses, teeth, cranial or spinal osteomyelitis
6
Q
how do CNS infections spread through the PNS
A
via viruses
-examples: Rabies, Herpes
7
Q
what are the parts of the meninges?
A
dura mater, arachnoid, pia (innermost)
8
Q
what produces the meninges, where is CSF located
A
85%- produced by choroid plexus of the lateral third and fourth ventricles
9
Q
there is a complete exhange of CSF every _ hrs because the brain is bathed in bacteria
A
3-4 hrs
10
Q
CSF circulates to the arachnoid space and is absorbed by arachnoid villi along the _ _ sinus
A
superior sagital
11
Q
tuberculus meningitis develops by seeding _ from _ or _ granulomas
A
CSF
subepidural or submeningeal
12
Q
CSF has no _; however _ are in the epidural space
A
lymphatics
lymphatics are in the epidural space
13
Q
infections from the retropharyngeal, posterior mediastinal, or retroperitoneal spaces may produce _
A
spinal epidural abscesses
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
15
Q
Rabies virus binds at or near _ receptors and the _ and ascends to the CNS via _ nerves
A
Acetylcholine receptors
NMJ
Motor
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
17
Q
what is meningoencephalitis
A
meningo- meninges
encephalitis- brain parenchyma
itis- inflammation
**inflamation of the meninges and brain parenchyma
18
Q
what is chemical meningitis
A
non-bacterial irritant in the subarachnoid space from a ruputred cyst or a chemical irritant
19
Q
what is acute pyogenic meningitis
A
inflammation of the meninges due to bacteria
20
Q
what is aseptic meningitis
A
inflammation of the meninges due to a virus
21
Q
what is chronic meningitis
A
inflammation of the meninges due to tuberculosis, spirochestes, or cryptpcoccus
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
23
Q
TB and neurosyphyllis have a predilection for the?
A
base of the brain
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
25
cerebral edema is accelerated by products released by both living and antibiotic lysed _
bacteria
26
Cerebral edema due to bateria is slowed and reversed by _
corticosteroids
27
symptoms of acute meningitis ? (suppurative)
headahce, meningeal irritation signs, high fever, confusion (coma)
28
the full syndrome of meningitis usually develops with several _ but it can develop over a few hours with a _ course
fulminant
29
pneumococcal meningitis is often found where?
convexities near the sagital sinus
30
h. influenzae meningitis is usually found where
basal location
31
acute pyogenic meningitis can lead to ?
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
32
acute meningitis follos the _ vasculature
leptomeningeal
33
pneumococcal meningitis has capsular polysaccharides tha tlead to a particularly gelatinous esudate that encourages
chronic adhesive arachnoiditis
34
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 _
neutrophils
focal cerebritis
35
what are the complications of bacterial meningitis
Meningogoccemia with a rash leading to waterhouse-friederischsen syndrome (b/l adrenal hemorrhage and death)
other complications: seziures, encephalitis, hearing loss, blindness, paralysis
36
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
gram stain
37
lumbar puncture gram stain vs. presumptive ID
gram negative diplococci:
gram positive diplococci:
gram negative pleomorphic:
gram positive cocci:
gram negative bacilli:
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
38
how is a lumbar puncture taken
a spinal needle is inserted between the 3rd and 4th vertebrae
39
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.
blood
last
glucose
bacteria
40
turbid=
chunky
41
Bacterial Menigitis CSF results
Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:
Opening pressure: elevated
Apperance: cloudy/turbid
WBC: greater than 1,000
Cell type: neutrophils
Protein: increased
Glucose: markedly decreased
42
Viral Menigitis CSF Lab values
Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:
Opening pressure: normal
Apperance: clear/colorless
WBC: less than 100
Cell type: lymphocytes
Protein: normal to elevated
Glucose: normal to elevated
43
Fungal/TB meningitis CSF values
Opening pressure:
Apperance:
WBC:
Cell type:
Protein:
Glucose:
Opening pressure: variable
Apperance: variable
WBC: variable
Cell type: lymphocytes
Protein: elevated
Glucose: decreased
44
who has a an increased rosk of meningitis
less than 5
older than 60
diabetes mellitus
immunosuppresion
sinusitis
IV drug use/bacterial endocarditis
Sickle cell anemia patients
45
what is the most common cause of meningitis in newborns (0-6months)
group B strep
E Coli
Listeria
GEL
46
what is the most common cause of menigitis in a child (6mo-6yo)
**Strep pneumoniae**
H. influenza (in the unvaccinated)
Neisseria menigitdis
group B strep
47
what is th emost common cause of meningitis in adolescents/young adults
N. Meningitidis
48
what is the most common cause of meningitis in the elderly
s. pneumoniae and listeria
49
immunosuppressed individuals with purulent meningitis may be due to?
Klebsiella/ anaerobic organisms
50
brain abcess has the same route as?
meningitis (follows the leptomeninge vessels)
51
acute bacerial endocarditis exposed you to _ abcesses
multiple brain
52
congential heart disease like a R to L shunt will cause brain abcesses to form how?
they remove the pulmonary filtration of organisms
53
non immunosuppresed brain absess are usually caused by?
strep or staph
54
presentation of a patient with a brain abcess
the patient will present with progressive focal neurologial deficits and signs on increased intracranial pressure
55
CSF of a brain abcess
high WBC count
high protein
normal glucose
56
complications of a brain abcess
herniation from ICP
rupture with spreading into the ventricles
meningitis
venous sinus thrombosis (patient can die)
57
how do we treat a brain abcess?
drainage and antibiotics
58
what does a brain abcess look like
liquefactive necrosis in the middle surrounded by edema and fibrosis
59
what is a subdural empyema
bacteria or fungus infedction of skull bones or sinuses that spreads to the subdural space
60
subdural empyemas can lead to thrmbophlebitis of the _ vessels
bridging leading to an infarct
61
signs and symptoms of a subdural empyema
similar to an abcess: focal neurological signs, lethargy, coma
62
what is usuallt the residual evidene of a subdual empeyema
thickened dura
63
treatment of a subdrual empyema
drainage
64
extra dural abcesses is usually associated with?
what is it?
associated with osteomyelitis
**abcess in the extradural space: may cause cord compression
65
osteomyelitis often arises from an adjacent focus of _
infection such as sinusitis or following a surgical procedure
66
neisseria meningitdis colonizes the _ and _ of asymptomatic arriers and is spread by direct contact with _ secretions
oropharynx and rhinopharynx
respiratory
67
colonization of neisseria meningitidis has a higher proportion in _ populations
crowded (dorms, prisons)
68
microbiology of neisseria meningitidis
gram negative diplococci with intracellular and extracellular neutrophils
69
what medium does neisseria meningitis grow on?
chocolate agar/chocolate blood agar
70
n. meningitidis is a rapidly progressive _ with a fever, _ and _ with petechial and _ lesions
septicemia
hypotension
purpuric lesions
71
outcome of N. meningitidis
purpura fulminans: hermorrhagic skin lesions
b/l hemorrhage of adrenal glands
72
chronic meningitis symptoms
4+ weeks duration
fever, headache, lethargy, confusions, stiff neck
73
chronic meningitis CSF
elevated proteins (lympocytic)
low glucose level (variable)
74
again what are the causes of chronic menigitis
tuberculosis, Neuroborreliosis, Neurosyhphilis
75
mycobacterium tuberculosis produes a _ meninoencephalitis within the _ space with a gelatnous or fibrinous exudate
diffuse
subarachnoid
76
outcomes of tuberculosis meningitis
obliterative endarteritis
encases cranial nerves and blocks CSF flow - hydrocephalus
tuberculoma
77
what is obliterative endarteritis ?
this is inflammation infiltration in the vessel walls/intemal thickening leading to arterial occlusion and infarction
78
tuberculosis meningitis has predilection for?
base of the brain (arachnoiditis)
79
what is a tuberculoma
intraparenchymal mass that has central caseous necrosis and calcifications
80
in order to test for tuberculosis menigitis you must perform what?
CSF smear- 15% positive
CSF culture-90% positive
a tuberculin test is typically negative
81
chronic meningiis can also be caused by borrelia burdorferi aka neuroborreliosis aka _ _ that has _ symptoms followed by a characteristic _ in about 4 weeks
lyme disease
neurological
rash (bulls eye)
82
what neurological symptoms are seen in lymes disease causing meningitis
cranial nerve palsies, peripheral neuropaties
83
CSF of neuroborreliosis (lymes disease) meningitis
antibodies
84
antibodies in the CSF of lymes disease chronic meningiti can cross react with what other diseases
mono, rhematoid arthritis, lupus, syphillis (can be misdiagnosed)
85
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
tertiary
HIV
86
what are the three types of neurosyphillis
meningovascular
paretic
tabes dorsalis
87
what is meningovascular neurosyphillis
a chronic meningitis that involves the BASE of the brain and results in a communicating hydrocephalus
88
complications of meninovascular neurosyphillis
obliterative endartitis/heubner arteritis
89
what is paretic neurosyphillis
progressive/insidious mental defects with mood alterations known as delusions of grandeur
ends in severe dementia
90
what deposts are in paretic neurosyphillis
iron deposits
91
what is the outcome of paretic neurosyphhillis
granular ependymitis:
proliferation of subependymal glia under a damaged ependymal lining and a communicating hydrocephalus
92
what is tabes dorsalis
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
joint damage in tabes dorsalis is known as
charcot joints (lightening pains)
94
terponema pallidum: neurosphyllis
immunoflourcense
spirochete
95
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 _
organism
enteroviruses
lymphocytic pleoytosis
protein
glucose
## Footnote
usually self limitis
96
pathogenesis of viral meningitis
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
in viral meningitis the brain mounts an inflammatory response with a populaiton of _
lymphocytes
98
most viral meningitis have a _ period
latency
this is important for many several viruses
99
on histology viral encephalitis will show
perivascular lymphocytic cuffs
microglial nodules
100
what is arhropod borne viral encephalitis
a virus in the west nile that causes encephalitis and invloves the spinal cord
101
symptoms of arthropod borne viral encephalitis
spinal cord involvement- polio like syndrome with paralysis
neuro deficits like seziure/confusion
focal signs (occular palsies, reflex asymmetries)
102
CSF of arthropod borne viral encephalitis
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
histology of arthropod borne viral encephalitis
foci of necrosis
neuronophagia
microglial nodules
104
what is neuronophagia
single- cell neuronal necrosis with phagocytosis of the dbris
## Footnote
macrophages surround it
105
what are micoglial nodules
small aggregates around foci of necrosis
## Footnote
lymphs and microglial cells
106
HSV 1 is common in population?
children and young adults
107
symptoms of HSV 1
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
inclusions in HSV 1
cowdry type A
109
HAV2 is common in
neonates born by vaginal delvery to women with active HSV
110
in HSV1 encephalitis of the _ lobe and destruction of the _ _
temporal lobe
cingulate gyrus
111
HSV has _ inclusions, _ of chromatin, and ground glass _ nuclei
intranucelar
margination
multinucelated
112
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
## Footnote
encephalitis
chickenpox
latent
trigeminal
shingles
113
what is post neuralgia syndrome
persistant pain as well as painful sensation following non painful stimuli in a person with shingles (can cause encaphalitis)
114
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 _
infants
immunocompromised
AIDs
periventricular
MICROencephaly
calcification
115
CMV encephalitis localised in the _ _ regions and causes seere heorrhagic necrotitzing _encephalitis and choroid plexitis.
paraventricular subependymal regions
ventriculoencephlitis
116
CMV also also radiculoceritits which is ?
inflammation of the spinal nerve roots
117
what kinds of inclusions are in CMV
intranuclear and intracytoplasmic
## Footnote
severe destruction of brain parenchyma
118
most cases of Polio have been erradicated by _ but a novel strain of enterovirus _
vaccination
D68
119
Polio is a _ virus that spreads through _-_ contamination
RNA
fecal-oral
120
what is the pathogenesis of poliomyeltitis
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)
## Footnote
can cause encephalitis
121
what is post polio syndrome
this is 25-30 years after an initial polio infection that presents with decreased muscle mass and pain
122
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
lyss
1-3 months
peripherial nerves
parathesias around the wound
123
symptoms of rabies
flaccid paralysis leading to respiratory center failure
violent motor responses and convulsions due to essxtraordinary CNS excitability
hydrophobia ( foaming at the mouth)
## Footnote
pins and needles at the site of a bat bite
124
what causes hydrophobia in rabies
contracture of the pharyngeal muscles that produces aversion to swallowing
125
how would you describe the rabies virus
bullet proof shape
126
histology of rabies virus (can lead to encephalitis)
negri bodies
in the purkinje cell (eosinophilic)
## Footnote
negri bodies are also seen in pyrimidal neruons of the hippocampus
127
HIV causes a _ meningitis that can be acute or chronic describe
aseptic
acute: perivascular inflammation
Chronic: microglial nodules with multinucleated giant cells
128
the vessels in HIV aseptic meningitis look?
abndomal with prominent endothelial cells and perivascular pigmented macrophages
129
the white matter in HIV aspectic meningitis looks
has myelin pallor and axonal swelling and gliosis
130
types of HIV aspectic meningitis
IRIS
HAND
131
with is IRIS
immune reconstiution inflammatory syndrome
(paradoxical deterioraiation after starting antiviral medication)
## Footnote
HIV aseptic meningitis
132
what is HAND
HIV associated neurocongitive disorders
which is HIV ssociated dementia with cognitive changes depsite treatment for HIV
133
HIV also is associated with increased incidence of ?
Primary CNS lymphoma
(this is most commonly an EBV+ B cell tumor)
134
histology of HIV encephalitis
a multinucleated giant cells WITHIN a microglial nodule
135
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 _
immunosuppression
oligodentrocyte
demyelination
immunusuppressed
subcortical
lipid laden macrophages
axons
136
immunosuppressive states
HIV, monocolonal antibody therapy, granulomatous diseases, chemotherapy
137
what stain can be done on PML
Myelin stain
## Footnote
glassy viral inclusions
138
what is subacute sclerosing panencephalitis (SSPE)
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
pathogenesis of SSPE
gliosis and myelin degeneratio nwith viral inclusions in the nuclei of oligodentrocytes and neurons there are also inflammation and neurfibrillary tangles
140
measles spreads through
air respiratory droplets
viral symptoms- rash (flat red spots)- hairline and spread downward + fever
141
fungal meningoencephalitis is primarily in _ patients and spreads _
immunocomprommised
hematogenously
142
diabetes mellitus fenal meningoencephalitis _ with direct extension
mucormycosis
143
what funcal meningoenceplitis can cause vasculitis
mucormycosis, asperiglliosis and candidia occasionally
vasculitis leads to thrmobosis of the vessels and infacrtion
144
endomeic pathogens that cause funcal meningoencephalitis
histoplasma, coccidoioces, blastomyces
145
fungal meningoencephalitis causes of parenchymal infection
candidia, and cryptococcus
146
cyrptococcous meningitis is associated with
aids
can be fulminant and fatal
147
causes of fungal meningoencephalitis
candida, mucor species, aspergillus fumigatus and cyrptococcous neoformans
148
mucormycosis is known as _ fungus and spreads from the_
black fungus
sinuses (runny nose, ne sided facial swelling, headache, fever, blurred vision)
149
cyrptococcus neofromas CSF findings
histology findings
CSF: india ink perparation with the cyrptococcal polysaccardie antigen
histologyL cyrptococcal soap bubbles
150
cyrotococcus neoformans spreads to the
perivascualr spaces (virchow-ribin spaces)
## Footnote
cyrtococcous gatti is in immunocompetent individuals
151
what stain can we do on tissue selection for cyptococcous neofromans
muscicarmine stain
152
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
HIV
gray-white
deep gray nuclei
ring enhancing lesions
petechial hemorrhages
tachyzoites and encysted bradyzoites
153
what protazoes cause central amebiasis
naegleria fowleri
acanthomeoba
154
what protazoa causes cerbral malaria
plasmodium falciparum
155
what is naefleria fowleri
a brain eating ameba that infects people through contaminated freshwater by entering the nose
156
what is acanthamoeba
a chronic granulomatous meningoencephalitis
157
what is plasmodium falciparum
this is a protazoa that results in long term congitivie defects and decreased blood flow
## Footnote
look up when this question comes up
158
what causes a rash on the palms and soles
HFMD
Kawasaki dz
rocky mountain spotted fever
secondary syphillis
159
what is creutzfeldt- jakob disease
abnormal forms of cellular proteins that results in a rapidly progressive neurodegenerative disorder
prion: PRP
has spongiform change in intracellular vaculoes
160
pathogenesis of CJD
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
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
7th decade
ioatrogenic (corneal transplant, brain transpolant)
myoclonus
7 month survivial rate
spongiform
162
what is VCJD?
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
CJD affects the cerebrellum but the _ also in VCJD
cortex
## Footnote
can see cortical plaques
164
kuru plaque stain in vCJD
congo red and PAS+
- amyloid
165
what is the fatal familial insomnia variant of CJD
codon 129 substitution that results in ataxia, autonomic distubrances, stupor and sleep disturbances
survivial is less than a year
166
what is myoclonus
involuntary jerking muscles contractions on sudden stimulation
167
kuru plques are representative of what in CJD and its variants
PRPsc (amyloid)
