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Adams 10th Ed > Chap 32-33: Infection of the CNS > Flashcards

Chap 32-33: Infection of the CNS Flashcards

1
Q

Two pathways by which infection reaches intracranial structures.

A

1) Hematogenous spread

2) Contiguous spread

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2
Q

Two pathways by w/c infection from ear or sinuses causes intracranial CNSi

A

1) infected thrombi form in diploic vein spread thru dural sinuses
2) osteomyeletic focus

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3
Q

In adult most common pathogenic organism:

A

1) Streptococcus pneumoniae
2) Neisseria meningitidis
3) Haemophilus influenzae (unvaccinated)
4) Listeria monocytogenesis
5) Staphylococcus

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4
Q

In neonate, pathogenic organism to consider

A

1) E. coli

2) group B streptococcus

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5
Q

To determine likely organism one must consider the ff:

A

1) age
2) clinical setting (community-acquired, nosocomial, post-surgical)
3) Immune status
4) Systemic and local cranial disease

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6
Q

First reaction to bacteria or toxin in the brain

A

Hyperemia of the meningeal venules and capillaries w/ inc permeability of vessels

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7
Q

Predominant cells in bac men during the first few days

A

Neutrophils w/ phagocytosed bacteria

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8
Q

After few days after the neutrophils inc the following occurs

A

Inc of lymphocytes and histiocytes

Exudation of fibrinogen then become fibrin

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9
Q

T/F. Process of resolution, inflammatory cells disappear in almost reverse order as they had appear.

A

TRUE

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10
Q

Hydrocephalus from meningeal reaction occurs due to

A

First purulent exudate around the base

Later by meningeal fibrosis

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11
Q

Three most common bacteria causing meningitis

A

1) S. pneumoniae
2) N. meningitides
3) H. influenzae
4) Listeria

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12
Q

Bacterial organism due to LP, spinal anesthesia, or shunting.

A

Pseudomonas

Enterobacteriaceae

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13
Q

Should be suspected in extremely rapid evolution w/ assoc petechial or purpuric rash and circulatory shock

A

Meningococcal meningitis

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14
Q

Rapid decline of the incidence of the bacterial organism due to vaccination

A

H. influenzae

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15
Q

Meningitis often preceded by infection in the lungs, ears or heart valves.

A

Pneumococcal meningitis

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16
Q

Meningitis follows URTI and ear infection in unvaccinated child

A

H. influenzae

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17
Q

Focal cerebral signs in early stages occur most frequently in

A

Pneumococcal

H. influenzae

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18
Q

Seizures in bac men is mostly encountered in

A

H. influenzae meningitis

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19
Q

Persistent focal cerebral lesion or intractable sz develops in 2nd week of infection due to

A

infectious vasculitis

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20
Q

In infants and neonates this may suggest presence of meningeal infection

A

fever, irritability, dec sensorium, vomiting, convulsions, bulging fontanels

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21
Q

Keys to early diagnosis of bac men

A

High index of suspicion

Liberal use of LP

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22
Q

Most significant factor in pathogenesis of meningitis in neonates

A

Maternal infection (UTI or peurperal fever)

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23
Q

In infants w/ meningitis, one must consider to find

A

Subdural effusion

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24
Q

T/F. Aspirated subdural effusions after bacterial meningitis are proven to be sterile

A

TRUE

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25
Q

Indespensible part of the examination of patients w/ symptoms and signs of meningitis due to high index of suspicion

A

Lumbar puncture

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26
Q

T/F. Tonsillar herniation may occur in fulminant meningitis independent of LP

A

TRUE

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27
Q

Pressures over ____mm H20 suggest presence of brain swelling and potential for cerebellar herniation

A

350

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28
Q

CSF w/ cell counts more than 50,000/mm3 raise the possibility of

A

brain abscess rupturing in the ventricles

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29
Q

Hemorrhagic CSF may occur in meningitis of

A 
Anthrax meningitis
Hantavirus
Dengue
Ebola
Amebic meningoencephalitis
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30
Q

Caveat in interpreting glucose CSF/serum ratio of less than 40%

A

Serum glucose should be less than 250mg/dL

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31
Q

Nigrovic criteria that may predict likely of low risk of bac men if the ff are absent

A

1) positive CSF gram stain
2) CSF absolute PMN count of >1000 cell/mL
3) CSF protein >80m/dL
4) Blood count PMN of >10,000
5) hx of sz at or after time of presentation

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32
Q

Cultures of the spinal fluid prove to be positive by how may percent in bac men

A

70-90%

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33
Q

Particularly useful in dx px w/ partially tx bac men by detecting bacterial antigens

A

CIE

Latex-particle agglutination test

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34
Q

Infrequently used in testing bac men but can be diagnostic and prognostic

A

LDH
LDH fractions 4 and 5 (high in meningitis produced by granulocytes)
LDH fractions 1 and 2 (high if there is neurologic sequelae or later die)

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35
Q

Positive in 40-60% of patients w/ H. influenzae, meningococcal, pneumococcal meningitis and provide clue as to the causative agent

A

Blood cultures

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36
Q

One should suspect in a patient w/ recurrent bacterial meningitis

A

Fistula / Sinus tracts

CSF rhinorrhea

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37
Q

Most specific and sensitive test for CSF leak

A

Beta2-transferrin test

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38
Q

T/F. Viral meningitis is far common than bacterial meningitis

A

TRUE

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39
Q

Nonbacterial meningitis when cultures are negative but may have reduction of glucose conc

A

EBV infection
Bechet disease
Mollaret meningitis
Vogt-Koyanagi-Harada Syndrome (iridocyclitis, psoriasis)

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40
Q

Empiric therapy for bac men in 0-4 weeks old

A

Cefotaxime plus ampicillin

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41
Q

Empiric therapy for bac men in 4-12 weeks old

A

3rd gen cephalosporin plus ampicillin (plus dexa)

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42
Q

Empiric therapy for bac men in 3mos - 50 y/o

A

3rd gen cephalosporin plus vancomycin (+/- ampicillin)

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43
Q

Empiric therapy for bac men in >50 y/o

A

3rd gen cephalosporin plus vancomycin plus ampicillin

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44
Q

Empiric therapy for bac men in immunocomporomised state

A

Vanco plus ampicillin plus ceftazidime

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45
Q

Empiric therapy for bac men in basilar skull fracture

A

3rd gen cephalosporin plus vancomycin

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46
Q

Empiric therapy for bac men in head trauma, neurosurgery CSF shunt

A

Vanco plus ceftazidime

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47
Q

Reason why ampicillin is added in immunocompromised state

A

Cover for Listeria

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48
Q

Duration of bac men treatment

A

10-14 days

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49
Q

Persistence of fever, or late appearance of neurologic deficits should raise the suspicion of

A 
subdural effusion
mastoiditis
venous sinus thrombosis
cortical vein phlebitis
brain abscess
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50
Q

In children particularly w/ H influenzae, use of dexamethasone results to

A

Less sensorineural deafness or neurologic sequelae BUT mortality NOT affected

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51
Q

Dose/ administration of dexamethasone in bac men for children

A

0.15mg/kg qid x 4 days

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52
Q

In adults, esp w/ pneumococcal meningitis, use of dexamethasone results to

A

Mortality REDUCTION and improved overall outcome

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53
Q

Dose/ administration of dexamethasone in bac men for adults

A

Dexa 10mg QID x 4 days, first dose prior to antibiotics

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54
Q

Value of repeat lumbar puncture

A

if px is worsening w/o explanation

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55
Q

Meningococcal prophylaxis

A

Ciprofloxacin single dose
Rifampin 600mh q12h (adults) or 10mg/kg q12h (children) for 2 days
NO PROPHYLAXIS if >2 weeks has elapsed since exposure

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56
Q

Rate of mortality for meningitis of :
H. influenzae
Meningococcal
Pneumococcal

A

5% (H. influenzae, Meningococcal)

15% Pneumococcal

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57
Q

One to consider if w/ meningococcemia w/ shock

A

Waterhouse-Friderichsen syndrome

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58
Q

Osler triad

A

Pneumococcal meningitis, pnuemonia, endocarditis

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59
Q

Neurologic sequelae occurs in ____ % in H. influenzae and ____ % in pneumococcal meningitis

A

25%

30%

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60
Q

In bacterial meningitis, the independent predictor of later sz is

A

presence of neurologic deficit

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61
Q

Deafness in meningitis is a result of

A

Suppurative cochlear destruction

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62
Q

Three common pathogens causing BACTERIAL ENCEPHALITIS

A

Mycoplasma pneumoniae
L. monocytogenes
Legionnaires disease

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63
Q

This bacterial encephalitis may present as rhombencephalitis

A

L. monocytogenes

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64
Q

Treatment of L. monocytogenes

A

Ampicillin (2g q4h) plus gentamicin (15mk TID)

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65
Q

Similar to Listeria but seen in India ans SEA, prone among diabetics, w/ chances of relapse

A

Melioidosis (Burkholderia pseudomallei)

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66
Q

Bacterial encephalitis w/ severe diffuse involvement of cerebrum, cerebellar or brainstem. CSF and CT seems normal. w/ tx using fluroquinolones.

A

Legionella

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67
Q

Exceptional feature of Anthrax meningoencephalitis

A

Hemorrhagic and inflammatory spinal fluid formula

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68
Q

Encephalitis presenting as slowly progressing memory or dementia assoc w/ wt loss, fever, anemia, steatorrhea, abdominal pain, athralgia, lymphadenopathy, hyperpigmentation.

A

Whipple disease

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69
Q

During the height of systemic bacterial or viral infection, the child sink to dec sensorium w/ neck supple, and CSF no changes, term is used for obscure cause

A

Acute toxic encephalopathy

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70
Q

Usual accompaniment of subdural empyema

A

Thrombosis of underlying cortical veins or sinuses

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71
Q

Usual origin of infection of subdural empyema

A

Frontal or ethmoid sinuses; hardly ever as bacteremia or septicemia

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72
Q

Tx of subdural empyema

A

Surgery plus antibiotics (ceftazidime plus metronidazole)

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73
Q

Focal sz or may involve 5th and 6th CN due infection of petrous part of temporal bone

A

Gradenigo syndrome

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74
Q

Usual involvement in intracranial septic thrombophlebitis

A

Transverse sinus
Cavernous sinus
Petrous sinus

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75
Q

Pathogens incriminated for intracranial septic thrombophlebitis

A

Streptococci and staphylococci

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76
Q

Brain abscess is always usually secondary to bacteremia particularly

A

Purulent pulmonary infections
Bacterial endocarditis
Ear infections

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77
Q

Children more than ___% of cerebral abscess are assoc w/ CHD

while ___% of CHD are complicated w/ brain abscess

A

60%

5%

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78
Q

Most common CHD implicated for brain abscess

A

Tetralogy of Fallot

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79
Q

Most common organism causing cerebral abscess

A

Virulent streptococci

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80
Q

In brain abscess, pus and proliferation of adventitia of blood vessels, evident in DWI of MRI occur by

A

2 weeks

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81
Q

T/F. Abscess is not uniform in thickness, it has thinner lateral aspect

A

FALSE. Medial aspect is thinner

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82
Q

Size of abscess that may produce positive scan

A

> 1cm

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83
Q

Brain abscess in MRI

A

T1: capsule enhances, hypointense interior w/ restricted diffusion
T2: surrounding edema, hypointense capsule

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84
Q

Surgical approach for brain abscess if:
solitary, superficial and encapsulated
Deep abscess

A

Total excision (superficial)

Aspiration (deep)

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85
Q

Percent Mortality in brain abscess if px is
Comatose
Alert

A

50% (Comatose)

5-10% (Alert)

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86
Q

Neurologic sequelae in brain abscess occurs by

A

30%

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87
Q

Two stages of TB men

A

1) Bacterial seeding in meninges and subpial region forming tubercles
2) Rupture of tubercles and discharge of bacteria

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88
Q

Early manifestation of TB men in
50% of cases
75% of cases

A

50% of cases: fever, malaise, headache

75% of cases: lethargy, confusion, stiff neck

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89
Q

Approximately, ____ of TB men have active TB in other parts

A

2/3

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90
Q

When to start HIV meds upon onset of anti-Kochs medication?

A

W/in 2 weeks

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91
Q

TB PCR of CSF have sensitivity of

A

80% w/ 10% false positive rate

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92
Q

Self-limiting form of meningitis in prevalent tuberculosis countries showing modest pleocytosis, normal or elevated protein, normal glucose

A

Tuberculous Serous Meningitis

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93
Q

Most frequent intracranial tumors among children in tropical countries

A

Cerebellar tuberculomas

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94
Q

Treatment meds and durations of TB men

A

HRZE x 2 mos

HR x 9-12 mos

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95
Q

Anti-Kochs drugs w/ highest to penetrate the BBB

A

INH

PZA

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96
Q

Treatment dose of Anti-Kochs in TB men

A

INH: 5mg/kg
RMP: 10mg/kg
EMB: 15mg/kg
PZA: 20mg/kg

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97
Q

Important adverse effects of INH

A

Hepatitis

Neuropathy

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98
Q

Important adverse effects of EMB

A

Optic neuropathy

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99
Q

Important adverse effects of PZA

A

Rash, GI disturbance, hepatits

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100
Q

In Vietnam study on corticosteroids and TB men, the outcome showed

A

Reduced mortality BUT no effect on disability

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101
Q

Dose of Dexamethasone in TB men

A

0.4mkd for a week then taper slowly from 3-6 weeks

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102
Q

Overall mortality of TB men is ____%
w/ HIV infected px higher around ____%
when Coma supervenes ____ %

A

10%
21%
50%

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103
Q

Neurologic sequelae occurs in TB men by

A

20-30%

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104
Q

Essential lesion in sarcoidosis

A

focal collections of epitheloid cells surrounded by lymphocytes and giant cells BUT caseation is LACKING found in all organs

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105
Q

Cranial nerve most frequently involved in sarcoidosis

A

Facial nerve

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106
Q

Diagnosis of neurosarcoidosis is based on

A

Clinical features

Biopsy evidence in other organs

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107
Q

Serum levels of this is increased in sarcoidosis

A

Angiotensin-converting enzyme

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108
Q

Main therapy of sarcoidosis

A

Corticosteroids (Prednisone 40mg x 2weeks, then 5mg tapering q 2weeks until reaching 10-15mg/d then maintain for several months)

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109
Q

Initial event in neurosyphilitic infection is ____ in 25% of all cases

A

Meningitis

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110
Q

Treponeme invades the CNS w/in ____ of inoculation w/ organism

A

3-18 mos

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111
Q

If CSF is negative by:
2nd yr chances are ____ to have neurosyphillis
5th yr chances are ____ to have neurosyphillis

A

5%

1%

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112
Q

All forms of neurosyphillis begin as

A

meningitis

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113
Q

Clinical forms of Neurosyphillis
Early clinical syndrome
Secondary syndrome
Tertiary syndrome

A

Early clinical syndrome: Aseptic meningitis & meningovascular
Secondary syndrome: Vascular syphillis (1-12 yrs)
Tertiary syndrome: General paresis, tabes dorsalis, optic atrophy, subacute myelitis

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114
Q

Clinical standpoint the most impt form of neurosyphilis

A

asymptomatic form, hence all px w/ syphilis should have as spinal fluid exam

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115
Q

T/F. Neurosyphilis clinical syndromes mostly exist in pure form of each

A

FALSE. Mostly are combination w/ one predominating

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116
Q

T/F. The clinical syndromes and pathologic reactions of congenital syphilis are similar to those late-acquired type

A

TRUE, they only vary by age

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117
Q

Sensitive indicator of the presence of active neurosyphilitic infection

A

CSF exam

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118
Q

CSF formula of Neurosyphilis

A

1) pleocytosis up to 100cell/m3, mostly lymphocytes (lower for AIDS px)
2) elevation of TP 40-100mg/dL
3) inc IgG w/ oligoclonal banding
4) positve serologic test

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119
Q

Gamma globulin represents in neurosyphilis as

A

specific antibody response to the organism

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120
Q

CSF changes once remission of neurosyphillis occurs in order

A

1) cells disappear first
2) TP returns to normal
3) Gamma globulin reduced
4) Serologic test last to revert to normal

121
Q

CSF changes that precedes or accompanies clnical relapse in neurosyphilis

A

Return of cells and elevation of protein

122
Q

T/F. Reagin tests (Kolmer or VDRL), if positive in CSF is virtually diagnostic of neurosyphilis

A

TRUE

123
Q

Serum reactivity alone for reagin tests w/o CSF means

A

Past exposure of syphilis but does not imply neurosyphilis

124
Q

T/F. Serum reagin tests are always positive in late syphilis or those w/ neurosyphilis

A

FALSE. Negative in majority

125
Q

If suspected false positive for reagin test, FTA-ABS if positive in serum means

A

practically have neurosyphilis

126
Q

Most reliable but expensive difficult to perform and available in few labs to diagnose syphilis

A

TPI (T. pallidum immobilization)

127
Q

Abnormal pupils that are unreactive to light but constricts w/ accomodation seen in asymptomatic neurosyphilis

A

Argyll Robertson pupils

128
Q

Meningeal syphilis occurs typically when

A

First 2 years

129
Q

The most common form of neurosyphilis nowadays, main manifestation for secondary syphilis

A

Meningovascular form

130
Q

Meningovascular syphilis typically occurs around

A

6-7 yrs, but can be early as 9 mos

131
Q

Pathologic changes of meningeal infiltration AND inflammation and fibrosis of small arteries known as

A

Heubner arteritis

132
Q

Paretic neurosyphilis occurs around ____ from original infection

A

15-20 yrs

133
Q

Form of neurosyphilis presenting as progressive dementia, dysarthria, myoclonic jerks, action tremors, sz, UMN signs, Argyll robertson pupils

A

General paresis

134
Q

Pathologic changes in general paresis form of neurosyphilis

A

Meningeal thickening
Brain atrophy
Secondary ventricular enlargement
Granular ependymitis

135
Q

Expected mental decline and death occurs in general paresis

A

3-4 yrs

136
Q

Major symptoms of tabes dorsalis

A

Lightning pain, ataxia, urinary incontinence, absent DTRs of lower ext, impaired position and vibration sense, romberg sign.

Argyll Robertson pupils in 90% of cases & optic atrophy

137
Q

Pathologic changes in the tabes dorsalis

A

Thinness and grayness of posterior roots in lumbosacral and thinning of spinal cord due to degeneration of posterior column

138
Q

Tx of Neurosyphilis

A

Pen G 3-4 MU q4h x 10-14 days

Alternatives: procaine penicillin, probenecid, ceftriaxone

139
Q

Lightning pains for neurosyphilis respond to

A

Gabapentin and CBZ

140
Q

Monitoring of pxs w/ neurosyphilis

A

Px re-examined q3-6 mos
CSF retested q 6 mos interval

ONCE cleared, another follow up after 12 mos w/ LP

141
Q

T/F. A weakly positive serologic VDRL test after cells and protein levels return to normal constitutes re-treatment

A

FALSE.

142
Q

Erythema chronicum migricans (migrating skin lesion) followed by acute radicular pain, chronic lymphocytic meningitis, peripheral or cranial neuropathies

A

Lyme disease (Borrelia burgdorferi)

143
Q

Lyme disease involves the ff organs

A

Skin
Nervous system
Heart (myocarditis, pericarditis, AV block)
Joints

144
Q

Most frequent cranial neuropathy in Lyme disease

A

Facial palsy

145
Q

Severe painful meningoradiculitis of cauda equina paraticulary characteristic of Lyme infection in Europe

A

Banwarth syndrome

146
Q

Most valuable screening for Lyme disease

A

ELISA

147
Q

Pragmatic diagnostic criteria for Neuroborreliosis

A

present in 4 of 5:

1) no past hx of neuroborreliosis
2) active CSF ELISA serology
3) anti-Borrelia antibody index greater than 2
4) favorable outcome after antibiotic tx
5) no alternative dx

148
Q

Treatment of Lyme disease

A

Doxycycline (100mg BID) x 14 days (rashes, CN palsy alone)

Ceftriaxone (2g OD) x 14 days, (CNS involvement)

149
Q

Type of meningitis in Leptospirosis

A

Aseptic meningitis

150
Q

The dx of fungal infection lies on two lines of clincal info

A

1) evidence of infection in other organs

2) subacute meningeal or multifocal encephalitic d/o

151
Q

Fungal infections tend to occur in px w/

A

Leukopenia
T-lymphocyte inadequate
Insufficient antibodies

152
Q

T/F. CSF formula for fungal meningitis among AIDS px maybe normal or minimal pleocytosis

A

TRUE

153
Q

CSF exam should include this aside from fungal studies

A

TB meningitis, leukemia/ lymphoma (as they may concur)

154
Q

Usual portal of entry for cyptococcosis

A

Respiratory tract

155
Q

Cryptococcosis occurs in AIDS px by

A

6-12%

156
Q

Test for cryptococcosis that is distinctive and diagnostic esp in AIDS px since CSF maybe normal

A

India Ink (positive in 75% of cases)

157
Q

Test for cryptococcosis when negative excludes it in AIDS px.

A

CALAS

158
Q

Medium where cyptococcus is grown

A

Sabouraud glucose agar

159
Q

Tx of Cryptococcal meningitis

A

Amphotericin B (0.7-1 mg/k/d) X 6 weeks until CSF culture is negative

160
Q

Addition of this drug to Ampho B results to fewer relapse

A

Flucytosine x 6 weeks until CSF culture is negative

161
Q

Drug regimen for crypto in AIDS px

A

Ampho B plus flucytosine x 2 weeks

Fluconazole x 1 yr to prevent relapse

162
Q

Fungal infection presenting as chronic sinusitis (sphenoidal), w/ base of skull osteomyelitis affecting adjacent intracranial structures resulting to infectious vasculitis

A

Aspergilosis

163
Q

Malignant infection of cerebral vessels occuring in diabetic pxs. drug addicts, hematologic malignancy presenting similar to Cavernous sinus thrombosis

A

Mucormycosis

164
Q

Most common cause of focal cerebral lesion among AIDS pxs

A

Toxoplasmosis

165
Q

Diagnostic criteria of Toxoplasmosis

A

Clinical syndrome
Radiographic feature
Elevated IgG titers of Toxo

166
Q

Tx of Toxoplasmosis

A

Co-trimoxazole x 6 weeks

Prophylaxis also with it among AIDS until CD4 count exceeds 250 x 6 mos

167
Q

Amoebic meningoencephalitis usual pathogen

A

Naegleria

168
Q

Cerebral malaria is typically caused by

A

Falciparum malaria

169
Q

Neurologic symptoms occur in malaria around____

AND the ones susceptible to it are ____

A

2nd-3rd week

Children in hyperendemic areas

170
Q

Leading cause of epilepsy and other neurologic problem in South America and India

A

Cysticercosis

171
Q

Cysticercosis is caused by

A

larval or intermediate stage of Taenia solium (pork tapeworm)

172
Q

Most common schistosoma involving nervous system

A

S.japonicum

173
Q

Organism for schistosoma w. tendency to localize in
Cerebrum
Spinal cord

A

Cerebrum: S. japonicum

Spinal cord: S. mansoni

174
Q

Tx of neuroschistosoma

A

Praziquantel plus corticosteroids

175
Q

Route of entry of viruses:
Mumps, measles, VZV:
Polioviruses / Enterovirus:
HSV :

A

Mumps, measles, VZV: Respiratory
Polioviruses / Enterovirus: oral-intestinal
HSV : mucosa / genital

176
Q

HSV, VZV and rabies, through peripheral nerve through what mechanism

A

Retrograde axoplasmic transport system

177
Q

Clinical syndrome of viruses

A

1) Acute aseptic meningitis
2) Recurrent meningitis
3) Acute encephalitis / meningoencephalitis
4) Ganglionitis
5) Chronic nervous tissue invasion by retrovirus
6) Poliomyelitis
7) PML or SSPE
8) Prions

178
Q

Bacterial causes of aseptic meningitis

A

Mycoplasma
Q fever (Ricketts)
Leptospirosis

179
Q

Clinical syndrome of aseptic meningitis

A

Headache, fever, meningeal signs, Lymphocyte pleocytosis w/ normal glucose

180
Q

Causes of aseptic meningitis in decreasing frequency

A

1) Enterovirus
2) HSV-2
3) Varicella`

181
Q

Virus associated w/ Mollaret meningitis

A

HSV-1 (more common) & HSV-2

182
Q

Fifth disease in children is caused by

A

Parvovirus

183
Q

Nonviral causes of aseptic meningitis and recurrent meningitis

A

1) Parameningeal infection (epidural abscess)
2) Partially tx bac men
3) Difficult to isolate organisms (TB / fungal/ syphilis)
4) Neoplastic invasion
5) Granulomatous, vasculitic, inflammatory dz
6) Chemical / allergic meningitis

184
Q

Associated w/ chronic neutrophilic meningitis

A

Fungal (Nocardia, Aspergillus, Actinomyces)

Mycobacterium

185
Q

Aseptic meningitis, bladder failure, vaginal or vulvar pain associated w/ HSV2

A

Elsberg syndrome

186
Q

Acute recurrent inflammatory CNS disease of small blood vessels assoc w/ ulcers in Middle Eastern origin

A

Bechet disease

187
Q

Core syndromes of Encephalitis syndrome

A

Seizures, alteration of sensorium, aphasia, hemiparesis, UMN signs, abn movt

188
Q

HSV encephalitis has selective damage in

A

Inferomedial temporal lobe

Frontal lobe

189
Q

T/F. Diffrentiation between viral and ADEM is NOT possible in clinical grounds

A

TRUE

190
Q

T/F. Postexanthematous and post-vaccinal are essentially forms of ADEM

A

TRUE

191
Q

Most common sporadic cause of encephalitis w/ no seasonal or geographic predeliction

A

HSV encephalitis

192
Q

Age distribution of HSV encephalitis

A

Skewed and biphasic
Between 5-30 y/o
Older than 50 y/o

193
Q

The most common encephalitis outside North America

A

Jap B encephalitis

194
Q

Most common viral infection among AIDS px

A

CMV

195
Q

Usual histopathologic hallmarks of viral encephalitis

A

1) Perivascular cuffing of lymphocytes and mononuclear cells

2) Patchy infiltration of meninges

196
Q

Most common viral cause of Herpes Simplex Encephalitis in
Adults
Neonates

A

Adults: HSV-1
Neonates: HSV-2

197
Q

Characteristic pathologic findings in HSV encephalitis

A

Intense hemorrhagic necrosis of inferomedial temporal lobe and medioorbital frontal lobe

198
Q

Characteristic localization of lesion in HSV encephalitis is explained by

A

Route of entry where reactivation in trigeminal nerve then spreads along fibers supplying the anterior and middle cranial fossae

199
Q

EEG finding highly suggestive of HSV encephalitis

A

Lateralized periodic discharges in temporal regions and slow-wave complexes at 2-3/sec interval

200
Q

T/F. CT scan can show hypodensity in temporal lobes in HSV encephalitis in 2/3 of cases

A

TRUE. MRI very sensitive

201
Q

Useful test in diagnosis of HSV encephalitis while virus is replicating in the first few days w/ 98 % sensitivity

A

PCR

202
Q

T/F. Antiviral treatment does not appear to affect HSV PCR results

A

TRUE

203
Q

False negative test likely occurs in first ____ hrs of febrile infection

A

48

204
Q

Tx for HSV encephalitis

A

Acyclovir (30mkd) x 10-14 days

205
Q

Relapse of HSV after acyclovir tx is seen among

A

Children, rarely in adults

206
Q

Mortality and morbidity in HSV encephalitis is governed by

A

1) Age
2) State of consciousness
3) Time of institution of acyclovir

207
Q

90% survival w/ acyclovir tx in alert px was seen upon giving it w/in

A

4 days

208
Q

Duration of AED in HSV encephalitis

A

One year or more then judge risk upon d/c:
Further sz
EEG abn
Exposure to danger situations (eg driving)

209
Q

Most common rabid species in USA
Wild:
Domestic:

A

Wild: racoons, skunks, foxes, bats
Domestic: Dogs, cats

210
Q

Incubation period of rabies virus

A

20-60 days (shorter as 14 days)

211
Q

Characteristic initial manifestation of rabies

A

Tingling or numbness at site of bite (inflammatory response once reaches sensory ganglion)

212
Q

Characteristic pathologic finding in rabies

A

Negri bodies prominent in pyramidal cells of hippocampus and purkinje cells

213
Q

Focal collections of microglia in rabies is called

A

Babes nodules

214
Q

After a bite of a healthy animal, surveillance of animal for ____ days is necessary

A

10

215
Q

Tx of Rabies bite

A

Post-exposure prophylaxis of HRIG 20u/kg around bite and half via IM and active immunization

216
Q

Two forms of active immunization of Rabies and difference

A

DEV (allergic encephalomyelitis and 23 doses)

HDCV (less allergic rxn w/ 5 doses at 0-3-7-14-28 days)

217
Q

Acute cerebillitis in children is commonly associated w/

A

VZV

218
Q

Common agent of shingles / herpes zoster

A

VZV

219
Q

Pathologic changes assoc w/ VZV

A

1) Inflammatory rxn of sensory ganglia
2) Inflammatory rxn in spinal roots and contiguous peripheral nerve
3) Poliomyelitis (rare)
4) Mild leptomeningitis

220
Q

Pathogenesis of herpes zoster

A

Spontaneous reactivation of VZV that was latent in the sensory ganglia due to waning immunity

221
Q

VZV primarily localized in

A

Trigeminal and thoracic ganglion cells

222
Q

Vesicular eruption is preceded by

A

Itching, tingling, or burning sensation of dermatome

223
Q

Usual duration of:
Vesicles
Pain and dysesthesia

A

Vesicles: 5-10 days

Pain and dysesthesia: 1-4 weeks

224
Q

Characteristic herpetic nature of skin eruption showing multinucleated giant cells in base of early vesicles

A

Tzanck smear

225
Q

Most common site of shingles in 2/3 of cases

A

T5-T10 dermatome

226
Q

Complication of VZV, histologically similar to granulomatous angitis and Wegener granulomatosis, presenting as focal neurologic sign after ophthalmic zoster

A

Zoster angitis

227
Q

Important inception of shingles

A

Attenuated live vaccine for adults >60 y/o

228
Q

Antiviral agents that shortens duration of pain and speeds healing of vesicles

A

Famciclovir (500mg TID x 7 days)
Valacyclovir (2g QID)
Acyclovir

229
Q

Drug of choice for preventing postherpetic pain

A

TCA drugs

230
Q

Drug of choice for postherpetic pain

A

Amitriptyline 50mg ODHS

Capsaicin ointment

231
Q

HIV infection result to reduction of what cell

A

CD4 cells (T-helper cells)

232
Q

Later stages of HIV, most common neurologic complication is

A

Subacute or chronic HIV encephalitis (dementia)

233
Q

Survival after onset of dementia in HIV

A

3-6 mos

234
Q

Most sensitive test in early stages of dementia in HIV

A

Psychomotor Speed Test (trail making, pegboard, symbol digit test)

235
Q

MRI changes in HIV encephalitis

A

Widening of sulci
Ventricular enlargement
Patchy white matter changes, ill-defined margins

236
Q

Form of HIV myelopathy

A

Vacuolar degeneration

237
Q

Anti-AIDS drug that causes myopathy due to its effect on mitochondria

A

Zidovudine

238
Q

Most common focal infection in AIDS

A

Toxoplasomosis

239
Q

Important differentials for Toxoplasmosis among AIDS px

A

CNS Lymphoma, hence a trial of tx of Toxoplasmosis first then if not work-up for lymphoma by biopsy

240
Q

Most common nonfocal neurologic infection of AIDS

A

CMV

Cryptococcus

241
Q

Shingles occur in AIDS if CD4 count is below

A

500

242
Q

T/F. Presence of HIV, accelerates transition of syphilis to late stages

A

TRUE

243
Q

Neurologic complication of IRIS in HIV

A

Progressive multifocal leukoencephalopathy

244
Q

Tropical spastic paraparesis is assoc w/ virus

A

HTLV-1 infection

245
Q

Delayed progression of muscle weakness that appears many years after acute paralytic illness

A

Postpolio syndrome

246
Q

Main reservoir and main route of polio virus

A

Human intestine; fecal-oral route

247
Q

Incubation period of polio

A

1-3 weeks

248
Q

Inapparent infections which are mild systemic symptoms w/pharyngitis or gastroenteritis

A

Abortive poliomyelitis

249
Q

Form of poliomyelitis presenting as aseptic meningitis, tenderness of muscles and pain in neck and back

A

Nonparalytic poliomyelitis

250
Q

Weakness manifest at the height of fever, w/ no progression after temp is normal for 48 hrs.

A

Paralytic poliomyelitis

251
Q

Atrophy of muscles in polio is detected in ____, maximal in _____ and is permanent

A

3 weeks of onset of weakness

12-15 weeks

252
Q

Common occurrence as well in early phase of paralytic poliomyelitis

A

Urinary retention

253
Q

Most frequently involved cranial muscle:

Due to affectation of:

A

Deglutition

Nucleus ambiguous

254
Q

Earliest histopathologic changes in anterior horns of cords

A

Central chromatolysis of nerve cells w/ inflammatory rxn

255
Q

Preventive measure for poliomyelitis

A

Attenuated live vaccine orally, two doses, 8 weeks apart

256
Q

Return of muscle strength occurs mainly in ____ months due to restitution of partially damaged nerve cells

A

3-4 mos

257
Q

Other main causes of sporadic poliomyelitic syndrome

A

RNA viruses - Echoviruses

258
Q

Also known as inclusion body encephalitis

A

SSPE

259
Q

Age group mostly affected by SSPE

A

Children and adolescent rarely beyond age 10

260
Q

Usual duration of asymptomatic period of measles infection to SSPE

A

6-8 years

261
Q

Clinical manifestation of SSPE

A

Personality and behavioral changes
Intellectual detoriation
Focal or generalized sz
Myoclonus, ataxia, visual disturbance

262
Q

Death occurs in SSPE w/in _____ years

A

1-3 years

263
Q

Characteristic EEG pattern for SSPE

A

Periodic discharges 2-3/s followed by flat pattern w/ 5-8 s interval between discharges

264
Q

CSF formula for SSPE

A

Minimal to absent cells
Inc protein
IgG high

265
Q

MRI findings of SSPE

A

Changes of subcortical white matter and periventricular region

266
Q

Histopathologic hallmark of SSPE

A

Eosinophilic inclusions in nuclei of neurons and glia cells

267
Q

Pathogenesis of SSPE

A

Delay or inadequate immune response hence incapable to clear suppressed infection

268
Q

Diagnosis of SSPE

A

Periodic complexes in EEG
Elevated IgG CSF
Elevated antibody titers in serum and CSF

269
Q

Drugs to improve and prolong survival in SSPE

A

Amantadine

Inosine pranobex

270
Q

Progressive rubella panencephalitis presents as

A

Congenital rubella (remember the tetrad) then decade later detoriation in behavior and cognition then seizures then becoming demented

271
Q

Characterized by widespread demyelinating lesion mainly in cerebral hemispheres w/ varied size and severity of lesion

A

Progressive Multifocal Leukoencephalopathy

272
Q

The incidence of PML in AIDS is ___

In contrast, the incidence of AIDS in PML is ____

A

5%

75%

273
Q

PML is usually associated w/ what medical conditions

A

Neoplasm

Chronic immunodeficiency state

274
Q

PML is associated w/ what virus

A

JC virus (human polyovirus)

275
Q

Poor prognostic sign for recovery from PML

A

CD4 count less than 100

276
Q

Approach to slow progression of PML or remission in AIDS px

A

Aggressive antiretroviral drug tx

277
Q

PML is associated with this syndrome when antiretroviral tx started

A

IRIS

278
Q

Viral encephalitis showing depigmentation of SN and locus ceruleus due to nerve cell destruction hence presenting w/ parkinsonism

A

Van Economo Disease

279
Q

Encephalitis presenting as intractable focal seizures and progressive hemiparesis due to presence of ____

A

Rasmussen encephalitis

Autoantibodies on glutamate receptors

280
Q

Prion protein (PrP) is normally encoded in

A

Chrom 20q

281
Q

Current theory of prion disease

A

Abnormal prion protein folding acts as template to convert PrP to PrPsc

282
Q

Profound dementia, diffuse myoclonic jerks, w/ visual or cerebellar signs

A

CJD (Subacute Spongiform Encephalopathy)

283
Q

Major neuropathologic changes in CJD

A

Neuronal loss and gliosis w/ vacuolation in cerebral and cerebellar cortices

284
Q

Only clearly demonstrated mechanism of spread of CJD

A

Iatrogenic

285
Q

Younger onset, w/psychiatric and sensory symptoms w/o usual EEG findings, due to transmission via infected meat

A

Variant CJD (Bovine spongiform encephalopathy)

286
Q

Most common isoform of CJD

A

MM Type 1 (Most common is MM while VV is least common; Type 1 is more frequent than Type 2)

287
Q

Typical EEG finding of CJD is seen in isoform

A

Type 1 cases

288
Q

Isoform assoc w/ MRI changes

A

MV2

289
Q

Isoform presenting as ataxia, psychiatric, lack of EEG changes, prolonged duration of illness

A

MV2

290
Q

CJD w/ cerebellar ataxia

A

Brownell-Oppenheimer variant

291
Q

CJD w/ visual disturbance

A

Heidenhain variant

292
Q

Typical EEG pattern seen in CJD

A

Diffuse non-specific slowing or high voltage slow-sharp wave complex in slow low voltage background; pseudoperiodic

293
Q

MRI seen CJD

A

Hockey-stick sign (hyperintense lenticular nuclei in T2

294
Q

MRI pattern of CJD is similar to what disease entity

A

Diffuse cerebral anoxia

295
Q

Immunoassay to test for CJD w/ 98% sensi and 80% specificity. Three repeated testing more likely to be positive

A

14-3-3

296
Q

Strong familial in AD inheritance, begins insidiously as cerebellar ataxia, corticospinal tract sign, nystagmus, mild dementia,

Mutation of prion protein gene

A

Gerstmann-Straussler-Scheinker Syndrome

297
Q

Rare familial disease, presenting as intractable insomnia, sympathetic overacitivity, and dementia, due to gliosis of medial thalamic nuclei. Assoc mutation w/ prion gene

A

Fatal insomnia

298
Q

Prion disease but exclusive to Fore linguist of New Guniea highlands, by eating infected brain tissue of the dead

A

Kuru

Adams 10th Ed (8 decks)

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