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CNS Flashcards

1
Q

RF for pneumococcal meningitis

A

**tends to be a/w other foci of infection (septic arthritis, PNA, IE)

  • asplenia
  • EtOH
  • CKD/CLD
  • DM
  • malignancy
  • basilar skull rx (w/ persistent CSF leak)
  • cochlear implants
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2
Q

manifestations of listeria CNS infections

A
  1. meningoencephalitis (the most common)
    1. neonates, IC, elderly
    2. increased risk seizures/focal neuro signs
  2. cerebritis (from direct hematogenous spread)
    1. F/HA, stroke-like hemiplegia
  3. rhomboencephalitis (a/w food outbreaks)
    1. IC
    2. biphasic; late = ataxia, nystagmus, CN palsies
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3
Q

meningitis +

rash, diarrhea

A

think of enterovirus

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4
Q

meningitis +

malaise, LAD, pharyngitis, maculopapular rash (in right epi group)

A

think HIV

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5
Q

common causes of recurrent meningitis

A

consider HSV-2

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6
Q

meningitis in:

lab personnel, pet owners, rodent-infested living conditions

A

consider LCMV

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7
Q

meningitis +

parotitis

A

mumps

(common cause of meningitis in unimmunized populations)

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8
Q

main causes of chronic meningitis

(e.g. 4+ wks of sx + pleocytosis)

A
  • TB
  • fungal
  • lyme
  • syphilis
  • malignancy
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9
Q

Predictive variables for diagnosis of TB meningitis

A

TBM results from rupture of tubercle into meninges

  1. >36yo (+2)
  2. blood WCC >5x106 (+4)
  3. number of days of illness _>_6 (-5)
  4. CSF WCC _>_900x103 (+3)
  5. CSF %PMNs _>_75 (+4)

Total score < 4 → TBM
Total score >4 → bacterial meningitis

Thwaites Index

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10
Q

undulant fever

CN palsy (esp blurred vision/hearing loss)

behavior changes/confusion

Mediterranean, Middle East
unpasteurized dair products/infected animals

Dx and Tx

A

Brucella

Tx w/ any of the two: doxy, CRP, rifampin

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11
Q

Cognitive impairment, ataxia, ophthalmoplegia, supranuclear gaze palsy
F, wt loss, peripheral LNs, myalgias

GI symptoms

A

think tropheryma whipplei

Tx: CRO, then TMP/SMX

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12
Q

excrutiating HA
rash + pruritus
paresthesias

peripheral/CSF eos

Asia, S Pacific

ingestion of shellfish, snails

A

think angiostrongylus cantonensis

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13
Q

etiologic agents of post-neurosurgical meningitis

A

most = enterobacterales, PSAR

also S aureus, CoNS

Candida in 5%

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14
Q

Common causes of encephalitis in…

  • US/UK
  • internationally
  • endemic areas
A
  • HSV, VZV, enterovirus
  • rabies, JEV
  • WNV, tickborne encephalitis virus, St Louis encephalitis virus
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15
Q

encephalitis + imaging with…

arteritis and infarctions

A
  • VZV
  • nipah virus
  • rickettsia rickettsia
  • syphilis
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16
Q

encephalitis + imaging with…

calcifications

A
  • CMV (if cortical lesions)
  • toxo (if periventricular lesions)
  • Taenia solium
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17
Q

encephalitis + imaging with…

cerebellar lesions

A
  • VZV
  • EBV
  • M pneumoniae
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18
Q

encephalitis + imaging with…

focal lesions in basal ganglia, thalamus, and/or brain stem

A
  • EBV
  • EEE
  • SLEV
  • JEV
  • WNV
  • enterovirus
  • influenza (acute necrotizing encephalopathy)
  • tropheryma whipplei
  • listeria
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19
Q

encephalitis + imaging with…

hydrocephalus

A
  • TBM
  • crypto
  • cocci
  • histo
  • balamuthia mandrillaris
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20
Q

encephalitis + imaging with…

space-occupying lesions

A
  • toxo
  • acanthamoeba
  • taenia solium
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21
Q

encephalitis + imaging with…

temporal/frontal lobe involvement

A
  • HSV, VZV
  • HHV-6
  • WNV
  • enteroviruses
  • syphilis (if medial lobes)
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22
Q

vesicles at site of inoculation + regional LAD
flu-like illness
paresthesias at inoculation site

invades CNS: diplopia, ataxia, agitation, seizures, asc paralysis

lab workers

A

Herpes B Virus

23
Q

Asia, Western Pacific

pig, wading birds = reservoir, transmitted by mosquito

Parkinson-like syndrome

A

Japanese Encephalitis Virus

24
Q

initial viremia: flu-like illness + arthralgias 7-14 days after tick bite

remission of 1 week

then CNS: meningitis, encephalitis, myelitis, radiculitis

A

Tickborne encephalitis virus

transmitted rapidly after attachment (early removal may not prevent)

Epi: European, Far Eastern, Siberian

25
Q

summertime

encephalitis or acute flaccid paralysis

50% w/ persistent neuropsych impairment

A

think WNV

26
Q

MCC brain abscess

A
  • Strep (incl milleri group and VGS)
  • SA
  • anaerobes (from ENT source)
  • if neurosurg, trauma, ear infection: consider Enterobacterales, PSAR as well
  • SE Asia (esp w/ liver abscess): consider hypermucoviscous Kleb pneumoniae
27
Q

Management of cavernous sinus thrombosis

A
  • culture/drainage of infected sinuses if possible
  • vanc + metro + 3/4 gen ceph
  • anticoagulation
28
Q

Clinical features of cavernous sinus thrombosis

A
  • signs: periorbital edema, chemosis, papillitis, oculomotor palsies, proptosis
  • IC artery and multiple CNs in the cavernous sinus
29
Q

Etiology of Septic Cavernous Sinus Thrombosis

RF

Etiologic Agents

A
  • RF: paranasal sinusitis (most important; remember NG tube causing sphenoid sinusitis), facial infection, dental infection
  • Etiologic: Staph (60-70%), Strep (~17%), GNR, pneumococcal, bacteroides (~2%)
30
Q

Therapy of brain abscess w/:

  • Aspergillus
  • Candida
  • Mucorales
  • Scedosporium
A
  • Vori
  • AMB
  • AMB
  • Vori (AMB resistant)
31
Q

Therapy of brain abscess w/:

  • Nocardia
  • MTB
A
  • TMP/SMX or sulfadiazine. Combo for IC pts or those failing standard therapy
  • INH + rifampin + pyrazinamide +/- ethambutol
32
Q

Therapy of brain abscess w/:

  1. Actinomyces
  2. Bacteroides
  3. Enterobacterales
  4. Fusobacterium
  5. PSAR
  6. SA
  7. Strep milleri, other strep
A
  1. PCN G
  2. metro
  3. 3/4th gen ceph
  4. metro
  5. ceftaz, cefepime, meropenem
  6. nafcillin, oxacillin, or vanc
  7. PCN G
33
Q

brain abscess w/ ring-enhancing lesion

seen in IC pts

resistant to AMB (may see persist/present despite tx w/ AMB in question stem)

A
  • scedosporium
  • tx w/ vori
34
Q

brain abscess in IVDU w/ basal ganglia infarct + rapid onset

A

think local cerebral mucormycosis

non-septated hyphae w/ right angle branching

35
Q

Empiric Abx Therapy of Brain Abscesses w/:

  1. OM/mastoiditis
  2. sinusitis
  3. dental sepsis
  4. penetrating trauma, neurosurgical
  5. lung abscess, empyema, bronchiectasis
  6. bacterial endocarditis
  7. Unknown
  8. Transplant Recipients
  9. HIV-infected pts
A
  1. aerobic/anaerobic strep, GNR, anaerobes - metronidazole + 3rd gen ceph
  2. the above + staph - metro + 3rd gen ceph + VANC
  3. aerobic/anaerobic strep, actinomyces - metro + 3rd gen ceph
  4. staph, GNs, clostridium - vanc + 3/4 gen ceph
  5. ? add nocardia coverage - metro + 3/4 gen ceph + TMP/SMX
  6. staph/strep - vancomycin
  7. vanc + metro + 3/4 gen ceph
    • aspergillus, nocardia - add vori, TMP/SMX or sulfadiazine
    • toxo, MTB - add pyrimethamine/sulfadiazine; consider RIPE for TB
36
Q

Abx tx with

  • N meningitidis:
    • PCN MIC <0.1
    • PCN MIC 0.1-1
  • H flu:
    • BLase negative
    • BLase positive
A
37
Q

Abx for Strep pneumo w/

  • PCN MIC
  • PCN MIC >0.12 w/ CRO MIC <1 vs CRO MIC > 1
A
38
Q

Empiric abx therapy

  • Immunocompromise:
  • Basilar skull fx:
  • Head trauma/neurosurgery:
  • CSF shunt or drain:
A
39
Q

Empiric abx therapy for meningitis

  • <1mo:
  • 1-23mo:
  • 2-50yo:
  • >50yo:
A
40
Q

meningitis w/ Vietnam, eating undercooked pig blood/intestine, pig exposure

A

Strep suis

41
Q

meningitis w/ spinal anesthesia or myelogram

A

consider strep salivarius

42
Q

meningitis w/ contiguous foci in head/neck

A

GNR, anaerobes

43
Q

meningitis in pt with CSF shunts and drains

A

think staph epi or deiphtheroids (cutibacterium)

44
Q

meningitis (MC in children)

concurrent pharyngitis/OM (>50% of cases)

adults RF: sinusitis, OM, SCD, DM, head trauma w/ CSF leak, PNA, splenectomy, EtOH

A

H flu

45
Q

epi RF for GNR meningitis

A

(kleb, E coli, serratia, PSAR, acinetobacter, salmonella)
*infrequent cause of CA-meningitis - often a/w underlying comorbidities

  • head trauma/neurosurgical pts
  • neonates, elderly
  • DM, liver dz
  • IC pts
  • pts w/ GNR BSI (commonly a/w BSI!)
  • ***strongy hyperinfection syndrome
46
Q

epi RF for GBS meningitis

A

_**Neonates:_

  • Early-onset septicemia a/w prematurity/PROM/LBW
  • Late onset meningitis (>7 days after birth)

Adults:

  • DM, cardiac/renal/liver disease, collagen disease, HIV, malignancy, EtOH, steroids
47
Q

children/young adults

can be a/w outbreaks

other RF: terminal complement deficiencies (C5-8), MSM with HIV, eculizumab

A

meningococcal meningitis

48
Q

Risk groups for developing lymphocytic choriomeningitis virus

A

(rare)

transmitted by rodents (no P2P)

  • lab workers
  • pet owners (hamsters, mice)
  • impoverished/unhygienic places
  • rodent breeding factory
49
Q

few/at least 10 episodes of meningitis lasting 2-5 days followed by spontaneous recovery

A

Recurrent benign lymphocytic meningitis (Mollaret)

MCC = HSV-2

50
Q

meningitis in summer/fall w/:

rhomboencephalitis

A

enterovirus 71

51
Q

meningitis in summer/fall w/:

pericarditis/pleuritis

A

coxsackievirus B

52
Q

meningitis in summer/fall w/:

Herpangina

A

coxsackievirus A

53
Q

meningitis in summer/fall w/:

scattered maculopapular rash

A

echovirus 9

54
Q

leading cause of “aseptic” meningitis

A

enteroviruses (85-95% of cases w/ identified etiology)

**summer/fall seasonality

outbreaks reported

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