CNS Flashcards
RF for pneumococcal meningitis
**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
manifestations of listeria CNS infections
- meningoencephalitis (the most common)
- neonates, IC, elderly
- increased risk seizures/focal neuro signs
- cerebritis (from direct hematogenous spread)
- F/HA, stroke-like hemiplegia
- rhomboencephalitis (a/w food outbreaks)
- IC
- biphasic; late = ataxia, nystagmus, CN palsies
meningitis +
rash, diarrhea
think of enterovirus
meningitis +
malaise, LAD, pharyngitis, maculopapular rash (in right epi group)
think HIV
common causes of recurrent meningitis
consider HSV-2
meningitis in:
lab personnel, pet owners, rodent-infested living conditions
consider LCMV
meningitis +
parotitis
mumps
(common cause of meningitis in unimmunized populations)
main causes of chronic meningitis
(e.g. 4+ wks of sx + pleocytosis)
- TB
- fungal
- lyme
- syphilis
- malignancy
Predictive variables for diagnosis of TB meningitis
TBM results from rupture of tubercle into meninges
- >36yo (+2)
- blood WCC >5x106 (+4)
- number of days of illness _>_6 (-5)
- CSF WCC _>_900x103 (+3)
- CSF %PMNs _>_75 (+4)
Total score < 4 → TBM
Total score >4 → bacterial meningitis
Thwaites Index
undulant fever
CN palsy (esp blurred vision/hearing loss)
behavior changes/confusion
Mediterranean, Middle East
unpasteurized dair products/infected animals
Dx and Tx
Brucella
Tx w/ any of the two: doxy, CRP, rifampin
Cognitive impairment, ataxia, ophthalmoplegia, supranuclear gaze palsy
F, wt loss, peripheral LNs, myalgias
GI symptoms
think tropheryma whipplei
Tx: CRO, then TMP/SMX
excrutiating HA
rash + pruritus
paresthesias
peripheral/CSF eos
Asia, S Pacific
ingestion of shellfish, snails
think angiostrongylus cantonensis
etiologic agents of post-neurosurgical meningitis
most = enterobacterales, PSAR
also S aureus, CoNS
Candida in 5%
Common causes of encephalitis in…
- US/UK
- internationally
- endemic areas
- HSV, VZV, enterovirus
- rabies, JEV
- WNV, tickborne encephalitis virus, St Louis encephalitis virus
encephalitis + imaging with…
arteritis and infarctions
- VZV
- nipah virus
- rickettsia rickettsia
- syphilis
encephalitis + imaging with…
calcifications
- CMV (if cortical lesions)
- toxo (if periventricular lesions)
- Taenia solium
encephalitis + imaging with…
cerebellar lesions
- VZV
- EBV
- M pneumoniae
encephalitis + imaging with…
focal lesions in basal ganglia, thalamus, and/or brain stem
- EBV
- EEE
- SLEV
- JEV
- WNV
- enterovirus
- influenza (acute necrotizing encephalopathy)
- tropheryma whipplei
- listeria
encephalitis + imaging with…
hydrocephalus
- TBM
- crypto
- cocci
- histo
- balamuthia mandrillaris
encephalitis + imaging with…
space-occupying lesions
- toxo
- acanthamoeba
- taenia solium
encephalitis + imaging with…
temporal/frontal lobe involvement
- HSV, VZV
- HHV-6
- WNV
- enteroviruses
- syphilis (if medial lobes)
vesicles at site of inoculation + regional LAD
flu-like illness
paresthesias at inoculation site
invades CNS: diplopia, ataxia, agitation, seizures, asc paralysis
lab workers
Herpes B Virus
Asia, Western Pacific
pig, wading birds = reservoir, transmitted by mosquito
Parkinson-like syndrome
Japanese Encephalitis Virus
initial viremia: flu-like illness + arthralgias 7-14 days after tick bite
remission of 1 week
then CNS: meningitis, encephalitis, myelitis, radiculitis
Tickborne encephalitis virus
transmitted rapidly after attachment (early removal may not prevent)
Epi: European, Far Eastern, Siberian
summertime
encephalitis or acute flaccid paralysis
50% w/ persistent neuropsych impairment
think WNV
MCC brain abscess
- 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
Management of cavernous sinus thrombosis
- culture/drainage of infected sinuses if possible
- vanc + metro + 3/4 gen ceph
- anticoagulation
Clinical features of cavernous sinus thrombosis
- signs: periorbital edema, chemosis, papillitis, oculomotor palsies, proptosis
- IC artery and multiple CNs in the cavernous sinus
Etiology of Septic Cavernous Sinus Thrombosis
RF
Etiologic Agents
- 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%)
Therapy of brain abscess w/:
- Aspergillus
- Candida
- Mucorales
- Scedosporium
- Vori
- AMB
- AMB
- Vori (AMB resistant)
Therapy of brain abscess w/:
- Nocardia
- MTB
- TMP/SMX or sulfadiazine. Combo for IC pts or those failing standard therapy
- INH + rifampin + pyrazinamide +/- ethambutol
Therapy of brain abscess w/:
- Actinomyces
- Bacteroides
- Enterobacterales
- Fusobacterium
- PSAR
- SA
- Strep milleri, other strep
- PCN G
- metro
- 3/4th gen ceph
- metro
- ceftaz, cefepime, meropenem
- nafcillin, oxacillin, or vanc
- PCN G
brain abscess w/ ring-enhancing lesion
seen in IC pts
resistant to AMB (may see persist/present despite tx w/ AMB in question stem)
- scedosporium
- tx w/ vori
brain abscess in IVDU w/ basal ganglia infarct + rapid onset
think local cerebral mucormycosis
non-septated hyphae w/ right angle branching
Empiric Abx Therapy of Brain Abscesses w/:
- OM/mastoiditis
- sinusitis
- dental sepsis
- penetrating trauma, neurosurgical
- lung abscess, empyema, bronchiectasis
- bacterial endocarditis
- Unknown
- Transplant Recipients
- HIV-infected pts
- aerobic/anaerobic strep, GNR, anaerobes - metronidazole + 3rd gen ceph
- the above + staph - metro + 3rd gen ceph + VANC
- aerobic/anaerobic strep, actinomyces - metro + 3rd gen ceph
- staph, GNs, clostridium - vanc + 3/4 gen ceph
- ? add nocardia coverage - metro + 3/4 gen ceph + TMP/SMX
- staph/strep - vancomycin
- vanc + metro + 3/4 gen ceph
- aspergillus, nocardia - add vori, TMP/SMX or sulfadiazine
- toxo, MTB - add pyrimethamine/sulfadiazine; consider RIPE for TB
Abx tx with
- N meningitidis:
- PCN MIC <0.1
- PCN MIC 0.1-1
- H flu:
- BLase negative
- BLase positive
Abx for Strep pneumo w/
- PCN MIC
- PCN MIC >0.12 w/ CRO MIC <1 vs CRO MIC > 1
Empiric abx therapy
- Immunocompromise:
- Basilar skull fx:
- Head trauma/neurosurgery:
- CSF shunt or drain:
Empiric abx therapy for meningitis
- <1mo:
- 1-23mo:
- 2-50yo:
- >50yo:
meningitis w/ Vietnam, eating undercooked pig blood/intestine, pig exposure
Strep suis
meningitis w/ spinal anesthesia or myelogram
consider strep salivarius
meningitis w/ contiguous foci in head/neck
GNR, anaerobes
meningitis in pt with CSF shunts and drains
think staph epi or deiphtheroids (cutibacterium)
meningitis (MC in children)
concurrent pharyngitis/OM (>50% of cases)
adults RF: sinusitis, OM, SCD, DM, head trauma w/ CSF leak, PNA, splenectomy, EtOH
H flu
epi RF for GNR meningitis
(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
epi RF for GBS meningitis
_**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
children/young adults
can be a/w outbreaks
other RF: terminal complement deficiencies (C5-8), MSM with HIV, eculizumab
meningococcal meningitis
Risk groups for developing lymphocytic choriomeningitis virus
(rare)
transmitted by rodents (no P2P)
- lab workers
- pet owners (hamsters, mice)
- impoverished/unhygienic places
- rodent breeding factory
few/at least 10 episodes of meningitis lasting 2-5 days followed by spontaneous recovery
Recurrent benign lymphocytic meningitis (Mollaret)
MCC = HSV-2
meningitis in summer/fall w/:
rhomboencephalitis
enterovirus 71
meningitis in summer/fall w/:
pericarditis/pleuritis
coxsackievirus B
meningitis in summer/fall w/:
Herpangina
coxsackievirus A
meningitis in summer/fall w/:
scattered maculopapular rash
echovirus 9
leading cause of “aseptic” meningitis
enteroviruses (85-95% of cases w/ identified etiology)
**summer/fall seasonality
outbreaks reported
