CNS Flashcards
Bacterial causes of meningitis
Infants (2-4 mnths)
S. agalactiae,
E. coli,
L. monocytogenes,
S. pneumoniae,
N. meningitides,
H. influenzae
Pressing a PIN on a baby will give a MEAN cry
Pneumonae, INfluenza
Monocytogenes,Ecoli, aglactia, Nisseria meningitis
Viral meningitis also reffered to as
Aspectic meningitis
Venezuelan Equine Encephalitis Virus- type
Alphavirus
Non-polio Enteroviruses common types
Enterovirus 71, Echovirus 18, Coxsackieviruses
Infants (2-4 mnths) Bacterial meningitis
S. agalactiae, E. coli, L. monocytogenes, S. pneumoniae, N. meningitides, H. influenzae*
Post splenectomy, complement deficiency
N. meningitides
This bacterial meningitis seen in
Infants -
– Adults >60y, alcoholics, cancer patients, renal transplant.
Listeria monocytogenes
Encephalitis CSF findings

Rabies virus dx
– Skin biopsy: Immunohistochemical staining - Rabies Ag
– Negri bodies: Intracytoplamsic inclusions in neurons
– Corneal smears – Rabies Ag
– Rabies virus neutralizing Ab – CSF or serum (unimmunized) Direct Ab Test
African Sleeping Sickness
Protazoa
African Trypanosomes
Vectors st. Louise vs. eastern equine

Schistosomiasis
Schistosoma species
Liver or bladder
brain or spinal cord vasculature
Haemophilus influenzae
• Clinical features
Slower onset (meningococcal meningitis), 3-4d – Follows: nasopharyngitis, sinusitis or otitis media – 1/3 survivors – neurologic sequelae
Predominant Demyelination imaging defect
JC virus
Most common cause (Chronic meningitis)
Mycobacterium tuberculosis
CSF findings in Western Equine Encephalitis Virus
CSF: pleocytosis (lymphocytic), normal-↑ protein, normal glucose
Primary amebic memeningoencephalitis (PAM)
Ameoba implicated
Naegleria fowleri
Underlying conditions related to Staphylococci
Diabetes mellitus
– Alcoholism
– Chronic renal failure (hemodialysis)
Dx of California Encephalitis Group
– IgM antibodies in CSF or serum
Listeria monocytogenes serotypes
Serotypes: 1/2b & 4b (80% cases)
St. Louis Encephalitis Virus distribution
Canada, US, Central & Southern America
GAE; skin or lung lesions
Amoeba implicated
Balamuthia mandrillaris
Eosinophilic Meningitis
Angiostrongylus cantonensis (rat lung worm)
Gnathostoma spinigerum
Clinical features of Streptococcus pneumoniae
Rapid 1-2 days (or gradual)
– Impaired consciousness common
Subependymal enhancement imaging defect
CMV ventriculitis
Meningitis
inflammation of meninges
Vector-borne viruses
Togaviridae
– Flaviviridae
– Bunyaviridae
– Reoviridae
Multifocal haemorrhagic infarctions & demyelinating lesions imaging defect
Varicella zoster virus vasculopathy
Basilar skull fracture + CSF leak
Puts you at risk for this bacterial meningitis
Streptococcus pneumoniae
Diagnosis neoforms
india ink (capsule)
CM1 defects (Hodgkin’s disease, steroid therapy), elderly
L. monocytogenes
Distribution of Venezuelan Equine Encephalitis Virus
Southern US, Central & S. America
Herpes simplex 1 & 2 connection to meningitis
Post neonatal
• Important: differentiate encephalitis from meningitis
– Most common: HSV 2 • primary to genital infection
• 36% women, 13% men
Bacterial meningitis Neonates (0-2 mnths)
Group B Streptococci (S. agalactiae), E. coli (other Gram –ve enterics), L. monocytogenes
Spirocheteal meningitis… whats the bacterial cause
Treponema pallidum
Slow onset (period of weeks) – ↓ Fever, lethargy – TB, Fungi & (Protozoa)
Chronic (RARE)
Brudzinski’s sign

Look up pic Flex knees and neck
Sx of California Encephalitis Group
Focalneurologicdisease
– Hemiparesis, aphasia, dysarthria, chorea
Biology behind prions
– Normal cellular glycoprotein: PrPc (↑ a helix, ↓ b helix)
– Infectious glycoprotein form: PrPsc (↓a helix, ↑ b helix)
Adults (Adolescents- >55y) Bacterial meningitis
N. meningitides, S. pneumoniae
Fontal, Temporal, Parietal, abscess
Predisposing/ bacteria
Trauma, Penetrating wound
S. aureus, Clostridia
Bacterial etiology of CSF shunts
– Staphylococci (epidermidis & aureus)
– Gram negative bacteria (E. coli, Klebsiella, Proteus & Pseudomonas)
– Streptococci
– Diphtheroids (Propionibacterium acnes)
– Anaerobes
– Mixed culture
Temporal lobe abcess what predisposes you, what bacteria
Otitis media, Mastoiditis
Streptococci, Bacteroides, Enterobacteriacea
HA-CNS infection: MRSA
- CSF shunts: S. epidermidis
- Mortality 14-77%
Staphylococci
Mycobacterium tuberculosis adult vs children
– Children (haematogenous disseminated tuberculosis) • Rapid
– Adults
• Indolent
Eastern Equine Encephalitis Virus distribution
US, Southern America, Caribbean
FOCAL CNS SYNDROMES
Brain Abscess
Subdural empyema
Epidural abscess
CSF findings in Colorado Tick Fever Virus
CSF: pleocytosis (mildly lymphocytic), normal-mildly↑ protein, normal glucose
Enterovirus Seasonality
Late Summer, fall
Yellow csf
Blood breakdown products Hyperbilirubinemia CSF protein ≥150mg/dL (1.5g/L), >100,000 RBC/mm3
St. Louis Encephalitis Virus- type
Flavivirus
Listeria monocytogenes
• Biology:
Gram +ve rod – Virulence:
• Internalin A & B • Listeriolysin O
PRIONS
Infectious proteins
– No Nucleic acid genome
– Resistant: formaldehyde (3.7%), dry heat, boiling, ethanol (50%) & ionizing radiation
– Sensitive: phenol (90%), household bleach, ether, NaOH (2 N), strong detergents (10% sodium dodecyl sulfate) & autoclaving (1 hour, 121oC)
Alcoholism, skull fractures, myeloma, splenectomy
S. pneumoniae
Clinical feature of Mycobacterium tuberculosis
Rupture in subarachnoid space
Distribution of Japanese Encephalitis Virus
Asia, Western Pacific, Australia
Dx of fungal brain abscess
CT scan
– Hypodense centre
– Peripheral uniform ring – Brain oedema
Fungal Meningitis lab values
Opening pressure Variable WBC count Variable Cell differential lymphocytes Protein 50-100mg/dL Glucose
Comparing meningitis lab values by organism

Japanese Encephalitis Virus type
Flaviviridae
>50 years Bacterial meningitis
S. pneumoniae, N. meningitides, L. monocytogenes, Aerobic Gram –ves
Eastern Equine Encephalitis Virus- type
Alphavirus
Granulomatous Amebic Encephalitis (GAE); skin or lung lesions; amebic keratitis
Ameoba implicated
Acanthamoeba species
Western Equine Encephalitis Virus- type
Alphavirus
Pathogenesis of CNS shunts
– Retrograde infection
– Skin
– Haematogenous seeding
– Colonization at surgery
Neisseria meningitidis
• Clinical features
Distinguishing feature
Quick onset
– Acute photophobia
– Skin petechiae → ecchymoses/diffuse petechial rash -
DIC
Neisseria meningitidis
• Prevention
2005, Quadrivalent: A, C, Y & W135
– Protection: ~3y
– No protection from carriage (MPSV4-menomune)
meningococcal conjugate vaccine seen as better
CSF findings in Measles
CSF: usually normal (↑Ig level)
Exposure to bats, other wild animals, dog bites, developing countries
Rabies
Brown CSF
Meningeal melanomatosis (Metastatic Melanoma)
characteristics of Enteroviruses
Picornaviridae
– Naked, icosahedral, small (25-30nm), ss +ve RNA
Echoviruses 30, 18, 16, 11, 9, 6 & 7
• Coxsackieviruses B1, B2, B3, B4 & A9 • Enteroviruses 71 & 70
Meningoencephalomyelitis
infection of meninges+ brain parenchyma+spinal cord
Colorado Tick Fever Virus dx
IgM by ELISA
Histoplasma capsulatum
• Geographic location
Ohio & Mississippi river valley, Central America
Distribution of Colorado Tick Fever Virus
WesternUS&Canada(Mountains)
NORMAL CSF VALUES
• WBC count: children & adults 0-5/mm3 (70% lymphocytes, 30% monocytes) neonates 32/mm3 • RBC count: None • [Glucose]: ratio to serum glucose ≥60% 40-70mg/dL not >300mg/dL • [Protein]: adults 18-58mg/dL (by 6-12 mnths old) newborn 150mg/dL
Brain abscess in the frontal lobe- what predisposes, and what organisms
Sinusitis, Dental abscess
Streptococci, Bacteroides, S. aureus, Haemophilus spp.
Abscess
localised infection in spinal cord or brain – Acute/Chronic Brain Abscess – Empyema – epidural or subepidural abscess
Lymphocytic choriomeningitis virus
Rare
– Contact with rodents & excreta (hamsters, rats, mice)
• Lab workers, pet owners, unhygienic housing conditions
Encephalitis –
inflammation of the brain parenchyma
Herpes viruses implicated in meningitis
HSV, VZV, CMV, EB virus & HHV -6, 7, 8
Most common fungal cause of meningitis
Cryptococcus neoformans (Cryptococcus gattii)
Rickettsia (RMSF) Seasonality
Late Summer & Spring
Herpesviruses Clinical features
Incubation period uncertain • Rapid onset – several days
– Fever (90-100%)
– Altered consciousness (97-100%) – Headache (70-81%)
CSF findings in California Encephalitis Group
CSF: pleocytosis (lymphocytic), ↑ protein, normal glucose
THis bacteria Uncommon, seen in Early postneurosurgical/post-trauma
Staphylococci
Eastern Equine Encephalitis Virus CSF/MRI findings
CSF: pleocytosis (neutrophil predominance (2/3)), ↑ protein, norm glucose, RBC’s common
– MRI: thalamus, basal ganglia, brain stem
THis bacteria
Group B Strep
• Most common: neonates (52% cases, US) • Mortalityrate:7-27%
Streptococcus agalactiae
Who is most at risk for encephalitis when infected with st. louise
>60
Blastomyces mostly presents with
Brain abscess
Temporal lobe & limbic imaging problem
HSV & HHV-6 encephalitis
Difference between Subdural empyema and epidural abcess
Epidural abcess- MRI pachymeningeal enhancement, superficial area of diminished intensity
Pink CSF
Blood breakdown products
Haemophilus influenzae
• Human carriage
80% children, 20-50% adults (URT) – Unencapsulated
Coccidioides dx
Eosinophils (CSF) Wright-Giemsa Stain
– Complement fixation test
sub acute sclerosing panencephalitis seen in
Measles
Western Equine Encephalitis Virus dx
WEE IgM antibodies in CSF or serum
CSF/MRI findings in Japanese Encephalitis Virus
CSF: pleocytosis (lymphocytic), mildly↑ protein, normal glucose
– MRI: normal
California Encephalitis Group- type
Bunyaviridae
Green CSF
Hyperbilirubinemia Purulent CSF
Colorado Tick Fever Virus type
Reoviridae
Rare cases protazoa affecting CNS
Free-living ameba
Streptococcus pneumoniae characteristics
Non-motile, Gram +ve diplococci – Virulence:
• Capsule
– (18 serogroups, 82% pneumonia = meningitis)
- IgA protease
- Pneumolysin (cytotoxin)
Tubercular Meningitis lab values
Opening pressure Variable WBC count Variable Cell differential Mostly lymphocytes (10–500 cells/ml) Protein 10-500mg/dL Glucose 20-40mg/dL
Enteroviruses epidemiology
85-95% all cases
• Age: Infants & Young children
– no previous exposure & immunity
- Adults(common)
- Geographic consideration - Worldwide distribution
- Seasonal consideration:
– Temperate climate: summer/fall (water) – Tropical: year round (faecal-oral)
Associated with congenital defects and AIDS
Protazoa affecting CNS
Toxoplasma gondii
Bacterial Meningitis Lab values
Opening pressure Elevated WBC count ≥1,000/mm3 Cell differential Neutrophils 90% (>100cells/ml) Protein 100-500 mg/dL Glucose 0-10mg/dL
US: Most common epidemic
West Nile Virus
Rabies tx
– Postexposure prophylaxis
– Wash wounds: soap & water + providone-iodine
– Vaccine
– Human rabies immunoglobulin (HRIG)
• Direct spread CNS
Trauma or injury
– Most common: Staphylococcus aureus
– Immunodeficient/HIV: Nocardia, Aspergillus, Candida
Orange CSF
Blood breakdown products Xanthochromia
Treponema pallidum known to cause
Clinical neurosyphilis
Syphilitic meningitis (0.3-2.4% untreated cases) – Meningovascular syphilis
– Parenchymatous neurosyphilis
– Gummatous neurosyphilis (rare)
CSF findings in Venezuelan Equine Encephalitis Virus
pleocytosis (lymphocytic), ↑ protein, normal-↑ glucose
Etiology of subdural empyema
– Streptococci (25-45%)
– Staphylococci (10-15%)
– Enterobacteriacea (3-10%) – Anaerobic bacteria (33%) – Polymicrobial
Candida found in
– Neonatal ICU (use of IV catheters)
Postneurosurgery
– Immunosuppressed
Haemophilus influenzae
• Biology characteristics
Non-motile, Gram –ve rods – Fastidious
- NADP (V) & Haematin (X), (Chocolate agar) – Virulence:
- Capsule (polyribitol phosphate) • Pili
- LPS
Types of Facultative anerobe bacteria
Klebsiella, E. coli, S. marcescens, P. aeruginosa
Neontates: E. coli K1
Pregnant women carry this in their rectum
West Nile Virus dx
ELISA
Cysticercosis
Taenia solium (pork tape worm)
Muscle and brain
West nile sx
60 years of age) – Brain parenchymal involvement
– CSF: pleocytosis, ↑ protein, normal glucose
– MRI: thalamus, basal ganglia, brain stem
• Poliomyelitis-like (acute flaccid paralysis)
– Motor neuron injury (anterior horn of spinal cord) – Brain parenchymal involvement
Most common: sporadic encephalitis
Herpesviruses
Routes of infections CNS
Direct Heamatogenous Neural tissue
Arboviruses (Arthropod-borne)
– Mainly encephalitis
Cerebral Malaria
Protazoa
Plasmodium falciparum
St. Louis Encephalitis Virus findings in csf/ mri
CSF: pleocytosis, ↑ protein, normal glucose
– MRI: normal, or substantia nigra
Neural tissue (rare)
Human Herpesvirus 1-3 – Rabies: peripheral→nerve axons→ganglia & spinal cord→brain
PRevention of polio
– 3 strains of Polio (1, 2 & 3)
– 4 Vaccines available
– Inactivated Polio Vaccine (IPV) - Salk
– Live Oral Polio Vaccine (OPV) - Sabin • Monovalent (mOPV1 & mOPV3)
• Bivalent (bOPV)
Most higher cortical function deficits.
• Progress over weeks-months: profound dementia (memory loss, impaired judgment, intellectual function
Creutzfeldt-Jakob disease
Immunocompromised (allogenic bone marrow transplants) herpes type
HSV 6
Pathogenesis of rabies

Multiple lobes brain abscess what predisposes you and organisms
Infective endocarditis, Congenital Heart Disease, Lung abscess
S. aureus, Streptococci (viridans), Fusibacteria, Nocardia
TESTS FOR MENINGISM
Inability to flex neck (chin to chest) • Inability to oppose nose with knee • Tripod sign: Inability to sit up without using hands • Kernig’s sign • Brudzinski’s sign
Head trauma/neurosurgery put you at risk for these bacterial meningitis
Facultative anerobe bacteria
St. Louis Encephalitis Virus dx
Anti-SLEV IgM antibodies in serum or CSF
What is the human carriage of strep pneumonia
throat & nasopharynx
Primary amoeba affecting CNS
Entamoeba histolytica
CSF normal pressure
Normal pressure: 70-180 mm H2O
Dx of Venezuelan Equine Encephalitis Virus
VEE IgM antibodies in CSF or serum
Bacterial causes of meningitis
Neonates (0-2 mnths)
Group B Streptococci (S. agalactiae),
E. coli (other Gram –ve enterics),
L. monocytogenes
ALE
Bacterial meningitis can be seen in Lyme
disease whats the bacteria
Borrelia burgdorferi
Polio virus transmission
Faecal-oral
Dx of Japanese Encephalitis Virus
– IgM antibodies in CSF by ELISA
– PCR
Eastern Equine Encephalitis Virus dx
EEE IgM antibodies in CSF by ELISA
CSF shunts
S. aureus
Bacterial causes of meningitis
Adults (Adolescents - >55y)
N. meningitides,
S. pneumoniae
Human carriage (5-30% healthy individuals, URT)
Neisseria meningitidis
Higher in military recruit camps, schools
Immunocompetent adults herpes type
HSV 1
Onset: hours-several days • Life-threatening • Meningism: Fever, Headache, Nuchal rigidity, Nausea & Vomiting, Photophobia • Altered mental status
Acute
ENCEPHALITIS
Inflammation of the brain parenchyma
Haematogenous dissemination cns
Respiratory tract infection: N. meningitidis – Insect bite: West Nile Virus – Transplacental: Rubella
Listeria monocytogenes
• Clinical features:
Subclinical-gastrointestinal like
– Neonatal
– Immunocompromised
Routine Tests for CSF
WBC count with differential RBC count [Glucose] [Protein] Gram stain/ India stain Bacterial culture/ Fungal culture
Neisseria meningitidis
• Biology characteristics
– Non-motile, Gram -ve diplococci
(kidney-bean shaped) – Fastidious
- 5-10% CO2, (Chocolate agar, Modified Martin-Thayer agar) – Virulence:
- Capsule (serogroups A, B, C, X, Y & W-135) • IgA protease
- Pili
- LOS
Increased Risk Factors csf shunt infections
– Premature birth
– Previous shunt infection
– Cause of hydrocephalus
– Length of the shunt procedure
– Shunt revision
Bacterial causes of meningitis
>50 years
S. pneumoniae,
N. meningitides,
L. monocytogenes,
Falcultative anerobes
Polio endemic
Endemic: Afghanistan, Pakistan, & Nigeria (Somalia, Ethiopia, Kenya, South Sudan & Cameroon)
Haemophilus influenzae
why has its rates dropped compared to previous years
Present: 7% cases (conjugate Hib vaccine @ 2 mnths/age)

MRI Fungal abscess in brain
Interhemispheric fissure
Alcoholism, post splenectomy, hypogammaglobulinemia
H. influenzae
This bacteria 15-35%
asymptomatic pregnant women
Streptococcus agalactiae
Myelitis
infection of spinal cord
Tick bite
Lyme disease
Fungal causes CHRONIC MENINGITIS
Cryptococcus
Histoplasma
California Encephalitis Group distribution
CEV, La Crosse & Jamestown – US; Tahyna - Russia
La Crosse: Mississippi & Ohio river basins
DIAGNOSTIC TESTS for encephalitis
Neuroimaging
– All patients MRI
– Distinctive patterns of abnormalities
Western Equine Encephalitis Virus distribution
Western US, Western Canada, S. America
Bacterial meningitis Most common: children & young adults
Neisseria meningitidis
Polio clinical features
– Inapparent-mild 90% cases
– Non-paralytic: Meningitis 8% cases (self-limiting)
– Paralytic disease 1% cases
– Polio encephalitis: Rare
– Incubation 1-2 wks
– Infection & death anterior horn cells (grey matter)
CDC PEP Recommendations of rabies
– Wash all wounds with soap and water
– 1 dose of HRIG & 4 doses of vaccine (Days 1, 3, 7 & 14 + 2 boosters on Day 0 and 3)
Bacterial causes of meningitis
4-6 mnths
N. meningitides,
S. pneumoniae,
H. influenzae
OVerv view of sx for viral meningitis
Usually acute benign, self-limiting, monophasic
– Symptoms: cranial neuropathy & raised intracranial pressure uncommon
Histoplasma capsulatum seen in
Immunosuppressed
– AIDS
– Solid organ transplants
Monkey handlers or monkey bite
Herpes B encephalitis
West Nile Virus- what type of virus
Flavivirus
Most frequently observed cause of bacterial meningitis (61% total cases, US)
Streptococcus pneumoniae
Lymphocytic choriomeningitis Seasonality
Winter
Coccidioides spp
• Geographic location
Central & Southern Arizona + Central Valley of California
4-6 mnths Bacterial meningitis
N. meningitides, S. pneumoniae, H. influenzae*
– Increased lymphocytes – Self limiting – Viral or non infectious (Absence of cultivable bacteria or fungi)
Aseptic (acute)
Kernig’s sign
Look up pic Elevate legs

Cryptococcus neoformans seen in
Immunosupressed & previously infected healthy
Overcrowding
Meningococcal meningitis
Rabies virus type
Rhabdoviridae
Transmission of prion dz
– Sporadic: CJD (85% cases), 50-75 year olds
– Inherited: GSS, FFI (10-15%)
– Ingested: Kuru (mostly disappeared)
– Iatrogenic: corneal transplants, contaminated EEG implants, possibly contaminated human growth factor
AIDS, other CM1 defects
C. neoformans
Hydatid Disease
Echinococcus species
Liver (75%) and lungs (15%) brain parenchyma
Paragonimiasis
Paragonimus
Lungs
Coccidioides spp seen in
CA-pneumonia,
Immunosuppressed individuals (AIDS)
Dx of polio
– CSF: PMN early→lymphocytes, ↑protein, normal
glucose
– CSF: RT-PCR
• Most common VIRAL CAUSES of meningitis
: Enteroviruses
Haemophilus influenzae Prevention:
Vaccine: Hiberix
Uncapsulated are becoming a problem… can not use current drugs against them
Histoplasma capsulatum Dx
– Histoplasma antigen
(CSF) – Cultures -ve
Rare invasion of the brain
Protazoa implicated
Entamoeba histolytica
Nipah Virus encephalitis
Malaysia
Eastern equine virus transmission cycle
