CNS Infections Flashcards
T/F you can do a lumbar puncture when they have a raised ICP
false. Do a ct head and fundoscopy first. if a mass or papilledema is present–> do not puncture
T/F you can do a LP when the INR is >1.4
false.
Lumbar Punctures
When NOT to:
- Raised ICP: do a CT head and fundoscopy first. If a mass or papilledema is present→ DO NOT PUNCTURE!!
- Bleeding risk: INR>1.4, or platelets <50.
T/F meningitis causes a focal neuro deficit
false. it is an infection of the meninges as a whole.
Fever, neck stiffness, change in mental status, focal neurological signs, seizures, petechial rash
Bacterial meningitis–> should isolate patient immediately
key infections that cause meningitis
Neonates: group B strep, E Coli, listeria monocytogenes
infants/children: strep pneumo, N. meningitis, Hib
adolescents/young adults: strep pneumo, N. meningitidis
Older adults: strep pneumo, N. meningitidis, listeria monocytogenes.
Risk factors of meningitis
patients with a splenectomy, sickle cell anemia, CSF leak, cochlear implants, those who are immunocompromised
these two MSK signs can help diagnose bacterial meningitis
Brudzinski’s sign: hip flex in response to knee flexion
Kernigs sign: pain in hamstring with knee extension
When to skip the lumbar puncture and start treatment for bacterial meningitis (PIGCSF)
P: papilledema
I: Immunocompromised
G: GSC ov 10 or lower
CNS seizures
S: seizures
F: focal neuro deficit.
immediately start ceftriaxone, vancomycin and steorids.
if a patient is over 65, what should you add to the meningitis ABX treatment?
add ampicillin in addition to the ceftriaxone, steroids and vanco
vaccination that can prevent against meningitis
pneumococcal conjugate vaccine
Tubercular Meningitis management (RIPE)
rifampin
isoniazid
pyrazinamide
ethambutol
outline how tubercular meningitis CBC profile changes upon duration of the disease
Investigations: MRI: cavitation lesions in the brain. LP: TB features, shifts from PMN dominant (day 1-21), and thne switches to lymphocytes
Identify the cerebrospinal fluid (CSF) profiles associated with bacterial, viral, fungal, syphilitic, and tuberculous neurological infections
Elevated WBC: lymphocytes suggest __ or __. ___ suggest bacterial
Elevated RBCs/xanothochromia: __ tap, __
Glucose: if low, __ infection. If normal, __/__ infections
Protein: __= viral, fungal, if __– bacterial
Elevated WBC: lymphocytes suggest viral or fungal. Neutrophils suggest bacterial
Elevated RBCs/xanothochromia: Traumatic tap, HSV
Glucose: if low, bacterial infection. If normal, viral/fungal infections
Protein: normal= viral, fungal, if elevated– bacterial
LP tap profile in someone with HIV
LP would be normal. Management is with HAART
PNS and CNS symptomsof HIV
PNS: myositis, distal sensory polyneuropathy, muscle pain. Autonomic involvement. Acute/chronic inflammatory demyelinating polyradiculopathy:lymphocytes+protein in CSF
CNS: motor neuron disease-like illness9 mix of UMN and LMN),
HIV-associated vacuolar myelopathy: in 50% of HIV patient on autopsy. UMN signs, autonomic signs (ED, urinary incontinence), progressive sensory deficits in the legs
- Dementia
Herpes Zoster (shingles)
Definition: reactivation of latent ___ __ virus
Symptoms: sharp burning itch with __→ very painful
Management:
Prevention: __ (over 50), Zostivax (over 60)
During the infection: __.
Herpes Zoster (shingles)
Definition: reactivation of latent varicella zoster virus
Symptoms: sharp burning itch with allodynia→ very painful
Management:
Prevention: Shingrix (over 50), Zostivax (over 60)
During the infection: acyclovir.
Post Herpetic Neuralgia (PHN)
Definition: pain ___+ after ___
Management:
1st line: ___ + capsaicin skin patches
2nd line: ___ and __
3rd line: notriptiline, __, venlafaxine
4th line: __
Post Herpetic Neuralgia (PHN)
Definition: pain 2mo+ after shingles
Management:
1st line: lidocain + capsaicin skin patches
2nd line: lyrica and gabapentin
3rd line: notriptiline, amitriptylin, venlafaxine
4th line: opioids
person comes in with fever, headache, back pain, fatigue, pharyngitis, conjunctivitis, and a tremor and confusion.
CSF shows lymphocyte pleocytosis, elevated protein and normal glucose
Dx?
elevated protein - more likely to be viral, normal glucose = less likely to be bacterial.
tremor and pharyngitis is key for WEST NILE VIRUS
West Nile Virus
Symptoms: fever, headache, back pain, fatigue, __, __
Neurological: __ IN 94% of patients, myoclonus, parkinsonism, confusion.
Direct infection of __ horn cells causes __-like __ __ paralysis
Labs:
CSF: lymphocytic pleocytosis (<1000cells, median 170), normal or elevated __,normal __.
Viral serology: diagnostic standard
Imaging: meningeal, __, __ abnormalities
Management: supportive
West Nile Virus
Symptoms: fever, headache, back pain, fatigue, pharyngitis, conjunctivitis
Neurological: TREMOR IN 94% of patients, myoclonus, parkinsonism, confusion.
Direct infection of anterior horn cells causes poliomyelitis-like acute flaccid paralysis
Labs:
CSF: lymphocytic pleocytosis (<1000cells, median 170), normal or elevated protein,normal glucose.
Viral serology: diagnostic standard
Imaging: meningeal, thalamic, BG abnormalities
Management: supportive
Brain Abscess:
Definition: inflammation and collection of infected material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal bone, epidural abscess) or remote (lung, heart, kidney). Infectious sources, within the brain tissue
Symptoms? Etiology? Management?
Symptoms: headache, confusion, slurred speech, weakness, numbness, +/- LOC, +/-twitching of arm or leg
Etiology: usually polymicrobial
S.viridans, S.milleri, S.aureus, S.pneumo, B.fragilis commonly found - Nocardiosis to be considered
Natural Course:
- Day 1-2: cerebritis
- Day 2-7: Central Necrosis
- Day 5-14: Early encapsulation
- Day 14+: late encapsulation
Management: vanco+penicillin + flagyl + ceftriaxone + dexamethasone + surgical drainage
Complications: Meningitis, ventriculitis
Classic triad for spinal epidural abscess
Symptoms: Classic Triad= back pain + fever + neurological deficit
Etiology: staph from IVDU, endocarditis, UTI, lung infections→ STAPH AUREUS #1
Risk factors: immunocompromised, alcoholic, diabetes
Investigations: STAT MRI with contrast or CT with contrast, blood cultures, urinalysis + culture, sputum cultures
Management:
Empiric ABX: Vancomycin + ceftriaxone
Neurosurgery decompression stat.
1 cause of adult-onset seizures in the world
Neurocysticercosis
Etiology: pork/pig tapeworm
Epi: #1 cause of adult-onset seizures in the world
Time from infection → symptomatic can be 6 months to 30 years (average 5 years)
Signs and Sx: seizures, long term muscle pain. Symptoms can take years to occur after infection. Will see cyst with dot inside.
Treatment: albendazole.
*Order an X-ray of thighs.
Outline the stages of lyme disease. Maangement?
3 stages:
Erythema Migrans (2-30 days)
Weeks to months later: 2nd stage→ systemic features
- Cardiac: arrhythmias, myopericarditis, ventricular dysfunction
- Neurologic; viral meningitis (headache, stiff neck, mildly wrong CSF), cranial neuropathy, polyneuropathy, radiculopathy, polyradiculopathy, polyradiculoneuropathy
- Pain, numbness, paraesthesias, weakness, decreased DTRS in a specific pattern
- Brachial plexopathy, lumbosacral.
3rd stage: months to years
- Cardiac: carditis
- Large joint arthritis
- Neurologic: chronic encephalomyelopathy: memory dysfunction, mild cognitive changes, psychiatric symptoms.
Management: doxycycline or minocycline
Rapidly progressive dementias:
Viruses: HSV encephalitis, HIV dementia, progressive multifocal leukoencephalopathy (PML
Fungal infections: parasites
Syphilis
creutzfeldt-Jakob disease (CJD)
Neurosyphilis
Etiology: treponema pallidum
Symptoms: Rapidly progressive cognitive and personality changes and dementia, loss of __ ___ sensation, non-reactive pupils
Main form of treatment?
Neurosyphilis
Etiology: treponema pallidum
Symptoms: Rapidly progressive cognitive and personality changes and dementia, loss of dorsal column sensation, non-reactive pupils\
Stages of Syphilis:
- Primary (3-90d): chancre (genital ulcer)
- Secondary (4-10wk): fever, headache, rash, generalized lymphadenopathy, alopecia, hepatitis, GI/renal symptoms, wart-like lesions on genitalia
- Tertiary (2-15yr): meningeal syphilis (headache, photophobia, N/V, cognitive changes, CN palsies, seizures), tabes dorsalis (loss of coordination of movement, sensory ataxia, shooting pains, loss of dorsal column function), meningovascular disease (inflammation of CNS vessels leading to thrombosis and infarction- usually MCA), chronic meningoencephalopathy (progressive dementia, neuropsych, personality changes, emotional lability, fatigue, sleep disturbances)
- Latent: positive serology with no signs/symptoms
MANAGE WITH PENICILLIN G
Investigations:
- CSF (send to venereal disease research lab)
- Serum (send to rapid plasma regain) Management: penicillin G
Management: Penicillin G
HSV Encephalitis
Symptoms: like bacterial meningitis (headache, photophobia, sore neck), seizures, confusion, behavioural changes, aphasia
Investigations:
- LP (xanthochromia due to hemorrhage not just traumatic tap; PCR)
- MRI
- EEG
Management: IMMEDIATELY r____ ___
Complications: mortality rate is 20%
HSV Encephalitis
Symptoms: like bacterial meningitis (headache, photophobia, sore neck), seizures, confusion, behavioural changes, aphasia
Investigations:
- LP (xanthochromia due to hemorrhage not just traumatic tap; PCR)
- MRI
- EEG
Management: IMMEDIATELY IV acyclovir
Complications: mortality rate is 20%
An opportunistic infection seen in immunosuppressed patients, which is often laying dormant in the kidney. Tends to target oligodendrocytes and cause demyelination. There is no treatment.
Progressive Multifocal Leukoencephalopathy (PML)/ John Cunningham (JC) Virus
Definition: opportunistic infection seen in immunosuppressed patients (HIV, immunosuppressant meds)
Epi: most people have latent JC virus (in their kidney)
Mechanism: targets oligodendrocytes → demyelination
Symptoms: vary based on where in the brain infects. “Usual” symptoms are confusion, weakness, visual field cuts (homonymous hemianopia), sensory changes, gait impairment. New neuro symptoms in a immunosuppressed individuals
Investigations: MRI (multiple lesions) + CSF + PCR are needed for dx
Management: no treatment, treat underlying (treat HIV or stop immunosuppressants)
Prognosis: serious neurological deficits are common
Definition: a prion disease leading to degeneration of brain
Symptoms: cognitive decline, myoclonus, weakness, ataxia, visual field deficits
Creutzfeldt Jakob disease CJD
T.Gondii can cause encephalitis, lymph node/liver/spleen enlargement, pneumonitis, chorioretinitis. What is the prophylactic treatment and management for this?
Management:
- Prophylaxis: septra
- Treatment: pyrimethamine + sulfadiazine + folinic acid (to avoid bone marrow toxicity)
A hippy in vancouver comes in with
headache, moody, arm weakness, bilateral tonic-clonic seizure.
What do you suspect and how do you treat?
Cryptococcus Gattii Meningitis:
Etiology: hotspot in Canada is Vancouver Island– spores found in nature
Treatment: sulfadiazine and pyrimethamine, folinic acid.
Symptoms: headache, moody, arm weakness, bilateral tonic-clonic seizure.
