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CNS CLERKSHIP > CNS infections > Flashcards

CNS infections Flashcards

1
Q

Untreated CNS infection may lead to?

A
  • Brain herniation and death.

- Cord compression and necrosis with subsequent permanent paralysis.

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2
Q

Describe pyogenic meningitis.

A

Thick layer of suppurative exudate covering leptomeninges over brain surface. With exudate in basal and convexity surface.

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3
Q

Thick layer of suppurative exudate covering leptomeninges over brain surface. With exudate in basal and convexity surface.

A

Pyogenic meningitis.

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4
Q

Microscopic findings in pyogenic meningitis?

A

Neutrophils in subarachnoid space.

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5
Q

Treatment of community acquired meningococcal meningitis?

A

Ceftriazone IV 2g BD for 5 days.

If penicillin allergic: Chloramphenicol IV 25mg/kg QDS.

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6
Q

Treatment of community acquired pneumococcus meningitis?

A

10 days Ceftriaxone IV 2g BD (If penicillin allergic: Chloramphenicol IV 25mg/kg QDS)
+ 4 days Dexamethasone IV 10mg QDS.

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7
Q

Viral meningitis is common in which seasons?

A

Late summer/autumn.

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8
Q

Viral meningitis is typically due to which viruses?

A

Enteroviruses e.g. ECHO virus.

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9
Q

Diagnosis of viral meningitis is by?

A
  • Viral stool culture.
  • Throat swab.
  • CSF PCR.
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10
Q

Treatment of viral meningitis?

A

Generally supportive as condition is self-limiting.

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11
Q

Symptoms of meningitis and septicaemia?

A
  • Fever.
  • Headache.
  • Vomiting, diarrhoea.
  • Muscle pain.
  • Stomach cramps.
  • Fever with cold hands and feet.
  • Stiff neck, dislikes bright lights, convulsions/seizures.
  • Drowsy/difficult to wake.
  • Confused and irritable.
  • Pale, blotchy skin, spots/rash.
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12
Q

Which pathogen is typically responsible for community acquired bacterial meningitis in neonates?

A

Listeria, Group B Strep, E. Coli.

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13
Q

Which pathogen is typically responsible for community acquired bacterial meningitis in children?

A

H. influenza.

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14
Q

Which pathogen is typically responsible for community acquired bacterial meningitis in ages 10-21?

A

Neisseria meningitidis.

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15
Q

Which pathogen is typically responsible for community acquired bacterial meningitis in those over 21 but younger than 65?

A

Strep. pneumoniae > Neisseria meningitidis.

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16
Q

Which pathogen is typically responsible for community acquired bacterial meningitis in those over 65?

A

Strep. pneumoniae > Listeria.

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17
Q

Risk factor for developing community acquired Listeria monocytogenes meningitis?

A
  • Decreased cell mediated immunity.
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18
Q

Risk factor for developing community acquired Staph. or Gram negative bacilli meningitis?

A

Neurosurgery/head trauma.

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19
Q

Risk factor for developing community acquired Strep. pneumoniae meningitis?

A

Fracture of cribriform plate.

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20
Q

Basilar skull fracture predisposes to bacterial meningitis of which causative pathogen?

A
  • Strep. pneumoniae.
  • H. influenzae.
  • Beta-haemolytic Strep group A.
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21
Q

Head trauma or post-neurosurgery predisposes to bacterial meningitis of which causative pathogen?

A
  • Staph. aureus.
  • Staph. epidermidis.
  • Aerobic GNR (gram -ve bacilli).
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22
Q

CSF shunt predisposes to bacterial meningitis of which causative pathogen?

A
  • Staph. epidermidis.
  • Staph. aureus.
  • Aerobic gram -ve bacilli.
  • Propionibacterium acnes.
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23
Q

Immunocompromised state predisposes to bacterial meningitis of which causative pathogen?

A
  • Strep. pneumoniae.
  • N. meningitidis.
  • Listeria.
  • Aerobic gram -ve bacilli inc. pseudomonas aeruginosa.
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24
Q

A complication of bacterial meningitis includes purulence, resulting in?

A
  • Clusters at base of brain.
  • Convexities of rolandic and sylvian sulci.
  • Exudate around nerves (CN III, VI are esp. vulnerable).
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25
Q

What prevents meningitis from becoming an abscess?

A

Pia mater.

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26
Q

Abscesses may cause secondary ventriculitis and thus?

A

Meningitis.

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27
Q

A complication of bacterial meningitis includes?

A
  • Purulence.
  • Invasion.
  • Cerebral oedema (temporal vs cerebellar).
  • Ventriculitis/hydrocephalus.
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28
Q

Symptoms of meningococcal meningitis are due to what?

A

Endotoxin.

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29
Q

Meningococcal meningitis most often occurs in who?

A

Young children.

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30
Q

N. meningitidis is carried where?

A

In the throat of healthy carriers.

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31
Q

Where might N. meningitidis be found in CSF?

A

In leukocytes.

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32
Q

What does H. influenzae require for growth?

A

Blood factors.

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33
Q

Most common meningitis causing type of H. influenzae in those under 4 years old?

A

H. influenzae type b.

34
Q

S. pneumoniae is commonly found where?

A

Nasopharynx

35
Q

Who is most susceptible to S. pneumoniae meningitis?

A
  • Hospitalised.
  • CSF skull fractures.
  • Diabetics/alcoholics.
  • Young children.
36
Q

Describe Listeria monocytogenes histologically.

A

Gram positive bacilli causing mainly bacteraemic illness.

37
Q

Who is most commonly affected by Listeria monocytogenes?

A
  • Neonates.
  • > 55 y/o.
  • Immunosuppressed esp. malignancy.
38
Q

Antibiotic of choice against Listeria monocytogenes?

A
  • IV ampicillin/amoxicillin.
39
Q

Listeria monocytogenes is intrinsically resistant to which antibiotic?

A

Ceftriaxone.

40
Q

Tuberculous meningitis is common in who due to what?

A

Elderly due to disease reactivation.

41
Q

How does Tuberculous meningitis present?

A

Often as non-specific ill health.

42
Q

Management of Tuberculous meningitis?

A
  • Rifampicin.
  • Isoniazide.
    and then add:
  • Pyrazinamide.
  • Ethambutol.
43
Q

Cryptococcal meningitis is due to which type of organism?

A

Fungus.

44
Q

Cryptococcal meningitis is associated with which disease?

A

HIV.

45
Q

Test for Cryptococcal meningitis?

A

Serum and CSF cryptococcal antigen.

46
Q

Management of Cryptococcal meningitis?

A
  • IV Amphotericin B/ Flucytosine.

- Fluconazole.

47
Q

Treatment algorithm for someone with suspected meningitis with no allergies, under 60 years old?

A
  • Cefotaxime 2g QDS OR Ceftriaxone 2g BD IV.

+ Dexamethasone 10mg QDS IV.

48
Q

Treatment algorithm for someone with suspected meningitis with no allergies, over 60 years old?

A
  • Cefotaxime 2g QDS OR Ceftriaxone 2g BD IV.
    + Dexamethasone 10mg QDS IV.
    + Amoxicclin 2g IV every 4 hours.
49
Q

What would be added to the treatment algorithm for someone with suspected meningitis and no allergies, where there is suspicion of penicillin resistant pneumococci?

A

+ Vancomycin 15-20mg/kg BD.
OR
+ Rifampicin 600mg BD.

50
Q

Treatment algorithm for someone with suspected meningitis with a penicillin or cephalosporin allergy, under 60 years old?

A
  • Chloramphenicol 25 mg/kg QDS IV.

- Dexamethasone 10mg QDS IV.

51
Q

Treatment algorithm for someone with suspected meningitis with a penicillin or cephalosporin allergy, over 60 years old?

A
  • Chloramphenicol 25 mg/kg QDS IV.
  • Dexamethasone 10mg QDS IV.
  • Co-trimoxazole 10-20mg/kg (of trimethroprim component) in four divided doses.
52
Q

Clinical signs of bacterial meningitis?

A
  • Fever.
  • Stiff neck.
  • Alteration in consciousness.
53
Q

Symptoms of bacterial meningitis?

A
  • Headache.
  • Vomiting.
  • Pyrexia.
  • Stiff neck.
  • Photophobia.
  • Lethargy.
  • Confusion.
  • Rash.
54
Q

How many tubes of CSF in lumbar puncture?

A

4

55
Q

What should be asked for in CSF interpretation?

A
  • Haematology: cell count, differential. TWICE.
  • Microbiology: gram stain and culture.
  • Chemistry: glucose and protein.
56
Q

CSF is 99% predictive of bacterial meningitis if?

A
  • WBCC >2000.
  • Neutrophils >1180.
  • Protein > 220 mg/dl.
  • Glucose <34 mg/dl.
  • Glucose (CSF/serum) <0.23.
57
Q

What infections, other than bacterial meningitis cause neutrophilic pleocytosis and low CSF glucose?

A
  • Viral meningitis (early stage).
  • Parameningeal foci/cerebritis.
  • Leakage of brain abscess into ventricle.
  • Amoebic meningoencephalitis.
  • TB meningitis (rare, usually early stage only).
58
Q

What are the non-infectious causes of neutrophilic pleocytosis and low CSF glucose?

A
  • Chemical meningitis e.g. due to contrast.
  • Behcet syndrome.
  • Drug-induced (NSAIDs).
59
Q

What is aseptic meningitis?

A

Non-pyogenic bacterial meningitis.

60
Q

What spinal fluid composition is typically seen in aseptic meningitis?

A
  • Low WBCC.
  • Minimally elevated protein.
  • Normal glucose.
61
Q

Name an infectious cause of aseptic meningitis?

A
  • HSV 1 and 2.
  • Syphilis.
  • Listeria.
  • TB.
  • Cryptococcus.
  • Leptopspirosis.
  • Cerebral malaria.
  • African tick typhus.
  • Lyme disease.
62
Q

Name a non-infectious cause of aseptic meningitis?

A
  • Carcinoma.
  • Sarcoidosis.
  • Vasculitis.
  • Dural venous sinus thrombosis.
  • Migraine.
  • drugs: Co-trimoxazole, NSAIDs.
63
Q

Indications for hospital admission in acute adult bacterial meningitis?

A
  • Signs of meningeal irritation.
  • Impaired conscious level.
  • Petechial rash.
  • Febrile/unwell with recent fit.
  • Any illness esp. headache with meningococcal infection even if received prophylactic antibiotic.
64
Q

Immediate management following hospital admission in acute adult bacterial meningitis?

A
  • Blood: culture and coagulation screen.
  • Initial antibiotic therapy until pathogens identified.
  • Throat swab to be plated ASAP.
  • Disrupt and swab/aspirate any petechial or purpuric skin lesions for microscopy and culture.
65
Q

Who needs CT before lumbar puncture?

A
  • Immunocompromised.
  • History of CNS disease.
  • New onset seizure.
  • Papilloedema.
  • Abnormal conscious level.
  • Focal neurological deficit.
66
Q

All adults with suspected meningits should undergo lumbar puncture except when?

A
  • Clear contraindication exists or there is confident clinical diagnosis of meningococcal infection with typical meningococcal rash.
67
Q

What should be given before lumbar puncture in adults with suspected acute bacterial meningitis?

A

Antibiotics.

68
Q

What causes meningococcal meningitis?

A

N. meningitidis.

69
Q

What should be given to all patients suspected of bacterial meningitis?

A

Steroids.

Antibiotics - Ceftriaxone or Chloramphenicol + Vancomycin if penicillin allergic.

70
Q

How should steroids be administered to patients suspected of bacterial meningitis?

A

10mg IV 15-20 minutes before or with the first dose of antibiotics. Then every 6 hours for 4 days.

71
Q

When should steroids not be given in suspected bacterial meningitis?

A
  • Post surgery.
  • Severe immunocompromise.
  • Meningococcal or septic shock.
  • If hypersensitive to steroids.
72
Q

What features on admission may suggest meningococcal meningitis in adults?

A
  • Haemorrhagic diathesis.
  • Deteriorating consciousness.
  • Multi-organ failure.
  • Rapidly developing rash.
  • Age >60.
73
Q

What is haemorrhagic diathesis?

A
  • Tendency to bleed (spontaneously, excessively, delayed onset etc).
74
Q

How does meningitis (of all types) in adults typically present on admission?

A
  • Tachycardia.
  • GCS <12 on admission.
  • Low GCS.
  • Cranial nerve palsy.
  • Seizures within 24 hours.
  • Hypotension.
  • Age >60.
75
Q

Initial management of bacterial meningitis with low GCS (<12) of fluctuating conscious level (fall in GCS of >2)?

A
  • High supervision area.
  • Baseline investigations.
  • Secure airway.
  • High flow O2.
  • IV 2g Ceftriaxone stat (+/- amoxicillin if >55 to cover listeria).
  • IV corticosteroids.
  • Don’t wait for CT scan/LP.
76
Q

Prevention of secondary meningitis?

A
  • Report to public health/Health protection all suspected cases ASAP to ensure appropriate measures used.
  • GPs must be aware of prevention policies to locate close contacts + implement chemoprophylaxis and vaccination.
  • GP records of close contacts of meningococcal disease should be labelled as increased risk for 6 months.
77
Q

Rifampicin contact prophylaxis regime of bacterial meningitis?

A

Rifampicin:

  • > 12 years: 600mg PO 12-hourly for 4 doses.
  • 3-11 months: 10mg/kg PO/IV 12-hourly for 4 doses.
78
Q

What warnings must be given to those on Rifampicin contact prophylaxis regime of bacterial meningitis?

A
  • Reduced efficacy of oral contraceptives.
  • Red urine.
  • Staining of contact lenses.
79
Q

Ciprofloxacin contact prophylaxis regime of bacterial meningitis?

A
  • 500mg PO single dose if >12 years. Avoid in younger children.
    NB this is not yet licensed but has been used extensively in school + community outbreaks.
80
Q

Ceftriaxone contact prophylaxis regime of bacterial meningitis?

A
  • Adults: 250mg IM single dose.

- <12 years: 125mg IV single dose.

81
Q

What vaccines may be given to prevent bacterial meningitis?

A
  • Neisseria meningitidis.
  • HiB.
  • Strep. pneumoniae.
82
Q

Meningococcal bacteria colonises what?

A

Nasopharynx of humans.

CNS CLERKSHIP (43 decks)

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