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Neurology > CNS infections > Flashcards

CNS infections Flashcards

1
Q

8 opportunistic CNS infections

A

1) HIV encephalopathy
2) CMV encephalitis
3) Aspergillosis
4) Primary CNS lymphoma/PTLD - post transplant lymphoproliferative disease
5) Aspergillosis
6) Cerebral toxoplasmosis
7) Progressive multifocal leukoencephalopathy = JC virus
8) Nocardia

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2
Q

8 other CNS infections

A

1) TB meningitis
2) Cerebral malaria
3) Neurosyphilis
4) Rabies
5) Acute poliomyelitis
6) Tetanus
7) GBS - group b strep
8) ADEM - acute disseminated encephalomyelitis - inflammatory flare up of CNS white matter causing demyelination - like MS but one flare up as opposed to multiple and can occur in children and lead to coma/death

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3
Q

3 routes of entry for CNS infection

A

Blood-borne (BBB or Blood-CSF barrier)
Neural - replication at peripheral site and then transportation up the axons
Direct invasion

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4
Q

What position and where do you do lumbar puncture?

A

Left lateral decubitus position with knees drawn up and neck flexed
In between L3 and L4 (level of iliac crest) because termination of spinal cord

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5
Q

What is meningitis?

A

Inflammation of the meninges - abnormal number of WBC’s in the CSF

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6
Q

Hallmarks of meningitis

A

Meningism
- Headache, N and V, neck and back stiffness and photophobia

If fever too and acute symptoms presentation then query infectious meningitis

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7
Q

Features of bacterial meningitis

A

Life threatening, poor prognosis, fever, altered consciousness, very unwell

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8
Q

Common bacteria in bacterial meningitis x4

A

Neisseria meningitidis (meningococcus)
Haemophilus influenzae
Strep pneumoniae (pneumococcus)
Listeria monocytogenes

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9
Q

Common bacteria in baby meningitis x 3

A

Group B strep (strep agalactiae),
E.coli
Listeria monocytogenes (typically affects children, elderly, pregnant women and immunocompromised adults)

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10
Q

Immunosuppressed meningitis infective agents x2

A

Listeria monocytogenes

Cryptococcus neoformans

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11
Q

CSF in bacterial meningitis x4

A

Raised protein (>1g - 0.4g = normal)
Raised CSF pressure
Clear colourless
White cell count v.raised - predominantly neutrophils

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12
Q

Meningococcal meningitis features

A

Young children and susceptible adolescents
Abrupt onset
Often accompanied by haemorrhagic, non-blanching skin rash of meningococcal septicaemia

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13
Q

Treatment of bacterial meningitis

A

Cefotaxime + ampicillin if >55 years

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14
Q

Viral meningitis features

A

Less severe, typically benign and self-limiting

Headache, photophobia and vomiting
But no LOC and patient appears generally well

Mild pleocytosis

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15
Q

Eg of infective viruses in viral meningitis x4

A

Enteroviruses (polio)
Mumps virus (50% no parotid swelling, can present before, during or after swelling)
HSV
HIV seroconversion illness

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16
Q

Focal neurological signs with meningitis

A

Indicates TB or abscess

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17
Q

What is encephalitis?

A

Inflammation of brain parenchyma - usually viral

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18
Q

Symptoms of encephalitis x5

A

Fever and meningism can occur

Behaviour and personality change is a common early manifestation

Progresses to reduced level of consciousness and coma

Seizures and focal neurological deficits are common

Many cause a mild self-limiting disease with headache and drowsiness

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19
Q

Causes of viral encephalitis in UK x5

A

HSV (commonest cause), VZV, other Herpes virus, Mumps, Adenovirus

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20
Q

Causes of viral encephalitis outside of UK x4

A

Japanese Encephalitis, West Nile Virus, Tick-borne encephalitis, Rabies

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21
Q

Which lobe often affected in HSV encephalitis?

A

Temporal Lobe - will show up on EEG and MRI

22
Q

Treatment of viral encephalitis

A

Urgent aciclovir

23
Q

CSF in encephalitis

A

White cells and protein raised
Clear and colourless
CSF pressure normal or slightly raised

24
Q

Mortality of HSV encephalitis and morbidity

A

80% without treatment and 30% with

Memory loss, personality change and epilepsy following infection

25
Q

Post-infectious encephalomyelitis - what is it?

A

Acute disseminated encephalomyelitis often follows many infections

Rarely 1-2 weeks after immunisation

Monophasic illness

Caused by immune mediated host response to infection

26
Q

Epidemiology of post-infectious encephalomyelitis

A

Typically young children and adults

27
Q

Treatment of post-infectious encephalomyelitis

A

Steroids and anticonvulsants

28
Q

Autoimmune encephalitis presentation

A

Limbic encephalitis, psychiatric disturbances and seizures

29
Q

3 egs of autoimmune encephalitis

A

1) Paraneoplastic limbic encephalitis
- typically with small cell lung cancer and testicular tumours
- antibodies in 60% of cases
- preceeds cancer diagnosis

2) Voltage-gated potassium channel limbic encephalitis
- older patients >50
- get faciobrachial dystonic seizures and neuromyotonia

3) Anti-NMDA
- younger women
- often ovarian teratomas

30
Q

Treatment of autoimmune encephalitis

A

IV immunoglobulin or plasma exchange

Followed by steroids

31
Q

What is a brain abscess?

A

Focal encapsulated area of infection

32
Q

Stages of a brain abscess?

A

Passes through them over about 2 weeks
Localised suppurative cerebritis (brain infection with suppuration)
To complete encapsulation

33
Q

What causes brain abscesses to develop?

A

Conditions that cause tissue necrosis with simultaneous infection by an appropriate organism - leads infection to reach brain by local spread or bloodstream

34
Q

Disease states which predispose to abscess

A

Chronic Lung Infection
Congenital Heart Disease (esp R-L shunts)
Bacterial Endocarditis
Infections in immunocompromised

35
Q

Bacterial usually causative of abscess

A

Streptococcus
Bacteriodes
Enterobacteria
Staph A

36
Q

What infective agents are more common in causing abscesses in immunosuppressed?

A

Fungi and protozoa

eg. toxoplasma, candida, listeria

37
Q

Presentation of abscess x 5

A

1) Short 1 month history and progressive

2) Signs of SOL and raised ICP
- Headache
- Vomiting
- Deteriorating consciousness
- Papilloedema

3) Focal features
- Seizures
- Hemiparesis
- Dysphasia
- Visual field defects

4) Signs of systemic infection
- Fever
- Malaise

OR

5) Signs of focal infection
- Ear ache
- Cough

38
Q

Signs on investigation with an abscess

A

CT or MRI - ring of enhancement - usually spherical - surrounding area of oedema

May be ventricular compression and midline shift (lumbar puncture contraindicated)

Look for primary cause of infection

39
Q

Treatment of abscess

A

1) Antibiotics
2) Surgical drainage or excision
3) Treat raised ICP and seizures
4) Treat source of infection

40
Q

Prognosis of abscess

A

Mortality has fallen (5-15%)

Can have neurological deficits, seizures, hemiparesis, speech and language disorders (all less than 50%)

41
Q

What is neurosyphilis caused by?

A

Spirochaete - Treponema pallidum

42
Q

When does neurological involvement occur in syphilis?

A

3rd stage of disease - typically many years later - in less than 10% of untreated cases

Often treated without knowing by penicillin for other infections

43
Q

Treatment of neurosyphilis

A

Parenteral benzylpenicillin for 2-3weeks

Neurological disease can be arrested but not reversed

44
Q

Adverse effect associated with neurosyphilis treatment

A

Allergic reaction - Jarisch-Herxheimer - by endotoxin produced by spirochaete when treated with antibiotics

Therefore penicillin often given with steroids

45
Q

The different presentations of neurosyphilis x 3

A

1) Meningovascular syphilis
- subacute meningitis with a gumma and paraparesis

2) Tabes Dorsalis
- demyelination in dorsal roots
- lightening pains usually in lower limb, chest or abdomen
- visceral crises
- sensory ataxia
- Neuropathic joints
- Argyll robertson pupils
- Ptosis and optic atrophy

3) General paralysis of insane
- psychiatric abnormality and weakness
- dementia, paralysis

46
Q

What are neuropathic joints?

A

Charcots joints

Painless joint damage

47
Q

What are argyll robertson pupils?

A

Small, irregularly shaped pupils
Do not react to light
But do accommodate

Occur in neurosyphilis but can also occur in diabetic retinopathy

48
Q

Occurrence of neurological symptoms in HIV patients - 3 features

A

80% of patients get them

Either directly or via opportunistic infections

Can be CNS or PNS or both

49
Q

3 types of Primary HIV infection neurological abnormalities

A

HIV encephalopathy (AIDS dementia)
HIV myelopathy
Acute atypical meningitis - self-limiting and occurs at seroconversion

50
Q

Opportunistic infections causing neurological deficits in HIV

A

CNS toxoplasmosis
Cryptococcal meningitis
JC virus
CMV, HSV2, VZV, Candida, Aspergillus

51
Q

3 other neurological deficits in HIV

A

Neoplasia - CNS lymphoma
Peripheral neuropathy
Myopathy

52
Q

Tetanus, Rabies, Malaria, TB

A

Can all cause neurological deficits - more details in notes

Neurology (10 decks)

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