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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
Post-infectious encephalomyelitis - what is it?
Acute disseminated encephalomyelitis often follows many infections Rarely 1-2 weeks after immunisation Monophasic illness Caused by immune mediated host response to infection
26
Epidemiology of post-infectious encephalomyelitis
Typically young children and adults
27
Treatment of post-infectious encephalomyelitis
Steroids and anticonvulsants
28
Autoimmune encephalitis presentation
Limbic encephalitis, psychiatric disturbances and seizures
29
3 egs of autoimmune encephalitis
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
Treatment of autoimmune encephalitis
IV immunoglobulin or plasma exchange | Followed by steroids
31
What is a brain abscess?
Focal encapsulated area of infection
32
Stages of a brain abscess?
Passes through them over about 2 weeks Localised suppurative cerebritis (brain infection with suppuration) To complete encapsulation
33
What causes brain abscesses to develop?
Conditions that cause tissue necrosis with simultaneous infection by an appropriate organism - leads infection to reach brain by local spread or bloodstream
34
Disease states which predispose to abscess
Chronic Lung Infection Congenital Heart Disease (esp R-L shunts) Bacterial Endocarditis Infections in immunocompromised
35
Bacterial usually causative of abscess
Streptococcus Bacteriodes Enterobacteria Staph A
36
What infective agents are more common in causing abscesses in immunosuppressed?
Fungi and protozoa | eg. toxoplasma, candida, listeria
37
Presentation of abscess x 5
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
Signs on investigation with an abscess
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
Treatment of abscess
1) Antibiotics 2) Surgical drainage or excision 3) Treat raised ICP and seizures 4) Treat source of infection
40
Prognosis of abscess
Mortality has fallen (5-15%) | Can have neurological deficits, seizures, hemiparesis, speech and language disorders (all less than 50%)
41
What is neurosyphilis caused by?
Spirochaete - Treponema pallidum
42
When does neurological involvement occur in syphilis?
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
Treatment of neurosyphilis
Parenteral benzylpenicillin for 2-3weeks Neurological disease can be arrested but not reversed
44
Adverse effect associated with neurosyphilis treatment
Allergic reaction - Jarisch-Herxheimer - by endotoxin produced by spirochaete when treated with antibiotics Therefore penicillin often given with steroids
45
The different presentations of neurosyphilis x 3
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
What are neuropathic joints?
Charcots joints | Painless joint damage
47
What are argyll robertson pupils?
Small, irregularly shaped pupils Do not react to light But do accommodate Occur in neurosyphilis but can also occur in diabetic retinopathy
48
Occurrence of neurological symptoms in HIV patients - 3 features
80% of patients get them Either directly or via opportunistic infections Can be CNS or PNS or both
49
3 types of Primary HIV infection neurological abnormalities
HIV encephalopathy (AIDS dementia) HIV myelopathy Acute atypical meningitis - self-limiting and occurs at seroconversion
50
Opportunistic infections causing neurological deficits in HIV
CNS toxoplasmosis Cryptococcal meningitis JC virus CMV, HSV2, VZV, Candida, Aspergillus
51
3 other neurological deficits in HIV
Neoplasia - CNS lymphoma Peripheral neuropathy Myopathy
52
Tetanus, Rabies, Malaria, TB
Can all cause neurological deficits - more details in notes

Neurology (10 decks)

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