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CNS infections Flashcards

1
Q

meningitis def

A

Inflammation of the arachnoid and pia mater in addition to the interposed CSF in the subarachnoid space

Extends throughout the subarachnoid space around the brain, spinal cord, and ventricles

med. emergency

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2
Q

clinical manifestations

A

ha, fever, menigismus + AMS

elderly may only present with lethargy, consider LP

insidious onset of symps >1 - several days

acute fulminant over sev. hrs -petechia over whole body

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3
Q

+ meningitis signs

A

Kernig

Brudzinski

CSF abnormalities

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4
Q

see slide 5

meningitis levels

A

bac: >1000 cells, PMNs, low glucose

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5
Q

presentation

A 
neck pain, photophobia
\+ Kernig's, Brudzinski's
-faint rash on lower legs
-close eyes, speech slurred: inc. CSF, inc. pressure on brain, at risk for herniation
*get CT before LP

-what to do next?
CT first, LP, blood Cx (i.e. pneumococcus meningitis)

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6
Q

abx?

A

ceftriaxone: high dose to penetrate CSF

+ vancomycin: empirical, slightly resistant org.

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7
Q

if suspect viral meningitis: tx

A

ADD acyclovir IV

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8
Q

meningococcal meningitis

A

Purulent CSF with G- IC and EC diplococci

Petechial or non-blanchable purpuric rash

*Terminal complement deficiency (C5-C9), @ risk for encap. org infections (gon, streph inf) asplenia, predispose patients to infection

Waterhouse - Friderichsen Syndrome: overwhelming sepsis–>intravasc. collapse-DIC

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9
Q

Kernig

A

lift knee up

+ if pain and opp. leg flexes up

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10
Q

Brudzinski

A

lift neck up

+ if pain and knees bend

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11
Q

Neisseria meningitis strains (meningococcal meningitis)

A

Groups A, B, C, Y, W-135

Vaccine does NOT cover serogroup B

40% of healthy hosts are nasopharyngeal carriers of meningococci
*most serious life-threatening form of bac meningitis

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12
Q

what to do with pt

A

Blood cultures, CT/MRI of brain, lumbar puncture
Do not delay IV antibiotics!
-ceftriaxone, vancomycin

Continue IV dosing until patient is afebrile for 4-5 days

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13
Q

steroids?

A

should be given early if given at all

  • controversial
    dec. ototoxicity
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14
Q

ppx?

A

close contacts
roommates, family in same house, HC workers w. intimate close contact
*droplet zone, i.e. person who intubated infected person

Rifampin x4
*Ciprofloxacin
Certriaxone IM (preggos)
if preg think ceph!

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15
Q 
fever, ha, neck pain
vomited 2x this morning
Z-pack for CAP (think Strep pneumo)
CT brain, LP
empiric abx

2700 WBCs (94% segmented neutrophils)

Protein 220 mg/dL high
Glucose 18mg/dL (serum is 130mg/dL) low
Gram stain reveals Gram positive diplococci

A

bacterial
pneumococcal meningitis

Most common bacterial agent of meningitis in adults;
if + blood culture consider HIV testing
Gram positive diplococci
No rash, though purpura fulminans in overwhelming sepsis

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16
Q

extremes for pneumococcal meningitis

A

Extremes of age, CSF leaks, sinusitis/otitis (bac spreads), alcoholism, splenectomy, multiple myeloma patients

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17
Q

tx

A

Ceftriaxone 2gm IV q12h
Vancomycin 15mg/kg IV load
Steroids?

dexamethaxone
1st 4 days

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18
Q

listeria meningitis

A

G+ rod

Extremes of age, patients with cell mediated immunosuppression
Hodgkin’s disease, HIV, PREGNANCY

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19
Q

listeria preceding FBI

A

Pregnant patients are occasionally advised to avoid lunchmeats and soft cheeses due to the risk of listeria

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20
Q

tx for listeria men.

A

IV ampicillin or IV meropenem

include AMP empirically if listeria extremes

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21
Q

G+ coccus that causes meningitis

A

Streptococcus pneumoniae (pneumococcus). This bacterium is the most common cause of bacterial meningitis in infants, young children and adults in the United States

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22
Q

G- coccus that causes meningitis

A

Neisseria meningitidis (meningococcus)

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23
Q

Cryptococcal meningitis

A

india ink stain, “bubbly”

Subacute headache in HIV+ patient
Buzz words:  Pigeon droppings, construction
Few lymphocytes in CSF
\+ India ink
\+ Cryptococcal Ag in CSF, serum, urine
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24
Q

Cryptococcal meningitis tx

A

Amphotericin B, +/- flucytosine; fluconazole (HIV+: on for rest of life if have mening. 2x!)

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25
Shunt Associated Meningitis
Be suspicious of skin flora in aspiration of shunt Coagulase negative staph Propionibacterium species Corynebacterium species Do not presume “contaminants” as you may conclude if these organisms were seen in blood cultures
26
G- rod that causes meningitis
Haemophilus influenzae (haemophilus)
27
Gram Negative Meningitis
Neurosurgical patients - including insertion of pressure monitors, drains Head trauma/skull fracture-->open portal ``` Remote focus (diverticulitis?)-->smolders (i.e. E. coli)-->enter blood-->enters CSF (may not just be UTI if bac in blood-Gall bladder) ``` Extremes of age Following prophylaxis for CSF leak **Gram positives empirically covered, select out for gram negative infections***
28
G+ rod that causes meningitis
Listeria monocytogenes (listeria)
29
recurrent memingitis: mollaret's
women 40-60 HSV 1?, HSV 2?, epidermoid cyst?
30
recurrent meningitis
Parameningeal focus - infection, epidermoid cyst, craniopharyngioma CSF leak, often following trauma Pneumococcus most common
31
recurrent meningitis: terminal ??
complement deficiencies
32
recurrent meningitis other presentations
SLE, migraines
33
med-caused "aseptic" meningitis
NSAID’s, azathioprine trimethoprim/sulfa, fluconazole
34
non-inf. etiology "aseptic" meningitis
Ca, AI
35
“Aseptic” Meningitis: VIRAL
Viral, difficult to culture organisms R/O primary HIV infection (part of acute retroviral syndrome) R/O primary genital herpes
36
Usual Aseptic culprits
Enteroviruses (Echo, coxsackie, polio, etc.) Herpes (HSV, VZV, EBV, CMV) Arboviruses (West Nile) Lyme disease Adenovirus Lymphocytic choriomeningitis virus Possible spirochetes? (leptospira, neurosyphilis, borrelia, etc.)
37
Acute Retroviral Syndrome
``` Fever, chills, myalgias Lymphadenopathy Rash - maculopapular Pharyngitis N/V, diarrhea -looks like mono ``` *Headache (if LP -> mild pleocytosis) Elevated LFT’s **HIV 1/2 Ab may be +/- or indeterminate
38
what's missing in acute retroviral syndrome?
upper resp. symptoms
39
West nile virus
2-15 day incubation period Most of the illness is the fever component ``` Fever/headache (~3/4) Muscle weakness and/or pain (~2/3) Rash (~3/4) Adenopathy Joint pain N/V, diarrhea (which may be severe, prolonged) Eye pain ```
40
west nile dx
Serologies for WNV IgM, IgG in the blood “Summer surveillance” panels available seasonally
41
west nile risks
West coast, standing water
42
Neurologic west nile virus
Meningitis – fever, nuchal rigidity, CSF pleocytosis Encephalitis – mental status changes (Meningo-encephalitis) waxing-waning Acute flaccid paralysis (polio-like), seizures, other neurologic syndromes CNS involvement within 24-48 hours of fever onset
43
Neurologic West Nile Virus | Greatest predictor of severe disease ?
is advanced age – mortality higher if patient >75yo | Dx: CSF IgM antibody for WNV
44
WNV tx
None known to be effective, including ribavirin, interferon or steroids-still given! No vaccine yet available IVIG with high titers of WNV antibody??
45
WNV assoc.
``` Transplantation Transfusion Breastfeeding Transplacental transmission Occupational exposure ```
46
Most common tick borne infection in the United States
Borrelia burgdorferi (Lyme) target, erythema migraines flu-like, fever, ha, aches
47
dx HSV encephalitis
by CSF HSV PCR classically HSV-1 Neurologic status at time of treatment predicts prognosis
48
HSV encephalitis
acyclovir
49
HSV encephalitis
Fever, bizarre behavior, focal TEMPORAL lobe findings including seizure and MRI abnormalities
50
focal CNS disease in HIV: toxoplasmosis
Acute onset, fever, +serology, multiple contrast + lesions with mass effect
51
focal CNS disease in HIV: lymphoma EBV PCR+
Subacute onset, no fever, SINGLE contrast + lesion with mass effect
52
Progressive Multifocal Leukoencephalopathy
JC virus with +PCR | Indolent, no fever, contrast negative lesions WITHOUT mass effect
53
PRION diseases
Buzz word “slow virus” Transmissible agent is a prion – devoid of nucleic acid ``` Creutzfeld-Jacob Disease Classic, Familial (14-3-3 protein found in CSF) Bovine Spongiform Encephalopathy (vCJD) Diagnosis by brain biopsy Kuru Scrapie Fatal Familial Insomnia ```
54
additional ddx
Botulism: diploplia, descending paralysis Use of “black tar” heroin Home-canned foods; toxin is heat labile Polio - mutant strains of oral vaccine, biowarfare Bell’s palsy – associated with HSV-1, also consider Lyme, HIV Tick paralysis Treatment? pull off
55
neuro lyme disease: early dissem. inf
Days to weeks later – facial palsy, meningitis, headache, encephalitis, cardiac manifestations (AV block) LP + Lyme Ab – treated with 4 weeks of IV ceftriaxone 2gm q24h
56
neuro lyme disease: Late disseminated infection
Months later – severe, chronic polyneuropathy, chronic encephalomyelitis, somatoform delusions
57
“Chronic Lyme Disease”
Poorly understood, symptomatically managed
58
HSV encephalitis LP
LP may be initially normal CLASSICALLY with high RBCs "bloody tap"
59
causes of chronic meningitis
Tuberculosis Fungal (candida, cryptococcus, aspergillus) Lyme disease Spirochete (syphilis, leptospirosis) Toxoplasma Non-infective (leukemia, SLE, tumor cells)
60
brain abscess
Classically with headache, high fever Think Strep viridans species (poor dentition?) Anaerobes Staph aureus (including MRSA) with trauma, IVDA patients Think fungal, yeast in diabetics, IVDA, neutropenic hosts Mucormycosis Candida Aspergillus
61
epidural abscess
Fever Back pain Neurological deficit (if absent – consider vertebral osteomyelitis, discitis) *S. aureus including MRSA most common High ESR/CRP -monitor for normalization At surgery, granulation tissue common Epidural phlegmon-sticky material
62
primary amebic encephalitis: change in smelling things after water skiing
Think Naegleria fowleri Following swimming in warm, fresh water Migration via olfactory nerve Suspect if change in taste or smell Tx: Amphotericin B (+ azithromycin?) Almost universally fatal

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