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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
Q

Shunt Associated Meningitis

A

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
Q

G- rod that causes meningitis

A

Haemophilus influenzae (haemophilus)

27
Q

Gram Negative Meningitis

A

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
Q

G+ rod that causes meningitis

A

Listeria monocytogenes (listeria)

29
Q

recurrent memingitis: mollaret’s

A

women 40-60

HSV 1?, HSV 2?, epidermoid cyst?

30
Q

recurrent meningitis

A

Parameningeal focus - infection, epidermoid cyst, craniopharyngioma
CSF leak, often following trauma
Pneumococcus most common

31
Q

recurrent meningitis: terminal ??

A

complement deficiencies

32
Q

recurrent meningitis other presentations

A

SLE, migraines

33
Q

med-caused “aseptic” meningitis

A

NSAID’s, azathioprine trimethoprim/sulfa, fluconazole

34
Q

non-inf. etiology “aseptic” meningitis

A

Ca, AI

35
Q

“Aseptic” Meningitis: VIRAL

A

Viral, difficult to culture organisms
R/O primary HIV infection (part of acute retroviral syndrome)
R/O primary genital herpes

36
Q

Usual Aseptic culprits

A

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
Q

Acute Retroviral Syndrome

A 
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
Q

what’s missing in acute retroviral syndrome?

A

upper resp. symptoms

39
Q

West nile virus

A

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
Q

west nile dx

A

Serologies for WNV IgM, IgG in the blood

“Summer surveillance” panels available seasonally

41
Q

west nile risks

A

West coast, standing water

42
Q

Neurologic west nile virus

A

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
Q

Neurologic West Nile Virus

Greatest predictor of severe disease ?

A

is advanced age – mortality higher if patient >75yo

Dx: CSF IgM antibody for WNV

44
Q

WNV tx

A

None known to be effective, including ribavirin, interferon or steroids-still given!
No vaccine yet available
IVIG with high titers of WNV antibody??

45
Q

WNV assoc.

A 
Transplantation
Transfusion
Breastfeeding
Transplacental transmission
Occupational exposure
46
Q

Most common tick borne infection in the United States

A

Borrelia burgdorferi (Lyme)

target, erythema migraines

flu-like, fever, ha, aches

47
Q

dx HSV encephalitis

A

by CSF HSV PCR

classically HSV-1

Neurologic status at time of treatment predicts prognosis

48
Q

HSV encephalitis

A

acyclovir

49
Q

HSV encephalitis

A

Fever, bizarre behavior, focal TEMPORAL lobe findings including seizure and MRI abnormalities

50
Q

focal CNS disease in HIV: toxoplasmosis

A

Acute onset, fever, +serology, multiple contrast + lesions with mass effect

51
Q

focal CNS disease in HIV: lymphoma EBV PCR+

A

Subacute onset, no fever, SINGLE contrast + lesion with mass effect

52
Q

Progressive Multifocal Leukoencephalopathy

A

JC virus with +PCR

Indolent, no fever, contrast negative lesions WITHOUT mass effect

53
Q

PRION diseases

A

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
Q

additional ddx

A

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
Q

neuro lyme disease: early dissem. inf

A

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
Q

neuro lyme disease: Late disseminated infection

A

Months later – severe, chronic polyneuropathy, chronic encephalomyelitis, somatoform delusions

57
Q

“Chronic Lyme Disease”

A

Poorly understood, symptomatically managed

58
Q

HSV encephalitis LP

A

LP may be initially normal
CLASSICALLY with high RBCs
“bloody tap”

59
Q

causes of chronic meningitis

A

Tuberculosis
Fungal (candida, cryptococcus, aspergillus)
Lyme disease
Spirochete (syphilis, leptospirosis)
Toxoplasma
Non-infective (leukemia, SLE, tumor cells)

60
Q

brain abscess

A

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
Q

epidural abscess

A

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
Q

primary amebic encephalitis:

change in smelling things after water skiing

A

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

CSI (75 decks)

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