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CP - JL > CNS Infections > Flashcards

CNS Infections Flashcards

1
Q

What is a brain abscess

A

A focal suppurative process within the brain parenchyma

Pus in the brain substance

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2
Q

What are the causes of a brain abscess

A

Often polymicrobial
Strep miller most common then staph aureus
Anaerobes, TB, toxoplasma gondii, gram -ve bacteria (e.coli and pseudomonas)

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3
Q

4 ways that brain abscesses develop

A

Direct spread from suppurative focus - middle ear, teeth, sinus
Haematogenous spread from distant focus - endocarditis or bronchiectasis (multiple abscesses)
Trauma
Cryptogenic - no focus

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4
Q

What is a common cause of abscess after trauma/surgery

A

Staph aureues

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5
Q

Presentation of a brain abscess

A

Headache, focal neurological deficit, fever, consuion, dizziness/seizures, neck stiffness

Papilloedema and coma are a late sign

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6
Q

What is a subdural empyema

A

In-between the dura and arachnoid mater

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7
Q

What causes subdural empyemas

A

Often polymicrobial

Aerogic gram -ve, strep penuomia, staph auresus, haemophilius

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8
Q

Where do subdural empyemas usually spread from

A

Sinuses (50-80%)

Or middle ear and mastoid (10-20%)

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9
Q

How do subdural empyemas present

A 
Headaches
Fever
Neurological focal deficit
Confusion
Seizure
Coma
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10
Q

How do we treat subdural empyema

A

Drainage of pus and culture to guide antibiotic therapy

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11
Q

What are complications of brain abscesses

A

Raised intracranial pressure - causes mass effect, coning

Rupture - into ventricles - causes ventriculitis - may result in death!!!!

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12
Q

How do we manage bran abcsesses

A

Drain them
Reduces the ICP, confirms the diagnosis, gets pus for investigations, examine antibiotics efficiency, avoid spread to ventricles - CAN BE FATAL

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13
Q

Why do we need specific antibiotics to treat brain abscesses

A

The distinct properties of the BBB and blood-CSF barrier means that only certain drugs can penetrate the CSF and brain

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14
Q

What drugs are good for penetrating pus

A

Ceftazidime (good for pseudomonas), metronidazole, ampicillin, penicillin, cefuroxime, cefataxime

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15
Q

How do we treat sinugenic/odontogenic abscesses

A

Ceftazidime (2-6 hrs), metronidazole (8 hrly)

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16
Q

How do we treat otogenic abscesses

A

benzyl penicillin, Ceftazidime (2-6 hrs), metronidazole (8 hrly)

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17
Q

How long do we treat drained abscesses for

A

4-6 weeks, oral switch may be an option

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18
Q

What is meningitis

A

Inflammation of the meninges

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19
Q

What is encephalitis

A

Inflammation of the brain

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20
Q

What is menino-encephalitis

A

Inflammation of the brain and meninges

Usually difficult to distibuish between encephalitis and meningitis

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21
Q

What is Aseptic meningitis

A

Clinical picture of meningitis
White cell count >5x10^5/L in CSF - may be higher in children
Negative bacterial culture in CSF
Viruses are the most common cause!

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22
Q

What is a virus capsid

A

Protein coat made up of capsomeres (subunits)

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23
Q

Where do some viruses derive their envelopes

A

From the host cell membrane

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24
Q

What is the most common type of meningitis

A

Viral meningitis

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25
Q

Who is meningitis most common in

A

Neonates and age 5

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26
Q

What are the most common causes of viral meningitis

A

Enteroviruses
Then HSV2 Also echovirus, coxsachie virus, parecho, polio

Good to determine their travel history

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27
Q

How does viral meningitis cause disease

A

Colonisation of mucosal surface
Invasion of the epithlieum
Disseminates and CNS invasion

Symptoms mainly due to the inflammatory response in the CNS

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28
Q

How can viral meningitis disseminate and invade the CNS

A

Via the cerebral microvascular endothelial cells
Via the choroid plexus epithelim
Spreads along the olfactory nerve

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29
Q

Presentation of viral meningitis

A

Fever
Meningeal symptoms (fever, neck stiffness, photophobia)
Someimtes viral prodrome - lethargy, myalgias, arthralgias, sore throat, D&V)

Also Kerning’s and Brudzinski’s sign

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30
Q

How might viral meningitis present in children

A

Meningeal symptoms may be absent

Look for nuchal rigidity and bulging anterior fontanelle

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31
Q

What is Kerning’s skin

A

Hip and knee flexed 90 degrees to the body
Cant extend knee due to pain/stiffness in the hamstrings

Spinal cord can’t stretch due to inflamed menignes

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32
Q

What is Brudzunkis sign

A

Lying down - flexing the neck causes the hips and knees to flex

Occurs because the spinal cord can’t stretch due to the inflamed meninges

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33
Q

What investigations do we do for meningitis

A

FBC, U&E, CRP, Clotting, blood culture (renal function often decreases)
CT of the head
Lumbar puncture

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34
Q

Why do we do CT of the head in menigitis

A

To look for evidence of raised ICP and look for a differential diagnosis

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35
Q

What do we ook for in lumbar puncture

A

Microscopy, culture, sensitivity
Protein
Glucose - do ration against blood
Viral PCR

try and do lumbar puncture within 1 hour

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36
Q

CSF findings in viral meninfits

A

White cell count pleocytosis (WBCs in the CSF)
Lymphocytic
Predominance of neutrophils in first 24 hours
Normal level of protein
Glucose ratio normal or low

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37
Q

What is the normal glucose ratio

A

50-66%

Normally there is less glucose in the CSF than in the plasma

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38
Q

What are other microbiology tests we can do for meningitis

A

Throat swab/stool sample for enteroviruses

Serology - for Mumps, EBV/CMV, HIV and other virses (travel indicated)

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39
Q

Treatment of viral meningitis

A

Start IV antibiotics e.g. cefotaxime if any risk of bacterial meningitis
No evidence for use of specific treatment
Supportive therapy

NOTIFIABLE DISEASE for prophylaxis

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40
Q

When does enteroviral meningitis commonly occur

A

Late summer/early autumn

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41
Q

Symptoms of enteroviral meningitis

A

Fever, vomiting, anorexia, rash, URT symptoms

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42
Q

Treatment of enteroviral meningitis

A

No specific treatment

Full recovery expected

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43
Q

What does HSV1 cause

A

Cold sores and viral encephalitis

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44
Q

What does HSV2 cause

A

VIral meningitis and genital herpes

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45
Q

2nd most common cause of viral meningitis

A

HSV2 - following primary infection or occur during/between relapses

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46
Q

Treatment of HSV2 meningitis

A

No evidence that acyclovir is effective

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47
Q

What is Mollarets meningitis

A

Recurring aseptic meningitis

48
Q

Can VZV cause meningitis

A

Rare cause but can occur during chickenpox or shingle s(look for rash) or occur on its own, or after vaccination

49
Q

How to treat VZV

A

No evidence acyclovir helps
But can help for the rash
Complete recovery normal

50
Q

Does mumps lead to meningitis

A

In 10-30% of people meningitis occurs 5 days after the onset of parotitis

51
Q

Symptoms of mumps related viral meningitis

A

5 days after the onset of parotitis
Abdominal pain
Orchitis

52
Q

Treatment of mumps meningitis

A

No specific treatment
Full recovery normal
Preventable with vaccine

53
Q

When can meningitis occur with HIV

A

Part of primary infection
Associated features of fever, lymphadenopathy, pharyngitis and rash

Symptoms are self-limiting

54
Q

Main cause of viral encephalitis

A

HSV1 causes 90% of viral encephalitis cases

55
Q

Presentation of viral encephalitis

A

Main difference to meningitis is the altered mental state and low GCS

Fever, headache and meningism (may be absent)
Also get focal neurologies! - seizures, weakness, dysphasia/aphasia, cranial nerve palsy, ataxia

56
Q

What investigations do we do in viral encephalitis

A

Bloods, CT, MRI, Lumbar, EEG

Findings generally the same as viral meningitis (low glucose, high protein)

57
Q

What changes are typically seen in viral encephalitis

A

Upton 75% show abnormal temporal lobe activithy

58
Q

How to treat viral encephalitis

A

High dose IV aciclovir 14-21 days - start on clinical suspicion
Oral switch not recommended

59
Q

Epidemiology of viral encephalitis

A

Rare but high mortality if untreated!
Bimodal incidence - under 20 years and over 50 years most affected
Equally spread between sexes

60
Q

HSE Pathogenesis

A

Primary infection vs reactivationn
Direct transmission of the virus along neural/olfactory pathways!
Reactivation in the trigeminal ganglia

61
Q

Where can HSE reactivate

A

In the trigeminal ganglia

62
Q

Mortality of HSE

A

Upto 70%
Poor prognosis if GCS les than 6
Survivors frequently have neurological problems, paralysis, speech loss and personality chagne

63
Q

What is acute disseminated encephalomyelopathy (ADEM)

A

Immune mediated CNS demyeliination

64
Q

What precedes ADEM

A

Viral infection or vaccination

65
Q

Clinical features of ADEM

A

Same as encephalitis - but the PCR for the virus will all be negative. Look for autoantibodies in the blood

66
Q

How do we treat ADEM

A

Steroids/other immunosuppressants recovery is variable

67
Q

Who does japanese encephalitis often affect

A

Children

68
Q

When can you get japanese encephalitis

A

Dog, fox, bat bites

69
Q

What is the mortality of japanese encephalitis

A

100%

70
Q

What is a common cause of encephalitis in the immunosuppressed

A

Toxoplasma gondii

71
Q

When do we get toxoplasma gondii

A

From cat faeces and undercooked meat

72
Q

What type of bacteria is neisseria meningitidis

A

Gram -ve diplocooci

Needs blood to grow

73
Q

Natural habitat of neisseria meningitidis

A

Nasopharynx 5-10% of people are carriers

74
Q

What increaeses before neisseria meningitidis

A

Increase in group A strep carriage before epidemics

Also increased rate in the first term of uni

75
Q

Where does neisseria meningitidis replicate

A

Crosses the BBB and replicates in the sub arachnoid space

76
Q

Presentation of neisseria meningitidis

A

Fulminant septicaemia - may get purpuric rash
Meningitis if it crosses the BBB
an get pyogenic meningitis without rash

77
Q

How do we treat bacteria meningitis

A

Cephalosporins then penicillin
Chemoprophylaxis for neisseria and meningitis - rifampicin and ciprofloxacin
Steroids for strep pneumonia only

78
Q

What groups of neisseria meningitidis do we have vaccines against

A

Groups A + C and W135 not B

Group A usually causes the massive epidemics

79
Q

What type of bacteria is haemophilia influenza

A

Gram -ve cocci

Needs blood to grow

80
Q

What type of haemophilia influenza causes meningitis

A

Type b - encapsulated

But 25-80% of the other types are non capsulated

81
Q

What type of haemphilius influenza do we have a vaccine against

A

Type b

82
Q

What type of bacteria is strep pneumonia

A

Gram +ve cocci
Needs blood for growth
Normal habitat the respiratory tract - transmission via droplet

83
Q

How do we test for strep pneumonia

A

Optochin test - it is sensitive to the optochin antibiotic

84
Q

What age groups do each of the bacterial meningitis affect

A

Neisseria - neonates and teens
Haemophilia - 2 months to 2 years
Strep pneumonia - all ages

85
Q

Normal CSF results

A

Cell Count

86
Q

Bacterial CSF Results

A

Cell Count >200
Cell Type Polymorphs
Glucose

87
Q

Viral CSF Results

A

Cell Count 20-200
Cell Type Lymphocytes
Glucose Normal or reduced
Protein Normal or increased

88
Q

TB CSF Results

A

Cell Count 20 -200
Cell Type Lymphocytes
Glucose Reduced
Protein Increased

89
Q

Cryptococcus CSF results

A

Cell Count 20 -200
Cell Type Lymphocytes
Glucose Normal or reduced
Protein Incresed

90
Q

What usually cause neonatal menngitis

A

Beta haemolytic streptococci
E. coli
Listeria

91
Q

Treatment of neonatal meningitis

A

Cephalosporins, ampicillin, gentamicin

92
Q

What is the most common form of meningitis

A

Lymphocytic/ Viral
Due to enteroviruses or HSV2
Just symptomatic treatment

93
Q

What happens in TB meningitis

A

Insidious onset

94
Q

How do we treat TB meningitis

A

Steroids

95
Q

What makes you more at risk of TB meningitis

A

Immunocompromised
Alcholic
From endemic area

96
Q

Meningitis complications

A

Death, sepsis, raised ICP

Deafness, delayed development, seizures, shakes, hydrocephalus

97
Q

Where is clostridium tetani usually found

A

Widespread in the soil -

98
Q

How does clostridium tetanus cause a disease

A

Non-invasive but produces a toxin

Toxin binds to ganglionic receptors preventing the release of inhibitor interneurons

99
Q

What symptoms do you get with clostridium tetani

A

Lockjaw - tonic muscle spasms, opinthons
Resp difficulties
CV instbility
Sympathetic nervous system problems

100
Q

Treatment of tetanus

A

Anti-toxin
Penicillin or metranidaole
Drugs for muscle spasms/relaxtants

101
Q

What is cryptococus

A

A yeat

102
Q

Describe cryptococcal meningitis infection

A

Insidious onset

Often get respiratory illness first

103
Q

How do we see cryptococcal infection histologically

A

Yeast seen in CSF with Indian Ink Stain

104
Q

How do we treat cryptococcus

A

Prolonger amphotericion, flucytosine or fluconazole

105
Q

What type of meningitis has a higher mortality

A

bacterial

106
Q

How do we look for bacterial meningitis

A

Gram staining

Shows intracellular gram -ove cocci

107
Q

How does neisseria meningitides cause disease

A

Able to modify inflammatory processes

108
Q

What are other complications of neisseria menigitidis

A

Chronic meningococcal bacteraemia with arthralgia
Focal sepsis
Conjunctivitis and endopthalmitis

109
Q

How many types of haemophilius influenza are there

A

6

It is part of the normal flora

110
Q

What is strep pneumonia often resistant to

A

Penicillin resistant

111
Q

Is there a vaccine for strep pneumonia

A

Conjugate vaccine available against common serotypes

112
Q

Other causes of lymphocytic meningitis

A

Spirochete - treponemal, borrelia

113
Q

How do we diagnose viral encephalitis

A

Diagnosis by detectingg viral nucleic acid in the CSF

114
Q

What test do we do for tB

A

Ziehl Neelson

115
Q

Why is TB diagnosis difficult

A

Difficutl to grow AFB

116
Q

How do we diagnose brain abscesses

A

Need a scan to confirm

117
Q

How does the tetanus toxin spread

A

Via bloodstream and retrograde transport

CP - JL (14 decks)

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