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Neurology 2 > CNS Infections > Flashcards

CNS Infections Flashcards

1
Q

what all does meningitis involve?

A
  • subarachnoid space
  • brain
  • blood vessels
  • ventricular system
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2
Q

types of meningitis

A
  • aseptic: viral
  • bacterial
  • other: fungal, protozoa, spirochetes, helminths
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3
Q

how is meningitis most commonly spread?

A
  • hematogenously

- blood stream invasion from respiratory tract

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4
Q

what big 3 things do you have to watch out for in the risk of meningitis?

A
  • otitis media (progressing to mastoiditis)
  • odontogenic
  • sinusitis
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5
Q

other RFs for meningitis

A
  • head trauma
  • anatomical meningeal defects
  • neurosurgical procedures
  • cancer
  • alcoholism
  • immunodeficiency
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6
Q

most common etiology of meningitis at 0-3 months

A
  • group B strep
  • E. coli
  • viral: HSV, enteroviruses, CMV
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7
Q

common enteroviruses

A
  • coxsackie
  • rhinovirus
  • polio
  • ECHO
  • entero
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8
Q

most common etiology of meningitis at 3 months to 3 years

A
  • nisseria meningitidis
  • strep pneumoniae
  • TB
  • viral: enteroviruses, HSV
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9
Q

most common etiology of meningitis at 3-12 years

A
  • strep pneumoniae
  • nisseria meningitidis
  • viral: enteroviruses, adenoviruses, HSV
  • fungal
  • mycobacterium (TB)
  • spirochetes
  • protozoans
  • helminths
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10
Q

meningococcal vaccine

A
  • not required in all states

- usually required before living in the dorms

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11
Q

classic triad of sx in meningitis

A
  • fever
  • stiff neck
  • altered mental status

*doesn’t really translate to real life - low sensitivity

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12
Q

nearly all patients w/ bacterial meningitis have a least 2 of the following:

A
  • fever
  • HA
  • stiff neck
  • altered mental status
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13
Q

clinical features of meningitis in neonates/children

A
  • **bulging fontanelle
  • fever
  • vomiting
  • lethargy
  • irritability
  • poor feeding
  • increase head circumference
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14
Q

every kid that comes into the ER under 2-3 months w/ a fever gets what?

A
  • sent to ER

- septic w/u

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15
Q

clinical features of meningitis in older children/adults

A
  • fever
  • HA
  • neck stiffness
  • confusion
  • nausea/vomiting
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16
Q

more advanced stage clinical features of meningitis in older children and adults

A
  • lethargy
  • photophobia
  • ophthalmoplegia
  • Bell’s palsy
  • meningeal signs: kernig’s, brudzinski’s, nuchal and spinal rigidity
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17
Q

kernig’s sign

A
  • reflex contraction and pain in hamstrings upon extension of leg that is flexed at the hip
  • tip: looks like a K
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18
Q

nuchal rigidity

A
  • unable to place chin on sternum

- involuntary contraction of neck muscles

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19
Q

spinal rigidity

A
  • stiffness of back

- involuntary spasms of erector spinae muscles (opisthotonus)

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20
Q

brudzinski’s sign

A
  • reflex flexion of hips and knees upon flexion of neck

- severe neck stiffness causes a pts hips and knees to flex when neck is flexed

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21
Q

making the diagnosis of meningitis

A
  • CBC
  • blood cultures
  • lumbar puncture
  • CT
  • electrolytes
  • x-ray
  • EEG
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22
Q

blood cultures for meningitis

A
  • have to get 2 draws from 2 different sites separated by 15 minutes
  • any positive out of that means positive diagnosis
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23
Q

when to do lumbar puncture

A

only after CT to r/o a space occupying lesion

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24
Q

what to test the CSF for after obtaining lumbar puncture

A
  • CSF profile (protein, glucose etc.)
  • CSF gram stain
  • CSF C&S
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25
Q

nl and elevated opening pressures when getting lumbar puncture

A
  • nl: 10 cm

- elevated: >25cm

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26
Q

which CSF sample should be sent for C&S?

A
  • the last one obtained during the lumbar puncture

- don’t want skin contaminate from the tap

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27
Q

where do you insert the needle in a spinal tap?

A

b/w the 3rd and 4th lumbar vertebrae

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28
Q

why do you have to get a CT before getting lumbar puncture?

A

the presence of a space occupying lesion could cause a brainstem herniation if a spinal tap was preformed

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29
Q

automatic signs that warrant a CT

A
  • papiledema
  • seizures
  • focal neurological findings
  • immunocompromised pts
  • moderate to severely impaired LOC
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30
Q

what to do while waiting to get CT

A
  • get blood cultures
  • start abx and steroids
  • cut off is 4 hours for giving abx and affecting CSF results
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31
Q

meningitis CSF profile bacterial vs viral

-glucose

A
  • bacterial: decreased

- viral: normal to low

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32
Q

meningitis CSF profile bacterial vs viral

-protein

A
  • bacterial: significantly increased

- viral: mildly increased

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33
Q

meningitis CSF profile bacterial vs viral

-white cell count

A
  • bacterial: increased (200-20,000)

- viral: increased (25-2000)

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34
Q

meningitis CSF profile bacterial vs viral

-predominant cell

A
  • bacterial: PMNs

- viral: lymphocytes

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35
Q

meningitis CSF profile bacterial vs viral

-pressure

A
  • bacterial: markedly elevated

- viral: slightly elevated

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36
Q

emergency tx for marked increase in ICP

A
  • hyperventilation (not as useful as they used to think)
  • mannitol
  • drain CSF
  • +/- dexamethasone 10 mg
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37
Q

how does mannitol work?

A
  • changes the osmolality of the blood to pull fluid out of brain
  • this is done in the ICU not rural OK
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38
Q

tx of meningitis

A
  • isolation: until 24 hrs after C&S
  • monitor vitals: glucose, acid-base, volume status
  • +/- anticonvulsants
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39
Q

tx of viral meningitis

A

supportive care - can usually go home

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40
Q

initiating tx before getting culture back for neonates (<1mo)

A

ampicillin + 3rd generation chephalosporin

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41
Q

initiating tx before getting culture back on infants/children/adults

A

3rd generation cephalosporin + vancomycin + ampicillin

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42
Q

prevention of meningitis

A
  • childhood immunizations: h. flu, s. pneumonia

- immunizations against n. meningitidis in special circumstances

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43
Q

in which case do you need to give prophylactic tx for the household and close contacts of someone w/ meningitis?

A

**nisseria meningitidis

also listed is h. flu but not as big of a deal

44
Q

complications after meningitis

A
  • HA
  • seizures
  • cerebral edema
  • hydrocephalus
  • deafness
45
Q

death outcomes in bacterial meningitis

A
  • s. pneumoniae - 25%
  • n. meningtidis - 10%
  • h. flu - 5%
46
Q

what sx are associated w/ a worse prognosis in meningitis?

A
  • extreme ages
  • delayed diagnosis and tx
  • stupor and coma
  • seizures
  • focal neurological signs
47
Q

nisseria meningitidis bacteria type

A
  • gram negative
  • aerobic
  • encapsulated diplococcus
48
Q

where do nisseria meningitidis commonly live?

A
  • mucosal surfaces of the human nasopharynx

- urogenital tract and anal canal to lesser extent

49
Q

population with high % of n. meningitidis

A
  • military camps

- college dorms

50
Q

who has increased likelihood of invasive disease in meninococcal meningitis?

A
  • immunocompromised
  • smokers
  • concurrent viral infection
  • crowded living conditions
51
Q

unique clinical sign of meningococcal meningitis that sets it apart from the other kinds

A

petechial rash

52
Q

describe the petechial rash seen in meningococcal meningitis

A
  • more common in younger pts
  • trunk, legs, mucous membranes, conjunctivae
  • purple-red in color
  • does NOT blanch to pressure
53
Q

what could a petechial rash progress to?

A

waterhouse-friderichsen syndrome

54
Q

waterhouse-freiderichsen syndrome

A
  • large petechial hemorrhages in the skin and mucous membranes and adrenal glands
  • fever
  • septic shock
  • DIC
55
Q

immunoprophylaxis for meningococcal meningitis

A
  • vaccination for close contacts of pts infected

- mass immunization of selected communities

56
Q

chemoprophylaxis for meningococcal meningitis

A
  • not recommended during epidemics

- can use in people in close contact w/ pts

57
Q

tx and dose for adult chemoprophylaxis for meningococcal meningitis

A
  • cipro

- single dose 500 mg

58
Q

tx and dose for children chemoprophylaxis for meningococcal meningitis

A

single IM injection of ceftriaxone

59
Q

what med can you not give kids under the age of 17?

A

fluoroquinolones

60
Q

complications d/t meningococcal meningitis

A
  • DIC
  • septic arthitis
  • pericarditis
  • pneumonia
  • communicating hydrocephalus
61
Q

define encephalitis

A

-inflammation of brain matter d/t direct invasion or hypersensitivity to a pathogen

62
Q

MC cause of encephalitis

A
  • viral:
  • HSV
  • mumps
  • measles
  • rabies
  • arboviruses (west nile)
  • HIV
  • polio
  • CMV
63
Q

other possible causes of encephalitis

A
  • bacterial
  • spirochetal: syphilis, RMSF
  • mycobacterial
  • fungal
  • parasitic
64
Q

how does encephalitis present?

A

essentially the same as meningitis

65
Q

diagnosis of encephalitis

A
  • lumbar puncture
  • CT/MRI/EEG
  • serologic studies
  • brain tissue biopsy (rarely get to this stage)
66
Q

what would encephalitis look like on a CT

A

empyema w/i spaces of the brain

67
Q

encephalitis tx

A
  • tx the cause if you can ID it
  • monitor vitals
  • supportive care
  • poor prognosis
68
Q

herpes encephalitis

A
  • acute, necrotizing, asymmetrical hemorrhagic process

- involved medal temporal and inferior frontal lobes

69
Q

type of herpes commonly associated w/ herpes encephalitis

A
  • herpes simplex 2

- but simplex 1 is more aggressive and more lethal

70
Q

signs and sx of herpes encephalitis

A
  • same as encephalitis

- temporal lobe dysfunction: olfactory hallucinations and behavioral disturbances

71
Q

tx for herpes encephalitis

A

IV acyclovir

72
Q

where does viral DNA exsist within the CNS?

A

trigeminal ganglion

73
Q

possible transmission of herpes encephalitis

A
  • olfactory transmission (hence temporal lobe)

- you have active lesion, you touch it, then pick nose

74
Q

when is a newborn at increased risk of HSV encephalitis?

A

-if mom is infected during 3rd trimester
or
-active lesion in vagina

75
Q

define brain abscess

A
  • focal infection
  • begins when organisms are inoculated into brain parenchyma
  • usually from a site distant from the CNS
76
Q

brain abscess can occur by what 3 mechanisms?

A
  • direct extension
  • hematogenous
  • penetrating head injury or neurosurgery
77
Q

examples of direct extension

A

spread of infection from:

  • sinuses
  • teeth
  • middle ear or mastoid
78
Q

hematogenous spread causing brain abscess

A
  • seeding of brain occurs from distant infection sites and often results in multiple abcesses
  • ex: IVDU
79
Q

MC presenting symptom of brain abscess

A

HA

80
Q

other clinical features of brain abcess

A
  • focal neurologic deficit
  • seizure
  • mental status change
  • n/v, stiff neck if cerebral edema
81
Q

exam findings with brain abscess

A

-focal neuro findings
-papilledema (advanced disease)
possible in infants:
-bulging fontanelles
-irritability
-enlarging head circumference

82
Q

lab to order w/ suspected brain abcess

A
  • CBC and sed rate: not reliable but helpful

- draw blood cultures

83
Q

pathognomonic CT finding in brain abscess

A

ring enhanced lesions

84
Q

tx for brain abscess

A
  • assess need for intubation
  • start abx ASAP
  • control seizures aggressively
  • neuro consult
85
Q

abx for direct extension brain abscess

A

penicillin G + metronidazole + 3rd generation cephalosporin

86
Q

abx for hematogenous spread brain abscess or from penetrating trauma

A

nafcillin + metronidazole + 3rd generation cephalosporin

87
Q

abx for postop brain abscess

A

vancomycin + ceftazidime or cefepime

88
Q

abx for brain abcess when there is no predisposing factors

A

metronidazole + vancomycin + 3rd generation cephalosporin

89
Q

different classifications of neurosyphilis

A
  • asymptomatic neuroinvasion
  • meningovascular syphilis
  • tabes dorsalis
  • general paresis
90
Q

asymptomatic neuroinvasion type neurosyphilis

A
  • CSF abnormalities w/o sx or sign of neurological involvement
  • no clinical significance
91
Q

meningovascular syphilis

A
  • inflammatory changed in meninges or vascular structures of brain
  • HA, cranial nerve palsies, ocular changes and possible CVAs
92
Q

tabes dorsalis

A
  • chronic, progressive degeneration of parenchyma of posterior columns of SC and posterior sensory ganglia and nerve roots
  • causes impairment of proprioceptions and vibration sense, argyll robertson pupils, weakness and unsteady gate
93
Q

general paresis

A

-generalized involvment of cerebral cortex causing poor concentration, memory loss, dysarthria, tremor in fingers and lips, HA, and personality changes

94
Q

classic CSF findings in neurosyphilis

A
  • elevated total protein
  • lymphocytic pleocytosis
  • positiv VDRL (venereal dz research lab)
95
Q

what lab to you continue to check in neurocyphilis

A

VDRL

-it is essentially a titer

96
Q

tx for neurosyphilis

A
  • high dose aqueous penicillin X 10-14 days

- then move to 2.4 million units benzathine penicillin IM weeks X 3 weeks

97
Q

what is the fungal infection you have to watch for?

A

cryptococcosis

98
Q

describe the fungus crytococcus neoformans

A
  • encapsulated yeast

- meningitis is the MC clinical presentation but can have pulmonary infection

99
Q

who will present w/ cryptococcus infection

**BOARDS

A
  • HIV pts

- CD4 count <50

100
Q

pathogeneis sof cryptococcus

A
  • organism is inhaled causing pulm infection first

- if host defenses not adequate then infection can disseminate

101
Q

clinical manifestations of cryptococcosis

A
  • CNS: HA, nuchal rigidity, lethargy, confusion, photophobia, papilledema, n/v
  • fever in 1/2 cases
102
Q

diagnosis of cryptococcosis

A
  • culture
  • CSF stain
  • latex agglutination test
103
Q

tx of cryptococcosis

A

-amphotericin B + flucytosine X 6 weeks
then
-fluconazole or itraonazole for pulmonary infection

104
Q

naegleria fowleri

A
  • primary amebic meningoencephalitis
  • “brain eating ameba”
  • 97% fatal
105
Q

where does naegleria fowleri thrive?

A

warm freshwater lakes and streams that aren’t flowing well - also soil

106
Q

mode of naegleria fowleri infection

A
  • penetrates through nasal mucosa

- NOT by swallowing water

107
Q

tx of naegleria fowleri infection

A

amphotericin B

Neurology 2 (21 decks)

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