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Neuro > CNS Infections - Exam 3 > Flashcards

CNS Infections - Exam 3 Flashcards

1
Q

What is meningitis? What is encephalitis? What is Meningoencephalitis?

A

Meningitis - inflammatory disease of the meninges surrounding the brain and spinal cord can be Bacterial, Viral or Fungal

Encephalitis - acute inflammation of the brain itself can be bacterial, Viral, (Parasitic, Fungi, Spirochetes)

Meningoencephalitis - inflammation of both the brain and the meninges

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2
Q

What are the 3 classic CNS infection s/s?

A

Fever
Headache
Altered mental status

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3
Q

What are the 3 meningeal signs?

A

nuchal rigidity

kernig

Brudzinski

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4
Q

**What is Kernig sign?

A
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5
Q

**What is Brudzinski sign?

A
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6
Q

What are some s/s of increased intracranial pressure?

A

Papilledema, poorly reactive pupils

Abducens (6th CN) palsy: horizontal diplopia

N/V

Bulging fontanelle (soft spot) in infants

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7
Q

What can a pt not due if they have abducens palsy?

A

eye that is affected, they cannot look laterally

can look medially but NOT laterally

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8
Q

What are the 3 layers of tissue that surround the brain and spinal cord?

A

Dura Mater- outermost layer - strong fibrous membrane

Arachnoid Mater - middle layer has cobweb like filaments that attach to the innermost layer

Pia Mater- innermost layer - a very thin and delicate membrane that is tightly to bound the surface of the brain

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9
Q

What layers contains blood vessels?

A

Subarachnoid Space - the space between arachnoid and pia mater

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10
Q

bacterial meningitis is an acute purulent infection of the ______ and the _______

A

arachnoid mater and the subarachnoid space

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11
Q

What give rise to the majority of bacterial meningitis cases?

A

Most cases result from previously colonized distant infection

from the Nasopharynx, respiratory tract, skin, GI tract and GU tract

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12
Q

In bacterial meningitis how does the bacteria have access to the CNS, give 2 ways it spreads? Which one is MC?

A

hematogenous spread - MC

direct contiguous spread from previous sinusitis, otitis media, mastoiditis, trauma, neurosurgical procedures

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13
Q

Where do newborns most common acquire bacterial meningitis?

A

pathogens colonized from the maternal intestinal or genital tract
or
transmitted from nursery personnel or caregivers at home

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14
Q

What pathogen is most common in adults with bacterial meningitis? healthcare acquired?

A

Streptococcus pneumoniae (~50-60%)
MC cause in adults >20 yrs old

S. aureus and coagulase-negative staphylococci-> think after a neurosurgery

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15
Q

What are the 3 MC pathogen for neonates (0-4 weeks old)?

A

GBS

e. coli

gram -negative bacilli

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16
Q

What are the top 3 MC pathogen for children older than 1 month?

A

Streptococcus Pneumoniae
Neisseria meningitidis¹
Haemophilus Influenzae type B (Hib)

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17
Q

What are the 4 MC symptoms associated with bacterial meningitis in adults? What is the classic triad? ___ out of 4 symptoms are present in most cases

A

Headache - MC
Fever - 2nd MC
Nuchal rigidity/meningeal signs

Altered mental status

2/4 present in most cases

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18
Q

What is nuchal rigidity?

A

pain with neck flexion

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19
Q

When is a meningococcal rash seen? Describe it

A

seen in septic meningitis with N. Meningitidis

maculopapular rash that become petechial and/or purpuric involving the trunk, LE, mucosal membranes, conjunctiva that DOES NOT BLANCH!!!

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20
Q

What are the historical red flags for bacterial meningitis?

A
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21
Q

Why would you want to order a coag profile in bacterial meningitis?

A

helps to differentiate who may need platelet or FFP after LP

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22
Q

Need to immediate collect _______ if you suspect bacterial meningitis

A

Immediate collection of blood cultures x 2 for gram stain, culture and sensitivity (C&S)

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23
Q

When working a pt up for bacterial meningitis, need prompt ________.

A

lumbar puncture

DO NOT delay LP for labs!

DO NOT delay empiric Abx therapy for LP or CT

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24
Q

**What are the guidelines to do CT scan BEFORE LP if:

A

Immunocompromised state

History of CNS disease: mass lesion, stroke, or focal infection

New onset seizure (within one week of presentation)

Papilledema

Abnormal level of consciousness

Focal neurologic deficit

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25
Q

When doing a LP, what is important to note? How many tubes do you need to collect for CSF analysis? What goes in each tube?

A

the opening pressure-> measured using a manometer

4 tubes

Tube 1 - Cell count and differential
Tube 2 - Glucose and protein levels
Tube 3 - Gram stain, culture and sensitivity (C&S)
Tube 4 - Cell count and differential (if repeat is needed¹) or special additional studies (depending on initial CSF analysis)

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26
Q

If RBC are present throughout all 4 samples of CSF fluid, what are you thinking? Blood present in the first sample only?

A

thinking there is a brain bleed

RBC in first sample tube only -> thinking you hit a small capillary

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26
Q

Draw the cerebrospinal fluid analysis chart know the first 5 rows

A
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27
Q

**What is the flow chart for bacterial meningitis management?

A
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28
Q

What do you also need to order in a pt with suspected bacterial meningitis?

A

Non urgent CT/MRI to rule out differential diagnoses

MRI is preferred

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29
Q

What is the goal of empiric therapy for bacterial meningitis? When is empiric therapy started?

A

to started empiric therapy within 60 minutes of patient arrival

started immediately after LP but do NOT delay abx therapy if LP is delayed

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30
Q

What is included in the empiric tx for bacterial meningitis for a pt 1 month old to 50 years old?

A
  1. Dexamethasone
  2. ceftriaxone PLUS Vanc PLUS acyclovir
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31
Q

When is dexamethsone given in BM? Why is it given?

A

give to ALL patients 0-20 minutes before the first dose of empiric abx and continued for 4 days

Administered to combat release of inflammatory cytokines initiated by antibiotic action on bacterial cell wall

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32
Q

What is included in the empiric tx for bacterial meningitis for a pt who is LESS than 1 month old?

A
  1. Dexamethasone
  2. cefotaxime + ampicillin + acyclovir
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33
Q

Why is ceftriaxone CI in neonates?

A

due to high risk of hyperbilirubinemia

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34
Q

What is the empiric therapy in a pt who is older than 50 OR immunocompromised?

A
  1. Dexamethasone
  2. ampicillin PLUS ceftriaxone PLUS Vanc PLUS acyclovir
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35
Q

What does ampicillin cover for when added to the empiric therapy for 50+ or immunocompromised pts?

A

covers L. monocytogenes

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36
Q

What are 2 ADD ON abx options in BM and why would you add each one on?

A

doxycycline: during tick season to cover tick-borne bacterial infections

metronidazole (Flagyl): covers gram-negative anaerobes coinciding otitis, sinusitis or mastoiditis

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37
Q

What are 3 general management strategies that can help control a pt’s elevated ICP?

A

elevation of the patient’s head to 30–45°

intubation with hyperventilation

mannitol

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38
Q

**How long should you continue abx treatment based on the pathogen? Give the 5 pathogens and number of tx days required

A
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39
Q

When is repeat CSF analysis indicated? What is the expected result?

A

no improvement within 48 hours after starting appropriate therapy

pathogen resistant to standard abx, 2-3 days after the initiation of therapy

Persistent fever > 8 days (without other known cause)

Repeat CSF cultures should be sterile

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40
Q

Your repeat CSF culture is positive despite appropriate therapy, what should you do next?

A

consider intrathecal (or intraventricular) antibiotics administration

aka give abx straight into the spinal cord

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41
Q

Once your culture and sensitivity report comes back and confirms the source is bacterial, what do you do?

A

stop the acyclovir

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42
Q

When is mortality the highest in BM? What is the trend? ___ out of 10 cases will be fatal. What is common in cases that do survive?

A

Mortality is highest in the first year of life, decreases in midlife, and increases again in old age

1/10 cases will be fatal

Significant neurologic sequelae in 30% of survivors
1 in 7 survivors will be left with a severe handicap

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43
Q

_______ is needed in bacterial meningitis until etiology is determined. How long do you need to continue after initiation of “effective” abx therapy in N. meningitidis?

A

Droplet precaution

continue for 24 hours

44
Q

What is the chemoprophylaxis for close exposure to meningitis involving H influenzae? What is the tx?

A

contact for ≥4 hours for at least 5 out of the 7 days before admission of index patient

AND

Anyone exposed under the age of 2 years

Anyone exposed who lives in a home with a child < 4 y/o

Anyone exposed who is not fully immunized against Hib

Tx: rifampin for 4 days

45
Q

What is the chemoprophylaxis for close exposure to meningitis involving N. meningitidis? What is the tx?

A

prolonged (>8h) exposure in close proximity (<3 ft)

direct exposure to oral secretions

Exposure 7 days prior to onset of symptoms up through 24 hours after initiation of appropriate antibiotic

tx: rifampin for 2 days

46
Q

How do you prevent bacterial meningitis in newborns? What if positive?

A

Vaginal/anal swab testing for group B strep between 35-37 wks gestation

if positive: prophylactic IV PCN to be administered during vaginal delivery

47
Q

How do you prevent bacterial meningitis related to neurosurgery?

A

Perioperative antimicrobial prophylaxis is indicated for patients undergoing any form of neurosurgery

48
Q

What is the prevention for BM?

A

vaccinations!!! specifically:

Streptococcus pneumoniae (PVC13, PPV23)

Neisseria meningitidis (MenB and MenACWY)

Haemophilus influenzae Type B (Hib)

49
Q

What is viral meningitis? What is another name for it?

A

a condition that presents with evidence of meningeal inflammation (H&P & CSF profile) with a negative bacterial culture

“aseptic” meningitis

50
Q

What is the MC etiology of viral meningitis? Who is the MC pt population?

A

enteroviruses

most cases occur in children younger than age 5

51
Q

What are the risk factors for viral meningitis?

A

neonates

immunodeficient pts

exposure to someone with viral meningitis

52
Q

What is important to note about viral meningitis?

A

travel and exposure history is important!!

concentrate on areas of endemic West Nile virus, Lyme disease, other tick borne disease

53
Q

Sexual exposure: HSV-1/2, HIV, syphilis are strongly associated with what type of meningitis?

A

viral meningitis

54
Q

What is important to note about the presentation of viral meningitis when compared to bacterial meningitis?

A

s/s are often LESS severe

mildly diminished LOC- drowsy or mild lethargy

profound alterations in consciousness, seizures and focal neuro deficits are NOT seen in viral meningitis

55
Q

clinical presentation of viral meningitis: __________ enteroviral infection, primary HIV or syphilis

A

Diffuse maculopapular exanthem

56
Q

clinical presentation of viral meningitis: __________ mumps in an unvaccinated patient

A

Parotitis/Orchitis

57
Q

clinical presentation of viral meningitis: __________ HSV

A

Genital/Oral Lesions

58
Q

clinical presentation of viral meningitis: __________ HIV

A

thrush

59
Q

clinical presentation of viral meningitis: __________ West Nile virus meningitis

A

Asymmetric flaccid paralysis

60
Q

What will the CSF fluid show in viral meningitis? ______ most important method of dx viral etiology

A

WBC - lymphocyte predominant
Gram stain of CSF will be negative for any growth

PCR for EACH individual virus has to be ordered

61
Q

______ may be elevated in mumps

A

amylase

62
Q

Blood, feces, and throat swabs for viral etiology but viral shedding in the ____ can persist for weeks and is NOT a reliable tool

A

stool

63
Q

What 4 viruses are not good candidates for serum testing when trying to find the cause of viral meningitis? Why?

A

Do not use viral serology for HSV, VZV, CMV, and EBV as these viruses are frequently seropositive

aka lots of people have had those viruses in the past and that DOES NOT mean it is the source of the present viral meningitis

64
Q

T/F: CT/MRI is necessary in uncomplicated viral meningitis

A

FALSE!! additional imaging is NOT indicated in uncomplicated viral meningitis

65
Q

What are the indications for CT/MRI testing in viral meningitis?

A

altered LOC
seizures
focal neurologic s/s
atypical CSF profiles
underlying immunocompromising treatments or conditions

66
Q

When are empiric abx/antivirals recommended in VM?

A

elderly

immunocompromised

a strong early suspicion of bacterial meningitis

67
Q

What do you do in VM if the dx is INDETERMINATE after CSF evaluation? When can you stop empiric abx in viral meningitis?

A

administer empiric antibiotics after obtaining blood and CSF culture specimens

OR

observe (without abx tx) and repeat lumbar puncture (LP) in 6 to 24 hours

Empiric abx can be stopped if pt is improving and culture is negative

68
Q

What is the management for viral meningitis?

A

Depends upon the clinical appearance of the patient and the underlying host factors

but most cases are self-limiting and tx is supportive: fluids, rest, symptomatic control

69
Q

What is the tx for HSV that has been confirmed with CSF analysis?

A

IV acyclovir (dose based upon weight)

Newborn - 3 months - 21 days
3 months and older - 10-21 days

70
Q

What is the tx for VZV with severe clinical presentation that has been confirmed with CSF analysis?

A

IV acyclovir - 10-14 days

only if severe clinical presentation

71
Q

What is the treatment for all other viral meningitis that have been confirmed with CSF testing? How long does it usually take to resolve?

A

d/c acyclovir and continue with conservative treatment

Majority of patients with viral meningitis have a self- limited course that will resolve in 7-10 days without specific therapy

72
Q

What is the prevention for VM?

A

vaccination!!

specifically polio, MMR and varicella (VAR/Zoster) vaccines

73
Q

What is the MC etiology of encephalitis? What are 3 other less common causes?

A

viral MC - herpesviruses (HSV, VZV, EBV)

autoimmune encephalitis
amebic encephalitis: motile trophozoites seen in wet mount of warm, fresh CSF
parasitic- toxoplasmosis

74
Q

When comparing encephalitis to meningitis, what is the major difference with regards to s/s?

A

encephalitis will have AMS when compared to meningitis

Psychotic symptoms: hallucination, agitation, personality/behavioral changes

75
Q

Encephalitis occasionally involves _____ and may result in 1 of 3 things. Name them

A

HPA axis

temperature dysregulation (hypothermia or hyperthermia)
Diabetes Insipidus
SIADH

76
Q

What are 3 finding in neonates that would make you think HSV? What 2 PE exams are NOT always accurate in babies?

A

herpetic lesions
keratoconjunctivitis
oropharyngeal lesions

Kernig and Brazinski signs are not always accurate in babies

77
Q

______ is the primary diagnostic test in encephalitis

A

CSF PCR amplification

CSF PCR for each individual virus still needs to be ordered

78
Q

After LP, what is the additional work-up for encephalitis? What increases the possibility of it being HSV etiology?

A

MRI/CT of the brain and EEG

focal finding on MRI and EEG abnormalities

79
Q

What is the criteria for a brain biopsy in a pt with encephalitis? What area of the brain do you want to bx?

A

have focal abnormality on MRI

negative CSF analysis/PCR

who progressively deteriorate despite treatment with acyclovir and supportive therapy

bx area that was inflamed on imaging

80
Q

What do you need to do for any suspected herpetic lesion?

A

Viral culture and Tzanck smear

81
Q

What do you need to do if you suspect autoimmune encephalitis?
amebic infection?

A

assess specific autoantibodies in serum/CSF

take a good pt history and look for exposure to warm, iron-rich pools of water
CSF analysis will resemble bacterial meningitis but motile trophozoites are seen in wet mount of fresh warm CSF

82
Q

What is the tx for encephalitis?

A

continuously monitor and tx any abnormal vital signs: O2, ventilation, fluids

control seizures with IV lorazepam

frequent neuro checks to look for deterioration or change in neuro status

elevate head of bed, control fever and pain, control of straining and coughing, prevent seizures and significant hypo/hypertension

empiric antiviral therapy: acyclovir

empiric abx therapy until bacterial men ruled out

83
Q

What 9 things are part of neuro-checks?

A
84
Q

Only _____ and_____ encephalitis have recommendations for definitive antiviral therapy.

A

HSV and VZV/EBV

85
Q

**What is the goal for empiric antiviral therapy for a pt with suspected encephalitis? What are you giving them specifically?

A

**GOAL: First dose should be administered within 30 minutes of arrival to ED but lab specimens and blood cultures should be obtained BEFORE first antiviral dose

Adults/Pediatric: IV acyclovir 21 days

86
Q

What needs to happen once a pt has completed the antiviral course for encephalitis?

A

CSF analysis for PCR should be repeated at the completion of antiviral therapy in those patients who were PCR (+).

If CSF PCR remains positive additional antiviral therapy should be given

87
Q

What are some sequelae that might happen after encephalitis?

A

Seizure disorder

Cognitive impairment

Movement disorders: tremor, myoclonus, parkinsonism

Hemiplegia

88
Q

What is the major difference in how encephalitis and meningitis presents?

A

Presence or absence of normal brain function is the most important distinguishing feature between the two

Meningitis: CEREBRAL FUNCTION is generally intact

Encephalitis: VERY common to see abnormalities in brain function

89
Q

Brain Abscess is an uncommon focal, suppurative infection within the brain _____ and surrounded by a _____

A

parenchyma

capsule

90
Q

What is cerebritis?

A

a non-encapsulated brain abscess

91
Q

What are risk factors for a brain abscess?

A

direct spread from a head source (otitis media, mastoiditis (33%)
paranasal sinusitis (10%)
dental infections)

hematogenous spread: infections anywhere else on the body

trauma/surgery

92
Q

_____ and ______ are the biggest infections that lead to a brain abscess

A

otitis media and mastoiditis (combined 33%)

93
Q

What are the 4 different stages of a brain abscess? Give days

A
94
Q

What is the MC presenting symptom for a brain abscess? Then what happens?

A

HA that is usually gradual, pts present usually after 10 days of HA

focal neurological deficits

fever

95
Q

focal neurologic deficits that present as hemiparesis, what lobe is involved?

A

(MC in frontal lobe abscess)

96
Q

focal neurologic deficits that present as aphasia/dysphasia, what lobe is involved?

A

(MC in temporal lobe abscess)

97
Q

focal neurologic deficits that present as nystagmus/ataxia, what lobe is involved?

A

(MC in cerebellar abscess)

98
Q

How is a brain abscess dx?

A

MRI with contrast!!! is preferred but CT with contrast if MRI not available

99
Q

_______ is done for a brain abscess to guide abx therapy

A

CT/MRI-guided stereotactic needle aspiration

100
Q

What is the tx for a brain abscess that is community acquired?

A

High dose of empiric parenteral antibiotics AND neurosurgical drainage of the abscess

ceftriaxone PLUS metronidazole

and anti-seizures meds prophylaxis

drain/remove abscess

101
Q

What is the tx for a brain abscess that is due to head trauma or neurosurgical procedure?

A

ceftazidime PLUS vancomycin
OR
meropenem PLUS vancomycin

and anti-seizures meds prophylaxis

drain/remove abscess

102
Q

When would you give steroids in a brain abscess?

A

Steroids ONLY if there is significant peri-abscess edema with associated mass effect and increased ICP

103
Q

_____ is recommended in all brain abscess except what 3 conditions?

A

Abscess drainage

abscess is neurosurgically inaccessible

small (<2–3 cm) or non-encapsulated abscesses

patients with an unstable condition to allow performance of a neurosurgical procedure

104
Q

When would you want to completely excise a brain abscess?

A

abscess is multiloculated or aspiration fails

105
Q

For a brain abscess, how long do patients need to be on parenteral abx therapy? What else do you need to monitor? How long do they need to stay on anticonvulsant therapy? When can they stop taking everything?

A

Minimum of 6–8 weeks of parenteral antibiotic therapy

Serial MRI or CT scans performed monthly or twice-monthly to document resolution of the abscess

Prophylactic anticonvulsant therapy for minimum of 3 months

therapy can be d/c once EEG is normal both pre- and post medication withdrawal

106
Q

What are poor prognostic signs for a brain abscess?

A

Rapid progression of the infection before hospitalization

Severe mental status changes on admission

Stupor or coma (60-100% mortality)

Rupture into the ventricle (80-100% mortality)

107
Q
A

Neuro (13 decks)

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