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Geriatrics/Neuro > CNS Infections - Young > Flashcards

CNS Infections - Young Flashcards

1
Q

what is the definition of meningitis?

A

Inflammation of the meninges of the brain and/or spinal cord

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2
Q

what are the 3 layers of the meninges?

A

dura mater (out layer lining skull)

arachnoid mater (contains blood vessels)

pia mater (covers brain)

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3
Q

2 most common types of meningitis?

A

Bacterial (acute bacterial meningitis)

Viral (aseptic meningitis)

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4
Q

what is a type of bacterial aseptic meningitis?

A

Lyme

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5
Q

what is the onset of acute bacteria meningitis?

A

rapid, >50% pts hav sx’s develop over 24hrs

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6
Q

what are the cardinal sx’s of acute bacterial meningitis?

A

HA, fever, neck stiffness

also AMS, but w/this need to think encephalitis is involved

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7
Q

what features of meningitis are also fond in non-meningeal conditions? it is NOT considered bacterial meningitis, if what sx is not the MAIN sx?

A

fever and HA

-not bacterial meningitis if HA is not MAIN sx

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8
Q

how does the pt describe the HA in meningitis?

A

generalized and severe “unlike” other HA’s

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9
Q

what is the most sensitive classic sign of meningitis? what does hypothermia represent?

A

fever

hypothermia may be seen and is sign of potential sepsis

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10
Q

what may AMS indicate in meningitis?

A

elevated ICP secondary to meningoencephalitic inflammation and cerebral edema or possibly delirium secondary to fever

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11
Q

what sx of bacterial meningitis will viral meningitis not have?

A

focal neurologic deficits

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12
Q

what are the focal neurologic deficits in bacterial meningitis?

A

palsy/dysfunction of CN III, VI, VII, VIII
-d/t focal thrombosis in the brain

CN 6 palsy -> get unopposed LR muscle (eye drifts medially)

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13
Q

what are the dermatologic findings of meningitis?

A

Petechiae and Purpuric rash

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14
Q

where are petechiae FIRST found in meningitis?

A

the palate

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15
Q

where are purpura found in meningitis?

A

posterior part of LE’s (dependent parts of the body)

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16
Q

what are petechiae due to? what do they look like when you press on them?

A

broken capillaries

they don’t blanch

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17
Q

what are purpura?

A

petechiae that cluster together

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18
Q

what are risk factors for meningitis?

A
  • > 50yo
  • ***Upper respiratory infection (pts usually have a hx of URI)
  • Otitis media
  • Sinusitis
  • Mastoiditis
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19
Q

what do pts with meningitis usually present with a hx of?

A

hx of URI

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20
Q

how do elderly people with meningitis present?

A

atypically

HA, but maybe no fever or neck stiffness

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21
Q

what is one thing to always ask pt with acute bacterial meningitis about?

A

ASPLENIA - b/c spleen gets rid of encapsulated organisms, so if don’t have spleen can’t get rid of bacterial meningitis

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22
Q

what type of bacteria causes acute bacterial meningitis?

A

encapsulated bacteria colonized the naso-oropharynx that penetrate the intravascular space

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23
Q

acute bacterial meningitis may also occur secondary to what?

A

bacteremia in remote focus (endocarditis, pneumonia)

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24
Q

what are the most common pathogens for acute bacterial meningitis?

A

Streptococcus pneumoniae (adults and kids)

Neisseria meningitides (adults and kids)

Haemophilus influenza type B (adults)

Group B streptococcus (adults)

Listeria monocytogenes (adults)

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25
Q

what 2 bacteria cause acute bacterial meningitis in kids?

A

Streptococcus pneumoniae

Neisseria meningitides

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26
Q

how does aseptic meningitis (viral meningitis) resolve?

A

without specific therapy/spontaenously

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27
Q

what is the most common virus that causes aseptic meningitis?

A

enterovirus

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28
Q

how is enterovirus transmitted?

A

from direct contact respiratory secretions, fecal-oral contact

ie. changing diaper infected infant

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29
Q

common viral causes of aseptic meningitis?

A

Enterovirus (most common)

HSV 1/2 (ask pt if have hx of herpes, ask when their last flare was)

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30
Q

most common presentation of aseptic meningitis?

A

abrupt onset headache, fever, nausea, vomiting, ***photophobia, nuchal rigidity

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31
Q

what is the most common fungal cause of aseptic meningitis?

A

cryptococcus (esp if immunocompromised)

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32
Q

dx studies for meningitis?

A

(1) CBC
(2) Chem-7
(3) Lactate
(4) CRP, ESR
(5) Blood cx’s
(6) ***LP
(7) Head CT

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33
Q

what will the CBC be like in elderly with meningitis?

A

normal CBC

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34
Q

what is a poor prognostic indicator of meningitis?

A

thrombocytopenia

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35
Q

what will CHEM-7 look like for meningitis?

A

Vomiting may cause evidence of volume contraction and dehydration (ie high Cr, BUN, low HC03 if poor perfusion)

Hyponatremia (SIADH)

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36
Q

what lab value is a poor predictor of mortality in pts with meningitis?

A

Lactate >4 (22% die at 3 days)

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37
Q

when do you obtain blood cultures for meningitis, after or before abx therapy?

A

BEFORE abx therapy

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38
Q

what is the ONLY way to dx meningitis?

A

Lumbar Puncture

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39
Q

why MUST you consider doing CT prior to LP for meningitis?

A

if think pt has elevated ICP, want to do head CT BEFORE LP so as not to put at risk for herniation

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40
Q

criteria for doing head CT BEFORE LP for meningitis?

A
  • Abnormal mental status
  • Seizure within 1-week presentation
  • Known CNS lesion/disease
  • Focal neuro findings on exam
  • Papilledema
  • > 60yo
  • Immunocompromised
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41
Q

what are 2 signs of elevated ICP?

A

posturing (rigidity) and aniscoria from CN3 palsy (sign pt is herniating)

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42
Q

do you delay abx therapy if high suspicion for acute bacterial meningitis even w/o LP or Ct?

A

NO!!!!

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43
Q

how long do you have to do LP after give abx for acute bacterial meningitis?

A

2-4 hours

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44
Q

what must you obtain when do LP for meningitis? how much CSF to obtain for PCR analysis?

A

opening pressure (elevate at 20-50mmhg)

obtain 4-8ml of CSF for PCr analysis

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45
Q

in what position can opening pressure ONLY be obtained?

A

Lateral-recumbinant position

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46
Q

at what WBC level does CSF have that increases likelihood of bacterial source?

A

CSF WBC >500

47
Q

bacterial meningitis LP CSF findings (WBCs, glucose, protein)

A

WBC 100-500 PMN’s

Glucose decreased

Protein elevated

48
Q

viral (aseptic) meningitis LP CSF findings (WBCs, glucose, protein)

A

WBC elevated 10-500 lymphocytic

Glucose normal

Protein elevated

49
Q

fungal meningitis LP CSF findings (WBCs, glucose, protein)

A

WBC 0-500 lymphocytic

Glucose normal to decrease

Protein elevated

50
Q

Tb meningitis LP CSF findings (WBCs, glucose, protein)

A

WBC 0-500 lymphocytic

Glucose decreased

Protein elevated

51
Q

tx for meningitis

A

abx (initial therapy)

steroids (dexamethasone)

antivirals (if think aseptic meningitis)

mannitol (if ICP elevated and increased OP)

52
Q

when are steroids given for meningitis?

A

PRIOR TO OR WITH first dose of antibiotics

53
Q

steroids are especially effective in tx of what bacteria causing meningitis?

A

S. pneumoniae

54
Q

what steroid is used for meningitis and at what dose?

A

Dexamethasone HIGH DOSE (10mg IV)

55
Q

what antibiotics are used in 16-50 y/o’s with meningitis and for what bacteria?

A

Vanco AND 3rd gen cephalosporin

Bacteria:
-N. meningitides, S. pneumo, H. influenzae

56
Q

what antibiotics are used in >50 y/o’s with meningitis and for what bacteria?

A

Vanco AND 3rd gen cephalosporin AND ampicillin

Bacteria:
-S. pneumo, N. meningitidis, ***Listeria, aerobic GN bacilli

57
Q

why give ampicillin for meningitis in >50 y/o’s?

A

b/c want to cover for Listeria

58
Q

what antibiotics are used in immunocompromised (drunk, DM, HIV, etc.) with meningitis and for what bacteria?

A

Vanco AND 3rd gen ceph AND ampicillin

Bacteria:
-Listeria, aerobic GN bacilli, S. pneumo, N. meningitidis

59
Q

what antibiotics are used in neurosurgery, head trauma, cerebrospinal trauma with meningitis and for what bacteria?

A

Vanco AND either 3rd gen cephalosporin with anti-pseudomonas or meropenem

Bacteria:
-Staph, aerobic GN bacilli, S. pneumo

60
Q

aseptic bacterial meningitis usually managed as what?

A

outpatient

61
Q

management options for likely viral meningitis includes…

A

Admit and treat IV ABX with CSF culture results in 24hrs

if confident and patient comfortable and reliable then d/c 24-48hr f/u +/- single dose of antibiotics

(ie. could use IM ceftriaxone which is q24hr)

62
Q

what is encephalitis?

A

inflammation of brain parenchyma (inflammation of your brain tissue)

63
Q

how does encephalitis occur?

A

Direct viral invasion (many different viruses cause this)

Hypersensitivity reaction to a virus or another foreign protein several weeks after exposure (Ex. Vaccine)

64
Q

what brain mater does encephalitis affect more?

A

gray matter > white matter

65
Q

what is the HALLMARK sign of encephalitis?

A

AMS

66
Q

encephalitis often accompanied by?

A

seizures (esp HSV)

67
Q

what is encephalomyelitis?

A

encephalitis that involves the spinal cord

68
Q

what is encephalomyeloradiculitis?

A

encephalitis that involves the nerve roots

69
Q

what are the manifestations of encephalitis? what’s the M/C?

A

primary (M/C) and secondary

70
Q

what is primary manifestations of encephalitis?

A

Get virus and IT causes encephalitis -> ***M/C

71
Q

causes of epidemic primary encephalitis?

A

Echo virus, Coxsackie virus, Arbovirus, Polio

72
Q

causes of sporadic primary encephalitis?

A

HSV, VZV, Mumps, Rabies

73
Q

what is secondary manifestation of encephalitis?

A

Post-infectious -> d/t own bodies immune response from viral infection or vaccine

74
Q

how do you dx primary vs secondary encephalitis?

A

LP and CSF PCR data excluding acute primary illness

***NO IRAL PROTEINS IN SECONDARY ENCEPHALITIS (b/c not actively infected)

75
Q

what is the most common etiology WORLDWIDE of secondary encephalitis?

A

antecedent URI with measles

76
Q

what are the M/C viruses causing encephalitis in immunocompetent pts?

A

HSV 1/2 and Enterovirus

77
Q

what is the M/C cause of viral encephalitis?

A

HSV 1/2

-can be from reactivation from dormant HSV in trigeminal ganglia

78
Q

other causes of encephalitis?

A

Arbovirus (West Nile Virus from mosquito)

Rabies

Powassan Virus (tick-borne)

79
Q

what is the ONLY tick-borne cause of encephalitis?

A

Powassan Virus

80
Q

what’s the mortality rate of rabies?

A

100%

81
Q

sx’s of Arbovirus (West Nile)

A

“summer” flu

82
Q

what is the greatest RF for Arbovirus (West Nile)?

A

being elderly

83
Q

how do you dx Arbovirus (West Nile)?

A

LP or serum IgM test

84
Q

tx of Arbovirus (West Nile)?

A

SUPPORTIVE TX

85
Q

who does LaCrosse Encephalitis occur in?

A

<16 y/o

86
Q

if survive Eastern Equine Encephalitis, what complications are they left with?

A

neurologic

87
Q

what is the greatest RF for St. Louis Encephalitis?

A

being elderly

88
Q

how to prevent Japanese Encephalitis?

A

vaccine for travelers

89
Q

what is given to pt if bitten by rabid animal?

A

PEP - active and passive immunization

90
Q

what mammals are vectors for rabies?

A

Raccoon, Fox, Coyote, Skunk, Bat

91
Q

is there a tx for rabies?

A

NO!!!

92
Q

what do you do for possible rabid domestic animals (dogs)?

A

10-day observation in quarantine to see if rabid behavior comes out

93
Q

at what age do most contracts rabies from dogs?

A

<15 y/o

94
Q

what is paraneoplastic encephalitis? d/t?

A

cancer related encephalitis

d/t: SCLC, Testicular cancer, thymoma, Breast, HL

95
Q

what is autoimmune encephalitis?

A

Abs to neuronal cell surface/synaptic proteins

-presence or absence of malignancy

Anti-NMDA

96
Q

what are the sx’s of autoimmune encephalitis? females with this most often associated with?

A

psychiatric manifestation, cognitive/speech dysfunction, seizures, autonomic instability, dyskinesia’s

Females often associated with teratomas

97
Q

dx for paraneoplastic and autoimmune encephalitis?

A

LP/CSF w/ antibody testing on serum and CSF

98
Q

tx of paraneoplastic and autoimmune encephalitis?

A

Early immunotherapy with IVIG and IV methylprednisolone

Early tumor resection (if have teratoma)

99
Q

what are the classic sx’s of encephalitis?

A

Fever, Headache, Change in MS

100
Q

what is the typical HPI of someone with encephalitis?

A

mild ‘flu’ or febrile viral illness with likely some evidence for meningeal involvement

101
Q

important risk factor for encephalitis, esp Arbovirus?

A

travel

102
Q

dx of encephalitis?

A

LP for CSF exam

CSF PCR -> HSV 1/2, VZV, Enterovirus

Head CT/MRI/EEG b/c pts have AMS

103
Q

what does Head CT/MRI show for encephalitis that is classic for HSV?

A

BITEMPORAL APPEARANCE AND ORBITOFRONTAL APPERANCE (CLASSIC OF HSV)

104
Q

what does EEG show if pt is having seizure?

A

focal spiking

105
Q

what’s the tx for encephalitis?

A

Acyclovir for HSV - otherwise supportive tx

Benzo’s/Anticonvulsants for seizures and for ppx

106
Q

what’s the M/C location for epidural abscess?

A

spinal (thoracolumbar region)

107
Q

M/C causes of epidural abscess?

A

hematogenous seeding from IVDA

direct extension from osteomyelitis

108
Q

median age for spinal epidural abscess?

A

50 y/o (35 y/o in IVDU)

109
Q

what are the 4 clinical stages of spinal abscess?

A
  1. ***Fever and focal back pain (M/C)
  2. Nerve root compression: radiculopathy; “shooting pain”
  3. Spinal cord compression: Cauda Equina sx’s
  4. Paralysis: abscess infarcts cord
110
Q

what’s the M/C sx of spinal abscess?

A

fever and FOCAL BACK PAIN

111
Q

what’s the FIRST SIGN of cauda equina?

A

Difficulty start/stop stream

112
Q

thinking of spinal epidural abscess is KEY in pts with what sx’s?

A

fever and SEVERE focal back pain

113
Q

how do dx spinal epidural abscess?

A

MRI

114
Q

what’s C/I in spinal epidural abscess?

A

LP

Geriatrics/Neuro (11 decks)

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