CNS INfections...long

Question 1

Kid comes in confused (global cortical dysfunction), drowsy (ascending arousal system of midbrain and thalamus is screwed up), and with stiff neck (meningeal inflammation). Also has rash consistent with inflammation of small blood vessels (small vessel vasculitis).

This is a classic presentation for

Answer 1

Meningococcla meningitis

Question 2

Bacterial meningitis

Answer 2

DISASTER>...can kill in hours
Treat empirically (before diagnosis)

Question 3

Bacterial meningitis can be caused by pathogens that get into the meninges how?

Answer 3

• blood borne and arrive from another infected location like the lungs
• May enter from a nearby infected structures, say the ear, when veins clot as in the case of otits media or mastoiditis
• direct entry from outside

Question 4

How do bacteria cross BBB

Answer 4

capsule and pili are the most important virulence factors here. They penetrate endothelial cells and cross BBB

Question 5

Once inside the CSF, the environment is perfect for bacteria because there are few immune cells on patrol and plenty of glucose

Answer 5

ok

Question 6

within hours the immune cells arrive in CSF

Answer 6

ok

Question 7

inflammatory respponse mediated by

Answer 7

IL-1 and TNF-Alpha….this inflammatoion results in small vessel vasculitis and thrombophlebitis with decrease in cerebral blood flow.

• Ischemia then leads to infarction with greater swelling
• Results in small vessel vasculitis and thrombophlebitis with consequent decrease in cerebral blood flow
• BBB breaks down
• increase in ADH leads to low sodium concentration and blood becomes hypo-osmolar. This provides a source of free water that exacerbates edema

Question 8

Whats important to realize about antibiotics in meningitis treatment?

Answer 8

They strongly stimulate the immune response by lysing the bacterial cell walls and releasing wall fragments that are highly antigenic. Cytokines, interleukins and inflammatory cascade occurs, vasculitis also occurs

Question 9

How do you counter this poor side-effect of antibiotics?

Answer 9

Give corticosteroids

Question 10

children older than 2 mos and adults, most common causes of bacterial meningitis are

Answer 10

pneumococcus and meningococcus

Question 11

Neonates?

Answer 11

Group B strep, Listeria (also in old ppl), E. Coli

Question 12

When there is direct penetration of the CSF via surgery or trauma, what are some causative organisms

Answer 12

Staphylococcus and Gram negatives

Question 13

The adrenal glands can be affected by meningitis. What hapens

Answer 13

They undergo hemorrhagic necrosis and you get an Addisonian crisis due to low corticosteroids…called waterhouse friedrichsen syndrome

Question 14

Listeria risk factors

Answer 14

whatever depresses the immune system….pregnancy, organ transplant, autoimmune disease, etc…

Question 15

Kernig’s sign

Answer 15

inability to straighten the knee with the patient supine and the hips flexed at 90 degrees

Question 16

Brudzinski’s sign

Answer 16

passive flexion of neck causes flexion of both legs and thighs

Question 17

What will labs show in bacterial meningitis?

Answer 17

• High White count on CBC and a marked increase in neutrophils
• Left shift
• Serum sodium may fall due to SIADH
• Prothrombin time and INR become elevated due to consumption of clotting factors in DIC
• Cultures are taken of blood and of every potential site from which the infection may have originated
• KNOW>..SERUM PROCALCITONIN will be hihg as will C REACTIVE PROTEIN

Question 18

A PCR test for the bacterial 16sribosomal DNA can confirm that the pathogen is bacterial

Answer 18

ok

Question 19

Best test for west nile

Answer 19

IgM

Question 20

CSF profile in bacterial meningitis?

Answer 20

tons of pols (normally no more than 5), Neutrophils predominate, Glucose is low (normal 50-100), Protein is increased.

Question 21

Treatment of bacterial meningitis causes the CSF profile to shift toward lymphocytic predominance

Answer 21

ok

Question 22

Treatment of bacterial meningitis

Answer 22

• Steroids FIRST! Dexemethasone within 15 minutes of ABs. The steroids suppress TNF and IL-1
• Then give antibiotics to treat different bugs
• withdraw these antibiotics as you narrow down what the pathogen is

Question 23

Subacute bacterial endocarditis

Answer 23

usually gram positive cocci— widespread septic embolism

Question 24

Four ways bacterial endo can affect the brain

Answer 24

1) Sepsis- can cause metabolic encephalopathy producing confusion, delirium, and coma
2) Can occlude a large cereral blod vessel and cause ischemic stroke
3) Can produce a focal brain are of ischemia and inflammation
4) Can embolize to a distal cerebral artery and cause focal inflammatory erosion of the vessel wall and produce a mycotic aneurysm

Question 25

What organism is responsible for approximately 50% of bacterial endocarditis

Answer 25

Strep Viridans

Question 26

When do you not want to do a lumbar puncture due to risk of herniation?

Answer 26

When there is mass effect

Question 27

Other signs of bacterial endo

Answer 27

• splinter hemorrhages
• Osler’s nodes
• Janeway lesions
• Roth’s spots

Question 28

Diagnosis of cerebral abscess

Answer 28

• headache (worse on lying down, present upon wakening)
• Papilledema and transient visual obscurations
• seizures
• focal neurological deficits
• Contrast CT or MRI with ring surrounding edema