CNSI Flashcards
What proportion of patients with active TB meningitis would also have TB elsewhere?
2/3
How does TB affect the spine?
- Compression of spinal roots and cord
- Direct parenchymal invasion
- Osteomyelitis causing an epidural abscess
- Osteomyelitis causing bone deformity affecting spine
- Arteritis causing cord infarct
Dose of anti tb meds?
5mg per kg H
10 R
15 E
20 Z
What cell is dysfunctional in patients with fungal meningitis?
T cells
T or F: Fungal meningitis presents with multiple cranial nerve involvement, arteritis with thrombosis, brain infarction, microabscesses and HCP?
True. much like TB
T or F CALAS is sensitive
T. 90% reliability to exclude the disease
How to grow crypto in the lab?
Saboraud agar at 37 deg cel
T or F In patients with AIDS, an elevated Toxo IgG titer + clinical syndrome + MRI findings are diagnostic of toxoplasmosis?
F. EXCEPT AIDS because they do not display an elevation of titers.
Antitbiotics for Toxoplasmosis?
Sulfadiazine and pyrimethamine
Treatment for Cysticercosis and Schistosomiasis
Praziquantel 20mg per kg
What do cerebral lesions of schistosomiasis look like?
Mixed necrotizing and ischemic parenchymal foci infiltrated with eosinophils and giant cells
Where is schistosomiasis endemic in the Philippines?
Mindoro Oriental and Sorsogon in Southern Luzon; the provinces of North, East and Western Samar; Leyte; and Bohol in Eastern Visayas, and all the provinces of Mindanao with the exception of Misamis Oriental, Davao Oriental and Maguindanao.
What are the most common cauasative organisms of septic thrombophlebitis?
Staph and strep
What are the CSF findings in septic cavernous sinus thrombophlebitis?
May be normal
What bacterial type of meningitis may take the form of a rhombencephalitis?
Listeria monocytogenes or burkholderia psuedomallei
What bacteria is responsible for Whipple Disease?
Tropheryma whipplei
Treatment for:
Listeria
Legionella
Mycoplasma
Legionella Levofloxacin, azithromycin
Listeria Ampicillin Gentamicin
Mycoplasma Azithromycin and Clarithromycin
Subdural empyema of sinus origin is due to?
Streptococci, non-hemolytic + viridans
What is the usual precedent of epidural abscess?
Osteomyelitis
What is the likely bac men pathogen in:
- Petechial and purpuric rash
- Alcoholics
- Splenectomized patients
- Meningococcal meningitis
2-3. Pneumococcal meningitis
What is the usual number of WBC in bacterial meningitis?
1000-10000
What bacterial meningitis presents with bloody CSF?
Anthrax
90% of bacterial meningitis patients will have a protein higher than?
45mg dl
What CSF value can distinguish between bacterial or fungal from viral meningitis?
Lactic acid is greater than 35mg dl in bacterial or fungal
Cultures of spinal fluid are positive in how many cases of bacterial meningitis?
70-90%
What are the 3 tests that can be used to determine if nasal fluid is of central origin?
- beta 2 transferrin test
- Protein hanky test if does not stiffen must be sf
- Glucose if 2/3 serum must be csf
What causes Mollaret meningitis?
Herpes simplex
What syndrome? Iridiocyclitis, poliosis, vitiligo and recurrent meningitis
Vogt Koynagi Harada
How to give dexamethasone to adults?
Dexa 10mg just before the first dose of antibiotics
Waterhouse Friedrichsen syndrome (adrenocortical hemorrhages) is associated with what kind of meningitis?
Meningococcimia. N meningitidis
What is osler triad?
Endocarditis, pneumococcal meningitis, pneumonia
What meningitis is frequently associated with hearing loss?
Pneumococcal meningitis
What is the common csf picture in aseptic meningitis?
Normal CHO with lymphocytic pleocytosis
What is the most common cause of viral meningitis?
Enterovirus: echo and coxsackie followed by HSV-2
The lymphocytic choriomeningitis virus is commonly acquired from what animal?
Hamsters/ rats
What drugs can causes aseptic meningitis?
IVIG, NSAIDS, antibiotics (Bactrim and Amoxicillin)
What is the most common cause of acute encephalitis?
HSV
What is the serogroup of Japanese encephalitis?
Flaviviruses
What are the neurologic complications of EBV (Infectious mononucleosis)?
Meningitis, Encephalitis, Facial palsy, polyneuritis of GBS type
CSF in herpes simplex encephalitis ALWAYS shows?
pleocytosis usually in the range of 10-200 lymphocytes
What is the incubation period of rabies?
20-60 days
Babes nodules and negri bodies are found in what disease/s?
Rabies.
babes- focal collections of microglia
negri- eosinophilic cytoplasmic inclusions mostly in the pyramidal cells of the hippocampus
What cleanser should be used for dog bites to avoid rabies?
Ammonium chloride
What is the mean latency of infection and AIDS?
8-10 years
What test is most sensitive for the early stages of AIDS dementia?
Trail making
What are imaging findings in AIDS dementia?
Widening of sulci, enlargement of ventricles and diffuse white matter changes with ill defined margins
What is the first proven viral polyneuritis in humans?
AIDS peripheral neuropathy
What AIDS medication is purported to cause a myopathy?
Zidovudine
Treatment for Toxoplasmosis?
Pyrimethamine and sulfonamide
What is the clinical picture of CMV encephalitis?
Acute confusional state + Cranial nerve signs
C for C! CMV with cranial nerve signs
A special result of HIV treatment may induce an intense inflammatory reaction to a coexistent infection called?
Immune reconstitution inflammatory syndrome. IRIS.
How long is the asymptomatic period after an infection with measles before SSPE happens?
6-8 years!
What is the EEG pattern of SSPE?
EEG of periodic 5 to 8 second bursts of 2-3/s high voltage waves followed by a relatively flat pattern
What part of the brain is usually spared in SSPE?
Cerebellum
What is the most common kind of sporadic CJD?
MM1
What are the variants of CJD?
- Prominent cerebellar ataxia
- Prominent visual distubance
- Brownell-Oppneheimer variant
- Heidenhain variant
Heiden is blind!
Brownell is dancing with oppenheimer!
What are the EEG findings in CJD?
Diffuse non-specific slowing –> stereotyped high voltage slowing + sharp wave complexes on low voltage background and slow
May also exhibit pseudoperiodicity
What are the MRI findings of CJD?
Hyperintensity of lenticular nuceli, cortex and basal ganglia on T2 and DWI.
What movement disorder is characteristic of CJD?
Myoclonus
How to differentiate SSPE and CJD based on CSF?
SSPE: CSF with elevated IgG
CJD: NORMAL
What can kill cjd prion?
autoclave 132 degrees celsius at 15lb/in2 OR 5% sodium hypochlorite immersion
Kuru plaques are predominantly in which part of the brain?
Cerebellum
What is a prion?
A proteinacious infectious particle that is devoid of nucleic acid resists the action of enzymes that destroy RNA and DNA
Normal prion protein PrP is normally encoded by a gene on the short arm of chromosome 20 in humans
Creutzfeldt-Jakob Disease is aka?
Subacute spongiform encephalopathy
What prior disease caused the mini 1986 epidemic called mad cow disease?
variant Creutzfeldt-Jakob Disease
Prion is identical to prions seen in bovine spongiform encephalopathy
What is the conformational change that PrPc being transformed to PrPsc goes through?
Helix to beta pleated sheets
What ist he most common type of isoform of the prion of CJD?
MM1 present in 2/3 of sporadic cases
What is the order of development of sxs in CJD?
Behavioral change
Ataxia
Visual disturbances
Myoclonus
RAPIDLY progressive over weeks
What sequences show hyperintensity in the lenticular nuclei and cortex (long contiguous segments) in CJD?
T2 and DWI
What is the Sn and Sp of 14-3-3 immunoassay of peptide fragments? For Creutzfeldt-Jakob disease
92
80
Re CJD: What is the histopathologic substrate of myoclonus and positive sharp waves in the EEG?
Loss of certain inhibitory neurons in the thalamic reticular nuclei
Microscopic vacuoles of the cytoplasmic processes of the glia give rise to the spongy appearance of the brain
NO EVIDENCE OF INFLAMMATION!!! One of the key pathologic features
Intoxication with what element can results in dementia and myclonus similar to CJD?
Lithium
Other DDX: SSPE, Hashimoto encephalopathy, carcinomatous meningitis
What characteristics of these prion diseases differentiate them from CJD:
- Gerstmann-Straussler-Scheinker Syndrome
- Fatal insomnia
- Kuru
- Gerstmann-Straussler-Scheinker Syndrome: Familial rather than sporadic, minimal dementia, presents with cerebellar ataxia
- Fatal insomnia: Insomnia, Sympathetic overactivity, no evidence that infected brain can transmit
- Kuru: Presents with ataxia, transmitted by cannibalism in the natives of New Guinea
Subacute sclerosing panencephalitis
- Infectious agent
- Presenting signs
- Prognosis
- Infectious agent: Chronic measles virus
- Presenting signs: Behavioural change, intellectual decline, loss of interest in activities –> Myoclonus, ataxia
- Prognosis: Death in 1-3 years while in decorticate posturing
SSPE diagnostics
EEG?
CSF?
Biopsy?
EEG: high voltage periodic bursts lasting 2-3s
CSF: No cells but CHON increased and there are Ogc bands
Biopsy: Degeneration of white matter axons and myelin with perivascular cuffing with mononuclear cells and fibrous gliosis WITH EOSINOPHILIC INCLUSIONS IN THE NUCLEUS AND CYTOPLASM of neurons and glia
What do the glia of PML brains look like?
Gigantic with deformed and bizarre shaped nuclei and mitotic figures– a feature that is otherwise only seen in malignant glial tumors
What percentage
of HIV patients have PML
of PML patients have HIV
5
75
What virus causes PML?
Polyoma virus, JC virus
70% of normal adult population will antibodies for it dormant in the kidney and marrow until immunosuppression allows for activation
In encephalitis lethargica (von Economo Disease, Sleeping Sickness) that was discovered in the wake of the influenza pandemic of World War 1, what is the terminal movement disorder seen?
Starts with ophthalmoplegia and pronounced somnolence
after a few weeks or months a parkinsonian syndrome supervenes
What are the two families of retroviruses known to infect humans? Where does HIV belong?
- Lentiviruses, HIV
2. Oncornaviruses, HTLV
What percentage of untreated AIDS patients will have neurologic abnormalities?
1/3 clinically
Autopsy all
What is the interval between infection and development of AIDS in adults?
Several months to 15 years
8-10 years mean latency time
What percentage of AIDS patient with present with HAND? HIV associated neurocognitive disorders?
3%
but 2/3 will have HAND once AIDS is established already.
Survival after dementia is 3-6 months
Quickly progressive over weeks to months only IF UNTREATED
What does the MRi of a HAND patient look like?
Widened sulci, enlarged ventricles, patchy but confluent or diffuse white matter changes with ill defined margins
What is the most common peripheral neuropathy pattern in AIDS?
Distal symmetrical, axonal polyneuropathy, predominantly sensory and dysesthetic dtype
Can also have mononeuropathy multiplex from vasculitis
The absence of IgG antibodies to toxoplasma should shift management in an HIV brain mass to addressing which pathology?
Primary CNS lymphoma
CMV CNS infection in HIV patients is characterised by the preponderance of which symptoms?
Opthalmoparesis Nystagmus Ptosis Facial nerve palsy Deafness
Starts with delirum and CN deficits
Tropical spastic paraparesis is due to what virus?
HTLV-1
How is polio transmitted?
Fecal oral
95-99% of infected patients are asymptomatic or experience only a non-specific febrile illness
Besides the central chromatolysis that occurs in the anterior horn of the spinal cord what other structures are affected in polio?
Brainstem nuclei! usually for muscles of swallowing and deglutition
Inflammatory lesions in the meninges accounting for meningitis, lesions in the dorsal root and ganglia accounting for muscle pain and paresthesia in parts that later become paralyzed, abnormalities of autonomic functions
Loss of respiration centers in the brainstem resulted in the use of an IRON LUNG
What cells in the brain are selectively damaged by the JC virus?
Oligodendrocytes leading to PML
T or F: Kernig’s and babinski is usually absent in viral meningitis?
T
what is the CSF glucose of viral meningitis?
Usually normal. NEVER BELOW 25mg per dl
What viruses make up the majority of acute aseptic meningitis?
Echovirus and coxsackie virus
Followed by HSV2 in adults
What viral infections can cause orchitis?
Mumps virus,
group B coxsackie virus infections,
infectious mononucleosis,
lymphocytic choriomeningitis (LCM virus FROM THE HOUSE MOUSE!!)
Contraction of the parvovirus that causes fifth disease in children by an adult will cause what type of neuro manifestation?
Brachial neuritis! Some with meningitis and encephalitis
What are ddx for NON viral causes of aseptic, chronic and recurrent meningitis?
- Parameningeal infectious such as an abscess
- Fungal or TB
- Neoplastic (carcinomatous meningitis)
- Granulomatous such as sarcoidosis
- Partially treated bac men
- Chemical meningitis such from when a craniopharyngioma ruptures
- Allergic: NSAIDs, IVIG
Besides presenting as chronic recurrent meningitis, what are other clues that will point towards the following diseases?
- Vogt Koyanagi Harada syndrome
- Mollaret recurrent meningitis
- Vogt Koyanagi Harada syndrome: iridocyclitis, depigmentation of a thick swath of hair, deafness, vitiligo near the eye, no lashes – looks like rogue!!!
- Mollaret recurrent meningitis, associated with HSV, 2 week episodes of the headache and fever recurring over several months or years
What is the mortality/ neuro deficit rate for patients with HSV encephalitis?
50%
What is the CSF picture of Herpes simplex encephalitis?
May be normal in the first few days but will invariably show pleocytosis– 10-200 lymphocytes
Increased CHON
Glucose usually normal rarely slightly less than 40mg per dl
Re: Herpes simplex encephalitis
- EEG picture
- MRI/CT
- When will HSV PCR of the CSF have a false negative?
- What is the dose for the medication?
- Lateralized periodic high voltage sharp waves in the temporal regions and slow wave complexes at regular 2-3 per second intervals
- CT 2/3 with hypodensity in temporal lobe; MRI signal change in almost all HSE patients in T2; with lesions that almost always enhance… T1 with hypointensity with edema
- First 48 hours of the illness
- 30mg per kg/day for 10-14 days
What is the prognosis of Herpes simplex encephalitis if treatment with begun within 4 days of onset of illness in an awake patient?
90% survival
Re: Rabies
- Length of incubation period?
- Pathology location in dumb rabies
- Diagnostic finding in histopathology?
- Length of incubation period? 20-60 days
- Pathology location in dumb rabies: spinal cord
- Diagnostic finding in histopathology? Negri bodies are eosinophilic cytoplasmic includsions AND Babes nodules which are focal collections of microglia
What should be used to cleanse rabies wounds?
Ammonium chloride shown to inactivate the virus
What is the regimen for post exposure prophylaxis for rabies?
- Human rabies immunoglobulin: 20U per kg of body weight (1/2 around wound 1/2 IM) effective for 20 days to give time for the HDCV to take effect
- Human diploid cell vaccine 1ml injections D0 D3 D7 D14 D28
Acute cerebellitis or acute ataxia of childhood is most related to which virus?
Chickenpox, Varicella
Chickenpox and herpes zoster is caused by what DNA virus?
Varicella
Similar structure to herpes simplex virus
Where is varicella virus usually located?
In the trigeminal and thoracic ganglion cells (T5-T10)
After initial chickenpox infection the virus is latent only to be awoken by immunosuppressive states such as: radiation, chemo, aids, lymphomas, elderly
10% of patients with lymphoma
25% of those with hodgkin disease
What is the Ramsay hunt syndrome?
Why is ophthalmic herpes scary?
Herpetic eruption of the EAM WITH FACIAL PALSY
Can cause involvement of the cornea and conjunctiva resulting in corneal anesthesia and scarring
How soon should acyclovir be given in herpes zoster (shingles)?
within 48 hours to shorten the duration of acute pain and speed up the healing of vesicles
Post herpetic neuralgia follows in 5-10 percent of shingles patients often in the elderly. What drug can ameliorate pain?
Amitriptyline
Which rickettsial disease?
- Confined to eastern and southeastern Asia transmitted by mites from infected rodents or humans
- Due to inhalation of materials infected with coxiella burnetti
- Transmitted by lice to humans and from person to person– in underdeveloped parts of the world only
- Confined to eastern and southeastern Asia transmitted by mites from infected rodents or humans; with necrotic ulcer and eschar at the site of attachment of the infected mite: Scrub typhus/ tsutsugamushi fever
- Due to inhalation of materials infected with coxiella burnetti: Q fever
- Transmitted by lice to humans and from person to person– in underdeveloped parts of the world only: Epidemic typhus
What are the the neurologic manifestations of typhus?
Starts with fever headache with a macular rash on the 4th febrile day –>
Delirium, stupor, optic neuritis
Brain shows swelling and proliferation of endothelial cells of small vessels and a microglial reaction with typhus nodules
What is the treatment for all rickettsial disease?
Doxycycline OR chloramphenicol
Re Toxoplasma: What is the mode of transmission?
Raw beef and cat feces
What are the manifestations of congenital infections in toxoplasma?
- Microcephaly
- Calcificaitons
- HCP
- Chorioretinitis
What can a presumptive diagnosis of toxoplasma be made?
- Rising serum antibody titers
- Positive IgM indirect fluorescent antibody
PATIENTS WITH AIDS USUALLY DO NOT DISPLAY AN ANTIBODY RESPONSE!!
What is the standard treatment for toxoplasmosis?
Oral sulfadiazine and pyrimethamine with leucoverin
What does the CSF of amebic meningitis look like?
Like bac men: High PMNs, NOT EOSINOPHILS, high protein and low glucose
Trophozoites
Treatment: Amphotericin B BUT STILL POOR PROG
What is the histopath of cerebral malaria?
Vessels packed with parasitized erythrocytes: small foci of necrosis surrounded by glia
Retinopathy signals severe malaria
When do neuro sypmtoms appear in a malaria infection?
second or third week
Treatment for cerebral malaria
Quinine and artesunate
What are the neurologic manifestations of trypanosomiasis?
- Kerandel hyperesthesia– Prounounced pain at sites of minor injury
- Diffuse meningoencephalitis at the second year of the infection– stupor, dysarthria, seizures, ophthalmoplegia
- Winterbottom sign– Posterior cervical adenopathy
Identify which parasite/ worm?
- Chitinoma, large fluid filled cyst:
- Cyst with scolex and late calcification:
- Severe myositis, nematode:
- Granuloma with a migrating track, nematode roundworm:
- Myelopathy, swimmer’s itch, trematode, single granuloma that may be large:
- Chitinoma, large fluid filled cyst: Hydatid disease (echinococcus)
- Cyst with scolex and late calcification: Cysticercosis (taenia solium)
- Severe myositis, nematode: Trichinosis
- Granuloma with a migrating track: Angiostrongyloidiasis
- Myelopathy, swimmer’s itch, trematode, single granuloma that may be large: Schistosomiasis
What is the source of trichinella spiralis? And what neurologic manifestations do they cause? Treatment?
Raw pork
Myopathy and rarely encephalitis with seizures
Tx: Prednisone and albendazole
What does the neuroimaging of a patient with neurocysticercosis look iike?
What tapeworm is responsible?
Initial: Scolex can be seen
Months later: Degeneration and calcification of multiple of the larvae in the parenchyma and subarachnoid space
Symptomatic/ malignant form: Similar to TB– hydrocephalus, vasculitis and stroke and CN palsies
Taenia solium
Tx: Prednisone and albendazole
What type of schistosoma usually invades the nervous system?
Brain: S. japonicum
Cord: S. mansoni
Puro J ang nasa isip! A man down there.
What is the treatment for schistosomiasis?
Pathology?
Dfx from cysticercosis via CT
Praziquantel
Mixed necrotizing and ischemic lesions infiltrated with esosinophils and giant cells.
Schistosomiasis lesions DO NOT CALCIFY. Unlike taenia cysticercosis lesions
What proportion of TB meningitis patients will have TB in another part of their body?
2/3
How long before a person with untreated TB med dies?
4-8 weeks
CSF profile of TB men?
50-500 WBC 50-50 PMN and lymphocytes early on –> lymphocytes predominate
CHON 100-200mg per dl bUT CAN BE HIGHER IF THERE IS FLOW BLOCK
CHO less than 40mg per dl
What is the Se of TB PCR in the CSF? False + rate?
80%
10%
Which among the TB meds have the highest CNS penetration?
In the case of multi-drug resistance what can be added as a fifth drug?
Doses?
INH and PZA
Ethionamide
Treat for 9-12 months
INH: 5mg/kg
give with 50mg pyridoxine daily to prevent neuropathy
RMP: 10mg/kg
ETA: 15mg/kg can cause optic neuropathy– red green color discrimination
PZA: 20mg/kg
AE of INH and ETA for TB treatment?
ETA: 15mg/kg can cause optic neuropathy– red green color discrimination
INH: 5mg/kg
give with 50mg pyridoxine daily to prevent neuropathy
also WOF abnormal liver test
In the classic Thwaites et al. study in Vietnam (2004), what was the benefit of giving dexamethasone and the dose at which it was given?
What was the population?
Outcomes: Decrease in mortality from 41.3 to 31.8%
Population: 14 years old and above with or without AIDS
BMRC grade 2 and 3
(0.4 mg per kilogram per day
for week 1, 0.3 mg per kilogram per day for week 2,
0.2 mg per kilogram per day for week 3, and 0.1 mg
per kilogram per day for week 4) and then oral treatment
for four weeks, starting at a total of 4 mg per
day and decreasing by 1 mg each week.
BMRC grade 1
Therefore, patients with grade
I disease received two weeks of intravenous therapy
(0.3 mg per kilogram per day for week 1 and 0.2
mg per kilogram per day for week 2) and then four
weeks of oral therapy (0.1 mg per kilogram per day for week 3, then a total of 3 mg per day, decreasing
by 1 mg each week)
How to grade the severity of TB meningitis?
MODIFIED British Medical Research Council criteria:
Grade I disease had
a score on the Glasgow Coma Scale of 15 with no focal neurologic signs;
Grade II had a score of either 11 to 14, or of 15 with focal neurologic signs
Grade III had a score of 10 or less.
Modified Vellore grading of tuberculous meningitis
and hydrocephalus
Grade I: GCS 15
Headache, vomiting, fever ± neck stiffness
No neurological deficit
Grade 2: II GCS 15
Neurological deficit present
Grade 3: GCS 9-14
Neurological deficit may or may not be present
Grade 4: GCS 3-8
Neurological deficit may or may not be present
What percentage of Sarcoidosis patients will have clinically significant neurologic deficits?
What is the most common CN affected by sarcoidosis?
5%
CN7
What is elevated in the serum of patients with pulmo sarcoid?
ACE levels elevated in 2/3
1/5 in those with chronic disease (not necessarily pulmo)
Why is there a dilemma in giving prednisone to sarcoidosis patients?
1/2 of them will remit anyway
Re: Syphillis
- How long before CNS is invaded after initial inoculation
- Initial neuro event in 25%
- What are later events in neurosyphilis
- How long before CNS is invaded after initial inoculation: 3 months
- Initial neuro event in 25%: Meningitis onset at about 2 years
- What are later events in neurosyphilis: Meningovascular (secondary syphillis)
- -> Paretic (tertiary syphillis) –> tabetic
IMPORTANT: TREAT DURING AYSMPTOMATIC SYPHILITIC MENINGITIS STAGE– may just have argyll robertson pupils accomodate but NO reaction to light
CSF picture of syphilllis?
What is in common with MS?
Cells up to 100 lymphocytes
CHON 40-200mg/dl
Positive serology
CHO normal
POSITIVE OLIGOCLONAL BANDS
With treatment what is the pattern of normalization in syphillitic meningitis?
Cells –> CHON –> gamma globulin –> serologic tests
Re serology:
Nontreponemal (reagin) VDRL test/ Kolmer
antibodies if in CSF is ALREADY DIAGNOSTIC OF NEUROSYPHILLIS
FTA-ABS is the specific treponemal test will always be positive if there is neurosyphillis
The absence of what clinical symptom will distinguish meningeal syphilis from TB meningitis?
FEVER. They also have headhache, papilledema, cranial nerve deficits, convulsions BUT THE PATIENT IS AFEBRILE
What is the most common manifestation of neurosyphillis accounting for 35% or NS syndrome? When does it manifest?
Meningovascular syphililis
6-7 years
range 9 months to 10-12 years
What is the pathology of meningovascular syphillis?
Heubner arteritis (fibrosis of small articles) Usually of medium to small caliber lenticulostriate arteries
Characteristic lesion is an internal capsular lesion with extending to the adjacent basal ganglia
What disease entity should be kept in mind for a 35-50 year old presenting with dementia and paresis? Dementia paralytica
Tertiary/ Parteic Neurosyphillis
Besides the nervous system what else is affected in tabes dorsalis?
Visceral crises
Gastric: Pain, constricting feeling, nausea vomiting pylorospams
May also happen to rectal crisis, laryngeal crises, genitourinary crises
What is the histopath of tabes dorsalis?
Inflammation along the posterior root usually of the lumbosacral region with secondary involvement of the posterior column causing thinning of the cord and slkight dorsal ganglion cell loss
What is the treatment regimen for neurosyphilis?
When to test again?
Penicillin G given at 18-24 million units daily for 14 days
Re-examine the patient every 3-6 months after treatment. CSF re test at 6 months– treat again based on CSF
What is the causative spirochete in erythema chronicum migrans?
Borrelia burgdorferi in the ixodid tick
THIS IS LYME DISEASE
What is the order by which the clinical manifestations of Lyme disease progress?
Ring erythematous lesion
Flu: Myalgia arthralgia headache
Neurologic:
Mengingoradiculitis especially in the Bannwarth syndrome of the Euro variant
Peripheral neuritis
In lyme disease what percentage will manifest neurologic and cardiac symptoms
15% and 8%
What is the most usual type of CN involvement with lyme disease?
CN 7 unilateral or bilateral similar to sacroidosis
How to detect lyme disease?
Treatment?
ELISA IgM and IgG for recent
IgG for later caes
90% of patients with acute or convalescent will be positive for IgM
Oral doxycycline 100mg BID for 14 days
Alt: Amoxicillin, Cefuroxime
IF WITH Menigeal, CNS, PNS involvement– most effective is CEFTRIAXONE 2g daily
When macrophages encounter the endotoxins from the bacteria what two cytokines are released that stimulate the local immune response?
Tumor necrosis factor
Interleukin-1
What subacute form of meningitis should be considered in a child with improved CSF picture but still drowsy, vomiting, refusing to eat?
Subdural effusion
What are the 2 pathophysiologies for CN involvement in bacterial meningitis?
- ACUTE: Inflammatory or vascular involvement of cranial nerve roots
- CHRONIC/ LATE: Meningeal fibrosis around optic nerves and spinal cord roots
Which age group (bac men)
E. coli and group B streptococcus?
Newborns
Top 4 bac men
N. meningitidis
H. influenzae
S. pneumoniae
L. monocytogenes
Which bacterial meningitis pathogen?
- Rapid, petechial or purpuric rash, large ecchymoses and lividity or the skin of the lower parts of the body when there is circulatory shock– 50% will have rash!
- Preceded by lung ear heart infection. Alcoholic, splenectomized patients, basilar skull fx.
- Follows URTI and ear infection in a child; seizures encountered most often here
- Rapid, petechial or purpuric rash, large ecchymoses and lividity or the skin of the lower parts of the body when there is circulatory shock– 50% will have rash!: Meningococcal meningitis
- Preceded by lung ear heart infection. Alcoholic, splenectomized patients, basilar skull fx.: Pneumonoccal
- Follows URTI and ear infection in a child: H. influenzae
What is the definition for elevated CSF for bac men?
Counts?
More than 18 cm H2O
250-100,000 85% neutrophils
CHON more than 45mg dl– 100-500 usually
CHO less than 40mg per dl or less than 40% of blood glucose concentration
What type of meningitis will have bloody csf?
In bac men what are the levels of
Cl
Lactate dehydrogenase
Lactic acid
Anthrax
Dengue
Ebola
Cl Low reflecting dehydration
Lactate dehydrogenase fractions 4 and 5 show a rise in bac men
Lactic acid elevated in bacterial and fungal more than 35mg dl
What percentage of bacterial meningitis patients will have positive blood culture
40-60%
How to know if rhinorrhea is csf vs mucous?
beta2 transferrin is found in CSF
High protein mucous makes hanky stiff
What antibiotics are indicated for the 0-4week bac men?
4-12 week
Cefotaxime with ampicillin
3rd gen with ampicillin PLUS dexamethasone
Dexa reduces incidence of deafness in h influenzae
AMPICILLIN IS FOR LISTERIA COVERAGE
Always add ampicillin for ICC patients
What antibiotics for bac men
3 months to 50 years old
3rd gen plus vancomycin
ABOVE 50 add ampicillin again
What antibiotics for basilar skull fracture
Head trauma/ csf shunt
3rd gen plus vancomycin
Vancomycin plus ceftazidime (for pseudomonal coverage)
Does of dexa for bac men in children 0.15mg per kg QID for 4 days
In adults
For H. influenzae sensorineural deafness
10mg IV before antibiotics then q6 for 4 days to decrease mortality, seizures and coma
What is prophylaxis for meningococcal exposure?
Single dose of ciprofloxacin
What is Osler triad?
Pneumococcal meningitis
Pneumonia
Endocarditis
high fatatlity rate
Why do bac men patients develop deafness?
Suppurative Cochlear destriction OR aminoglycoside use
What are the common bacteria that can cause an encephalitis?
Give their treatments.
Mycoplasma pneumoniae– Macrolides: Azithromycin
Listeria monocytogenes: Ampicillin with gentamicin
Legionella: Levofloxacin or azithromycin
What is the clinical picture of a Listeria encephalitis?
Rhombencephalitis– typical meningitis symptoms followed by asymmetric cranial nerve palsies and signs of cerebellar dysfunction
What bacteria is responsible for: Encephalitis with seizures following a cat scratch and adenopathy?
Bartonella henslae
What is the characteristic feature of Bacillus anthracis infection?
Hemorrhagic meningoencephalitis
only in 5% is the CNS involved
What are the 3 cardinal features of whipple disease? What is the causative organism?
- Cognitive changes with psychiatric features
- Myoclonus
- Ataxia
- Oculomasticatory and skeletal myorhythmias
Tropheryma whipplei
What is the most common organism in subdural empyema?
Streptococcus (nonhemolytic and viridans)
What is the route of the majority of brain abscesses to the brain?
What % do not have a known focus?
Hematogenous
20%
What does an early abscess look like on MRI?
Restricted diffusion
T1 hypointense
T2 capsule hypointense
Capsule is THINNER on the side directed to the lateral ventricle
Cerebritis: Dot sized areas of decreased density that enhance with Gad
What % of patients with congenital heart disease will also develop a brain abscess?
5%
What is empiric treatment for an abscess?
Vancomycin
3rd Cephalosporin
Meropenem/metronidazole
What is the duration of treatment of the following pathogens for bacterial meningitis? (days)
Neisseria meningitidis H. influenzea S. Pneumoniae S. agalactiae Gram negative bacilli Listeria monocytogenes
Neisseria meningitidis 7 H. influenzea 7 S. Pneumoniae 10-14 S. agalactiae 14-21 Gram negative bacilli 21 days or two weeks beyond the first sterile CSF culture in neonates Listeria monocytogenes 21 days or longer
