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P Intergrated Y2 > CP Central Nervous systems > Flashcards

CP Central Nervous systems Flashcards

1
Q

Define = Meningitis

A

Inflammation of meninges

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2
Q

Define = Encephalitis

A

inflammation of brain

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3
Q

Define = Meningo-encephalitis

A

inflammation of brain and meninges

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4
Q

Aseptic Meningitis

  • provide clinical picture
  • what is most common cause
  • other causes x7
A 
White cell count >5x106/L (5/mm3) in cerebrospinal fluid (CSF)
Negative bacterial culture of the CSF
Viruses are the commonest cause, others include:
Partially treated bacterial meningitis 
Listeria
TB
Syphilis
Malignancy,
Autoimmune conditions, 
Drugs
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5
Q

What is the basic infectious particle of a virus

A

viron

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6
Q

what do viral proteins form

A

capsid, membrane projections

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7
Q

what do viral enzymes do

A

used for replicating genetic material, influencing transcription and protein modification

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8
Q

Epidemiology of viral meningitis

A

COMMON - children neonates

5-15 cases per 100,000

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9
Q

Aetiology of viral meningitis

A 
Enterovirus - commonest cause
Echoviruses
Coxsackie viruses
Parecho viruses
Enteroviruses 70 and 71
Poliovirus
Herpes viruses
Herpes Simplex Virus 2 (HSV 2) >> HSV 1
Varicella Zoster Virus (VZV)
Cytomegalovirus (CMV), Epstein Barr Virus (EBV)
HHV6, HHV7
Arboviruses (e.g. Japanese Encephalitis virus)
Mumps Virus
HIV
Adenovirus
Measles
Influenza
Parainfluenza type 3
Lymphocytic choriomeningitis virus (LCMV)
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10
Q

What must you always check if you think the patient has viral meningitis

A

travel history, sexual history, and

IMMUNOCOMPROMISED

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11
Q

Pathogenesis of viral meningitis

A

colonization of mucosal surfaces
invades epithelial surface
replicated in cells
desseminates and invades CNS - via cerebral micro vascular endothelial cells, choroid plexus epithelium, olfactory nerve

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12
Q

How does the enterovirus enter the CNS

A

blood stream (haematogenous spread)

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13
Q

How does HSV or VZV enter CNS in viral meningitis

A

traveling up peripheral nerves (neurotropically)

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14
Q

clinical presentation of viral meningitis

A

Fever,
Meningism (headache, stiffneck, photophobia)
Children = bulging anterior fontanelle

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15
Q

What is Kernig’s Sign

A

With hip and knee flexed to 90o, the knee cannot be extended due to pain/stiffness in the hamstrings

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16
Q

What is Brudzinski’s sign

A

Flexing the neck causes the hips and knees to flex

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17
Q

What is nuchal rigidity

A

Resistance to flexion of the neck

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18
Q

What investigations for viral meningitis

A

Bloods - FBC, U&E, clotting, culture
CT head (do 1st)
Lumbar puncture - ASAP
Viral PCR - gold standard

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19
Q

CSF findings viral meningitis

A

White cell count
Pleocytosis = white cells in CSF
Lymphocytic, usually

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20
Q

CSF findings Bacterial meningitis

A 
High opening pressure
WBC - 100-20,000 v high
high protien
high glucose
gram stain 60-90% +ve
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21
Q

Treatment

A 
IV antibiotics 
cefotaxime if bacterial
HSV and VZV = aciclovir
supportive therapy
NOTIFY PUBLIC HEATH
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22
Q

Enteroviral Meningitis

A

COMMONEST UK
fever, vom, anorexia, rash, URT symptoms,
No specific treatment
Full recovery

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23
Q

HSV - Herpes Simplex Virus 1

causes/

A

Cold Sores and viral encephalitis

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24
Q

HSV2 - Herpes simplex virus 2 causes

A

genital herpes, meningitis
2nd common cause
Mollarets meningitis - recurrent aseptic meningitis

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25
Q

VZV - varicella zoster virus

causes

A

Chickenpox, shingles
Meningitis RARE but possible
Aciclovir may be useful
normal recovery expected

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26
Q

Mumps meningitis

A

10-30% mumps cases
CNS symptoms 5 days post parotisis
No specific treatment
preventable with vaccination

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27
Q

HIV and meningitis

A

can occur as part of primary infection
fever, lymphadenopathy, pharyngitis, rash
IMPORTANT TO DIAGNOSE

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28
Q

Viral Encephalitis
Main causes
others

A 
90% Herpes Simplex Virus1
Other viruses causes:
VZV, EBV, CMV
Adenovirus
Measles
Mumps
Enteroviruses (including polio)
Arboviruses (e.g. West Nile, Japanese B, St Louis, Eastern and Western Equine Encephalitis)
Influenza
Rubella
HIV
Rabies
Other causes:
Bacteria (e.g. Strep pneumoniae, Neisseria meningitidis, TB)
Malignancy (paraneoplastic)
Autoimmune
Acute disseminated encephalomyopathy (ADEM)
Other immune-mediated
29
Q

what percentage of viral encephalitis are unknown aetiology

A

37%

30
Q

clinical presentation of viral encephalitis

A 
Altered mental state
confusion --> coma
fever, headache, meningism
Focal neurology
seizures
weakness, dysphasia, cranial nerve palsy, ataxia
31
Q

What should patient be started ON for viral encephalitis

A

IV aciclovir

if ANY change in mental state even if not 100% sure encephalitis

32
Q

Viral encephalitis investigations

A

Bloods - FBC, U&E, CRP, clotting, serology
CT
LP - microscopy, culture and sensitivity, protien and glucose, viral PCR
MRI - looking for HSV
EEG - 75% in HSV encephalitis have abnormal temporal lobe activity

33
Q

Treatment for Viral encephalitis

A

HIGH dose IV aciclovir

14-21 days

34
Q

HSE epidemiology

A

rare

high risk 50 yo

35
Q

HSE pathogenesis

A 
Direct transmission of virus via neural or olfactory pathway
OR 
Reactivation in trigeminal 
ganglia
acute focal necrotising encephalitis
inflammation of brain
36
Q

outcome HSE

A

untreated - 70% dead
survivors - paralysis, speech lose, personality change
BEST - aciclovir within 4 days of symptoms

37
Q

Acute disseminated encephalomyelopathy (ADEM

A

immune mediated CNS demyelination,
clinical findings = encephalitis
CSF findings - Viral meningitis
Treatment - steriods

38
Q

What are the different types of primary bacterial infections of the CNS

A 
Meningitis
Encephalitis
Ventriculitis
Brain Abscess
Ventriculoperitoneal shunt and external ventricular drain infection
subdural empyema
eye infections
39
Q

What is a brain abscess

A

focal suppurative process within the brain parenchyma (pus in the substance of the brain

40
Q

What causes brain abscesses

A 
often polymicrobial
60-70% Streptococci "milleri"
10-15% Staph aureus common post trauma
Anaerobes
Gram -ve enteric bacteria
fungi, TB, toxoplasma gondii, nocardia, actinomyces
41
Q

4 clinical settings of brain abscess pathogenesis

A
  • Direct Spread from contiguous suppurative focus
  • haematogenous spread from distant focus
  • trauma
  • cryptogenic - no focus
42
Q

Clinical presentation of brain abscess

A

headache - COMMON
focal neurological deficit 30-50%
confusion
fever

43
Q

Management of brain abscess

A

Drainage = gold standard

44
Q

why should brain abscesses be drained

A 
1 - reduce intercranial pressure
2 confirm diagnosis
3 obtain pus for microbiological investigation
4 enhance efficacy of antibiotics
5 avoid infection spread to ventricles
45
Q

Antibiotics treatment for brain abscess?

A 
ampicillin
penicillin
cefuroxime
cefotaxina
ceftazidime 
metronidazole 
Challenge penetration of drugs into CSF blood barrier and blood brain barrier
46
Q

What empirical treatment for a

ODONTOGENIC abscess

A

IV cefotaxime 2g 6hourly

IV metronidazole 500mg 8hourly

47
Q

Empirical treatment plan for OTOGENIC abscess

A

IV benzyl penicillin 2.4g 6 hourly
IV ceftazidime 2g 8hourly
IV metronidazole 500g 8hourly

48
Q

possible complications for brain abscess

A

rained intracranial pressure
mass effect
cloning
rupture into ventricles causing ventriculitis

49
Q

Subdural empyema

  • define
  • causes
  • pathogenesis
A

1) Infection between dura and arachnoid mata
2) causes often polymicrobial
anaerobes, streptococci, gram -ve, strep pneumoniae, haemophilus influenzae, staph aureus
3) spread infection from sinuses 50-80%, middle ear and mastoid 10-20%, distant site 5%, can be post trauma or surgery

50
Q

Subdural empyema

  • presentation
  • management
A

1) headache, fever, focal neurological deficit, confusion, seizure, coma
2) urgent drainage of pus, antimicrobial agents

51
Q 
Ventriculoperitoneal VP shunt
External ventricular drain EVD infection
- what
- how 
- diagnosis
- treatment
A

1) device to monitor inter cranial pressure or drain excess CSF
2) colonised by organisms that cause ventriculitis
3) CSF microscopy and culture (usually coagluase -ve staph)
4) device removal, intraventricular antibiotics

52
Q

What is Neisseria Meningitidis

A
  • gram -ve diplococci
  • require blood for growth
  • 13 capsular types: A,B,C W135 -and Y are most common
  • Can be detected by PCR
  • natural Habitat = NASOPHARYNX
  • 5-20% people are carriers
  • crosses blood brain barrier and multiplies in subarachnoid space
53
Q

What can be causes be Neisseria Meningitidis

A

1 ) Fulminant septicaemia

2) septicaemia with purpuric rash
3) Septicaemia with meningitis
4) Pyogenic (purulent) meningitis with no rash
5) Chronic meningococcal bacteraemia with arthralgia
6) Focal sepsis
7) Conjunctivitis, endophthalmitis

54
Q

Treatment for Neisseria Meningitidis

A
  • Ceftriaxone, cefotaxime
  • Penicillin
  • Intensive Care
  • Chemo prophylaxis of contacts = Rifampicin, ciprofloxacin
  • Vaccination - group A,C, W135
55
Q

What is Haemophilius Influenzae

A
  • must be grown in blood
  • small pleopmorphic Gram -ve cocci-bacilli
  • six antigenic types a-f
  • type b causes most invasive disease
56
Q

Carriage of Haemophilus influenzae

  • normal carriage
  • passage to blood stream
  • virulence factors
A

Normal

  • restricted to humans
  • 25-80% carry non-capsulated strain
  • 5-10% carry capsulated stains

Throat - invade submucosa - blood

Virulence factors

  • type b capsule
  • Fimbrae, IgA proteases, outer membrane proteins, liposaccahrides
57
Q

Treatment for Haemophilus influenzae

A

Treatment
Ceftriaxone, cefotaxime
Ampicillin
β-lactamase producing strains common

Chemoprohylaxis of contacts of invasive disease
Rifampicin

H.influenzae Type b conjugate vaccines
Dramatic reduction in the incidence of invasive disease

58
Q

What is Streptococcus Pneumoniae

A
  • gram +ve cocci - cells grow in pairs
  • needs blood or serum from growth
  • polysaccahride capsule: 95 capsular types
  • normal habitat - human respiratory tract
  • transmission - droplet spread
59
Q

Treatment Streptococcus pneumoniae

A

Ceftriaxone, cefotaxime
- Penicillin resistant common in some parts of the world

  • No Chemoprohylaxis of contacts of invasive disease
  • Conjugate vaccine available against common serotypes
  • reduction in the incidence of invasive disease in children introduced US
60
Q

When should steroids be used in meningitis in adults

A
  • given shortly before 1st dose of antibiotics
  • S. pneumoniae = give steroids
  • no benefit - meningococcal meningitis
61
Q

Neonatal meningitis?

A

Group B beta-haemolytic Streptococci
Escherichia coli
Listeria monocytogenes

Neonatal
Neonatal infection. Variable onset
Early ( 5 days). Usually meningitis.

Cefotaxime
Ampicillin and gentamicin

62
Q

Complications for meningitis

A

Death
overwhelming sepsis, raised intracranial pressure
Deafness, delayed development, seizures, stroke, hydrocephalus

63
Q

Lymphocytic meningitis

A

Viral meningitis
Most common form of meningitis
Enteroviruses
Herpes simplex

Benign outcome
Symptomatic treatment

Spirochete
Treponemal
Borrelia

Note Polio virus can cause meningitis that may lead to paralysis
Prevented by vaccination

64
Q

Tb meningitis

A
  • insidious onset
  • diagnosis - hard - AFB not seen on microsopy
  • 12 months standard Tb treatment
  • steroids beneficial
65
Q

Cryptococcal Meningitis

A 
cryptococcus = yeast
common problem patients with late stage HIV
lymphocytic meningits
prolonged course of treatment 
- amphotericin, flucytosine, fluconazole
66
Q

Clostridium tetani

A
  • Gram +ve spore forming bacillus
  • terminal round spore
  • strict anaerobe
67
Q

Spread of clostridium tetani

A

organism widespread in soil
organism - non invasive but produces tetanospasmin
- toxin genes plasmid encoded
- toxin spreads via blood stream and retrograde transport
- binds to ganglioside receptors, blocks release of inhibitory interneurones
- convulsive contractions of voluntary muscles

68
Q

What does clostridium tetani

A

Tetanus (lockjaw)
Tonic muscle spasms
Trismus
Opisthotonus

Respiratory difficulties

Cardiovascular instability
(sympathetic nervous system)

69
Q

Treatment of Clostridium tetani

A

Treatment
Antitoxin (horse or human)
Penicillin or metronidazole

Drugs for spasms
Muscle relaxants
Respiratory support

Prevention
Toxoid

P Intergrated Y2 (13 decks)

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