Crash course: CNS infections + STIs Flashcards by Georgia Leggett

What is meningitis?

Inflammation of the meninges

Can be bacterial, viral or fungal (or TB)

Presents with meningism

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What are the signs of meningism?

Stiff neck (nuchal rigidity)
Kernig’s sign
Brudzinski’s sign

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List 5 symptoms of meningitis

Headache
Photophobia
Fever
N+V
Drowsiness

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Give 4 signs of meningococcal disease

Non-blanching petechial rash
Altered mental status
Skin mottling
Cold + painful extremities

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What is encephalitis?

Inflammation of brain parenchyma

Usually viral, rarely AI

Presents systemically unwell, altered mental state- personality change

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What is a brain abscess?

Infective collection in the brain parenchyma

Presents with swinging fevers + SOL

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What are the most common causes of meningitis in neonates?

Group B Strep
Listeria monocytogenes
E. coli

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What are the most common causes of meningitis in adults?

Neisseria meningitidis
Streptococcus pneumoniae

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What are the other causes of meningitis in the elderly in addition to Neiserria and Steptococcus?

Group B Strep
Listeria monocytogenes

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What can cause meningitis in the
immunocompromised?

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What are the three classifications of meningitis? What are the usual causative organisms?

Acute: bacterial
Chronic: TB, Spherocytes, Cryptococcus
Aseptic: acute viral

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Which organism causes meningococcal meningitis?

Neiserria Meningitidis

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What are the 3 most common causes of meningitis in children/ young adults?

Neiserria Meningitidis
Haemophilus influenzae (rare in vaccinated countries)
Streptococcus pneumoniae

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What are the viral causes of meningitis?

Enterovirus: Adenovirus, Cocksackie
HSV-2
HIV seroconversion (rarely)

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Name 2 fungal causes of meningitis. In which patients?

Cryptococcus neoformans: HIV

Cryptococcus gattii: immunocompetent

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How is meningitis diagnosed?

LP
Ideally LP before abx, but like with cultures, don’t delay abx
If any Sx consistent with raised ICP or SOL, need brain imaging first

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Give 4 signs of raised ICP

Focal neurology
Papiloedema
Reduced GCS
Seizures

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What analytics are used on CSF in meningitis?

Biochemical analysis
Gram stain for bacteria
PCR for viruses
Ziehl-Neelson stain forTB
India ink stain for Cryptococcus

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Describe the appearance, white cells, protein, glucose of CSF and opening pressure on LP in BACTERIAL meningitis?

Cloudy + turbid
↑↑↑ WCC
Massive neutrophilia
↑↑ Protein
↓ glucose (<40% plasma glucose, as bacteria consuming)
↑ opening pressure

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Describe the appearance, white cells, protein, glucose of CSF and opening pressure on LP in VIRAL meningitis?

Clear
↑ WCC
Lymphocytosis
N/ ↑ protein
N glucose (>60% plasma glucose)
N/ ↑ opening pressure

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Describe the appearance, white cells, protein, glucose of CSF and opening pressure on LP in FUNGAL meningitis?

Fibrin web
N/ ↑ WCC
Lymphocytosis
N/ ↑ protein
N/ ↓ glucose (<40% plasma glucose)
↑ / ↑↑ opening pressure

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Describe the appearance, white cells, protein, glucose of CSF and opening pressure on LP in TB meningitis?

Cloudy + viscous
↑ WCC
Lymphocytosis
↑↑ protein
↓↓ glucose (<30% plasma glucose)
↑ opening pressure

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What is normal opening CSF pressure?

10-20

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Describe management of meningitis

In community: IM Benzylpenicillin

In hospital:
IV Ceftriaxone/ Cefotaxime
(+ Amoxcillin/ Ampicillin if baby or >50y)
+ Acyclovir if can’t exclude encephalitis

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When should steroids be used for meningitis ?

Give dexamethasone as if caused by strep pneumoniae or haemophilus influenzae, 5d dex reduces the incidence of sensorineural hearing loss Give dex with the 1st dose of cef, once LP done + organism confirmed, if S. pneumoniae or H. influenzae continue for 5d. If neither, stop dex

When should meningitis prophylaxis be given?

If meningococcal meningitis + exposure within 7d before onset Oral ciprofloxacin or Rifampicin

What is the most common cause of encephalitis in the UK?

HSV 1

Name 2 rare causes of encephalitis

Previous hx of measles: subacute sclerosing panencephalitis (SSPE) HIV/ on monoclonals: Progressive multifocal leukoencephalopathy

What is the treatment for encephalitis?

Empirically treat with Acyclovir MRI + CSF PCR can help identify precise organism

What usually causes brain abscesses?

Typically mixed organisms Staphylococcus/ Streptococcus + anaerobes is common If patient with HIV: suspect toxoplasmosis

In HIV patients, what organisms are associated with what pathology?

Cryptococcus: meningitis Toxoplasmosis: brain abscess

What investigations are used for brain abscesses?

MRI: Classically shows a ring-enhancing lesion (CT)

What is used for treatment of brain abscesses?

Abx: Gentamicin + metronidazole Surgical drainage Consider steroids + anti-seizure meds (load on Levateracitam)

What is the most common STI?

Chlamydia caused by Chlamydia trachomatis

How does chlamydia present?

Asymptomatic: 70% F: cervicitis (discharge, bleeding) + dysuria, PID M: discharge, dysuria Reactive arthritis

What are 5 symptoms of reactive arthritis?

Anterior uveitis Dysuria Oligoarthritis Balanitis Keratoderma blennorrhagicum

How do serovars L1-3 of chlamydia present? In which patient groups?

Lymphogranuloma venereum Presents first with proctitis Painful, swollen, enlarged inguinal LN = Bubos Common in MSM

How does chlamydia present in neonates? When?

Ophthalmia neonatorum 1-2w after birth

How is chlamydia diagnosed? What treatment is used?

NAAT (can't culture) Tx: Doxycycline (7d) or Azithromycin (STAT)

How does gonorrhoea present?

Less commonly asymptomatic Typical STI Sx: PID Disseminated gonococcal infection

How does gonorrhoea present in neonates? When?

Ophthalmia neonatorum First few DAYS after birth

How is gonorrhoea diagnosed?

Culture = GS In practice NAAT

What is treatment for gonorrhoea?

IM ceftriaxone

What are 3 key symptoms of disseminated gonococcal infection?

Migratory poly/ oligoarthritis Dermatitis: maculopapular or vesicular Tenosynovitis

List 3 further complications of disseminated gonococcal infection

Septic arthritis Endocarditis Perihepatitis: Fitz-Hugh-Curtis syndrome

What s the most common cause of septic arthritis in young adults?

Neisseria gonorrhoea

What causes syphilis?

Treponema pallidum

What are the stages of syphilis?

Primary: painless CHANCRE Secondary: Unwell, condyloma lata, lymphadenopathy, maculopapular rash Latent phase: can last decades Tertiary: gummatous disease, aortitis, neurosyphilis, tabes dorsalis

What is a chancre?

Painless ulcer on genitals (occasionally oral)

What are condyloma lata?

greyish warty, painless lesions, on genitals or mouth

Describe the 4 features of tertiary syphilis

Gummatous disease: erodes through cartilaginous structures in mouth + face Aortitis: inflammation + formation of aneurysms Neurosyphillis: argyll robinson pupils Tabes dorsalis: degeneration of spinal cord

What is treatment for syphilis?

IM Benzathine penicillin

What must you be aware of when treating syphilis?

Jarish Herxheimer reaction When started on abx for a couple of days feel worse: fevers, rigors When killing sphirocytes they release preformed toxin → inflammatory response → give paracetamol Rarely can be more unwell → steroids

What is the investigation for primary syphilis?

Darkfield microscopy of chancre sample

If a chancre sample is not possible, what investigations should be used for syphilis?

Non-treponemal tests = VDRL, RPR tests Treponemal tests =TPHA,TP-EIA

Give an advantage and disadvantage of non-treponemal tests and treponemal tests

NT: Titre reduces with Tx. NOT specific to syphilis +ve for HIV, lupus T: Specific. But stay +ve even if treated

How should non treponemal and treponemal tests be interpreted?

If both +ve: active syphilis If NT +ve, T -ve: probably cross reaction indicating something else If NT -ve, T +ve: previous treated syphilis

What are the buzzwords/ phrases for Chancroid?

Caused by Haemophilus ducreyi Painful ulcers +/- lymphadenopathy Tropical regions

What are the buzzwords/ phrases for Donovanosis/ Granuloma inguinale?

Caused by Klebsiella granulomatis Painless red ulcers "beefy" Tropical regions Donovan bodies on histology

What are the buzzwords/ phrases for Trichomoniasis?

Cause by Trichomonas vaginalis Yellow-green discharge Strawberry cervix

What are the buzzwords/ phrases for genital warts?

Human papillomavirus

What are the buzzwords/ phrases for HSV?

Painful ulcers Fluid filled vesicles