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ABIM > ID-CNS Infections > Flashcards

ID-CNS Infections Flashcards

1
Q

What is “aseptic” meningitis and what is the most common cause?

A

Aseptic meningitis is when CSF bacterial cultures are negative and is most commonly caused by viral meningitis.

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2
Q

What is the most common cause of viral meningitis?

A

Enteroviruses: Mostly circulate in summer and fall. Include coxsackievirus, echovirus, or other nonpolio enteroviruses.

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3
Q

What are three ways that herpes simplex virus can cause meningitis?

A
  1. primary infection of the CNS
  2. secondary infection (primary infection at another site), such as HSV-2 and someone with genital ulcers
  3. reactivation of a latent infection presenting as aseptic meningitis
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4
Q

What are the difference in typical presentations from HSV-1 and HSV-2?

A

HSV-1: Presents as an encephalitis

HSV-2: Presents as a meningitis

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5
Q

What is Mollaret meningitis? What virus is it associated with?

A

It is a benign recurring form of lymphocytic meningitis and HSV-2

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6
Q

Aside from enteroviruses and herpesviruses, what are other viral causes of meningitis?

A
  1. Primary HIV infection, usually self limited, rash and pharyngitis
  2. Mumps virus, less common now because of the MMR, but can occur in unvaccinated kids
  3. Arboviruses: West Nile or St. Louis encephalitis virus
  4. EBV, adenovirus, CMV, VZV
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7
Q

What are clinical clues of a mumps meningitis?

A

Unvaccinated
Parotitis (inflammation of parotid glands)
Orchitis (testicular inflammation)

Clinical Description: It typically starts with a few days of fever, headache, muscle aches, tiredness, and loss of appetite. Then most people will have swelling of their salivary glands. This is what causes the puffy cheeks and a tender, swollen jaw

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8
Q

Difference in CSF profile between patients with viral versus bacterial meningitis.

Parameters:
opening pressure
leukocyte count
leukocyte predominance
glucose
protein
gram stain
culture
A

CSF PARAMETER VIRAL BACTERIAL
opening press <250 200-500
leukocyte count <1000 >1000
leukocyte predom lymphocytes neutrophils
glucose >45 <40
protein <200 100-500
gram stain negative positive 60-90%
culture negative positive 70-85%

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9
Q

Describe the presentation of meningitis in primary HIV infection

A

Primary HIV infection, usually self limited, rash and pharyngitis

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10
Q

Diagnosis of viral meningitis

A
  • PCR-enterovirus and HSV
  • Ab detection-West Nile
  • Serological testing-for mumps, could provide adjunctive testing and additional testing to assist with clinical suspicion
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11
Q

Nonviral causes of aseptic meningitis?

A 
spirochetes
fungi
mycobacteria
syphilis
Borrelia burgdorferi (Lyme disease)
Fungal organisms
medicaitons
autoimmune
malignancy
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12
Q

Treatment of viral meningitis

A

Supportively with empiric antibiotics given until CSF fluid cultures exclude bacterial meningitis

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13
Q

What are risk factors for bacterial meningitis?

A
  • Colonization of the nasopharynx with potential meningeal pathogens
  • Complement deficiency
  • Anatomic or functional asplenia
  • Glucocorticoid use
  • Diabetes
  • Hypogammaglobulinemia
  • Altered cell-mediated immunity
  • Exposure to someone infected with Neisseria meningitides or traveling to areas of the world where certain organisms are more prevalent and endemic (such as sub-saharan Africa)
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14
Q

Most common causes of bacterial meningitis?

A

S. pneumoniae and N. meningitidis, both now have vaccines but may show up in the unvaccinated or people with appropriate risk factors

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15
Q

Aside from pneumococcal and meningococcal, what are the most common causes of bacterial meningitis?

A
  1. Group B Strep: diabetes, alcoholism, malignancy, liver disease
  2. Staph: neurosurgery, CNS prosthetic device, secondary from bacteremia
  3. H. influenzae: pediatric vaccines now… but at risk if not vaccinated. Especially if functionally or anatomically splenic.
  4. Listeria monocytogenes: Elderly, immunosuppressed, decreased cell-mediated immunity because of meds or medical conditions
  5. Gram negative bacterial: nosocomial setting, complication of neurosurgery
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16
Q

When is CT of the head required before lumbar puncture?

A

If signs or symptoms of increased intracranial pressure or a CNS mass lesion, such as papilledema, focal neurological deficits, or altered mental status are present, immunocompromised, or history of CNS disease (mass lesion, stroke, focal infection)

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17
Q

Diagnosis of bacterial meningitis

A
  • Elevated CSF lactate
  • CSF culture, gram stain
  • Elevated opening pressure
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18
Q

What is the management of adults suspected of having bacterial meningitis?

A

If CT is performed, lumbar puncture performed…

+Gram stain: Dexamethasone+TARGETED antimicrobial therapy

  • Gram stain: Dexamethasone+EMPIRIC antimicrobial therapy
  • dexamethasone is used to help avoid neurological complications, including: seizures, hearing loss, cranial nerve deficits, paresis

DURATION:
7 days-meningococcal, haemophilus influenza
10-14 days- pneumococcal meningitis
21 days-staphylococcal, gram negative, Listeria

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19
Q

Empiric antibiotic regimen for bacterial meningitis:

-immunocompetent host age <50 with community acquired bacterial meningitis

A

IV Ceftriaxone OR Cefotaxime

PLUS

IV Vancomycin

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20
Q

Empiric antibiotic regimen for bacterial meningitis:

-Patient age >50 or those with altered cell-mediated immunity (T or B cell issues)

A

IV ampicillin (Listeria)
IV ceftriaxone OR cefotaxime
IV vancomycin

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21
Q

Empiric antibiotic regimen for bacterial meningitis:

-Allergies to beta lactams

A

IV moxifloxacin instead of cephalosporin

IV Bactrim instead of ampicillin

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22
Q

Empiric antibiotic regimen for bacterial meningitis:

Hospital-acquired bacterial meningitis

A

IV vancomycin plus either IV ceftazidime, cefepime, or meropenem

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23
Q

Neurosurgical proccedures

A

IV vancomycin plus either IV ceftazidime, cefepime, or meropenem

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24
Q

Diagnostic workup for a brain abscess

A

Clinical: severe headache, occasional fever, don’t really get neck stiffness, if severe get nausea and vomiting

Imaging: contrast enhanced CT

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25
Q

Treatment for brain abscess

A

Empiric antibiotics

> 2.5cm: Surgical drainage or stereotactic drainage

26
Q

Empiric antibiotic for brain abscess with:

Otitis media or mastoiditis

A
  • streptococci, bacteroides (anaerobic), Prevotella (GNs), Enterobactereceae (GNs)
  • Metronidazole + third generation cephalosporin (ceftriaxone or cefotaxime)
27
Q

Sinusitis

A
  • Streptococci, Bacteroides, Enterobacteriaceae, Staphylococcus aureus, Haemophilus species
  • Metronidazole + third generation cephalosporin (ceftriaxone or cefotaxime)
28
Q

Dental Sepsis

A
  • Mixed Fusobacterium, Prevotella, and Bacteroides species, Streptococci
  • Penicillin plus metronidazole
29
Q

Penetrating trauma after Neurosurgery

A
  • S. aureus, streptococci, Enterobacteriaceae, Clostridium species
  • Vancomycin plus a third generation cephalosporin (ceftriaxone or cefotaxime)
30
Q

Lung abscess, Empyema, Bronchiectasis

A
  • Fusobacterium, Actinomycetes, Bacteroides, and Prevotella species, Streptococci, Nocardia species
  • Penicillin plus metronidazole plus a sulfa drug (TMP-SMX)
31
Q

Endocarditis

A
  • S. aureus, streptococci

* Vancomycin plus gentamicin

32
Q

Hematogenous spread from pelvic, intra-abdominal, or gynecological infections

A
  • Enteric gram-negative bacteria, anaerobic bacteria

* Metronidazole plus a third generation cephalosporin

33
Q

Immunocompromised patients, HIV-infected patients

A
  • Listeria species, fungal organisms (cryptococcus neoformans), or parasitic, or protozoal organism (Toxoplasma gondii); Aspergillus, Coccidioides, Nocardia
  • Metronidazole plus a third generation cephalosporin, anti-fungal or parasitic agent
34
Q

Spinal epidural abscess–how do they form?

A

Hematogenous or through an infected vertebrae

35
Q

Risk factors for epidural abscess

A

IVDU, epidural catheter, paraspinal glucocorticoids, analgesic injections, diabetes mellitus, HIV infection, trauma, tattooing, alcoholism, and acupuncture

36
Q

Most common organism causing an epidural abscess

A

Staph aureus

Less common: gram negative bacilli, strep, anaerobic organisms, fungi or unusual pathogens

37
Q

Signs and symptoms of an epidural abscess

A

Back pain with accompanying neurological symptoms such as bowel or bladder dysfunction, lower extremity weakness, paresthesias, and in last stages paralysis

38
Q

Diagnosis of epidural abscess

A

MRI preferred

Microbiologic sampling with CT guided needle aspiration and blood cultures

39
Q

Treatment of epidural abscess

A

surgical drainage and empiric antibiotic therapy

followed by serial imaging to watch for resolution (4-6 weeks after therapy)

40
Q

Cranial subdural empyema–anatomy

A

occurs between the dura mater and the arachnoid mater

41
Q

Treatment of a subdural empyema

A

Immediate neurosurgical intervention

42
Q

Risk factors for subdural empyema

A

sinusitis, otitis media, mastoiditis

43
Q

Clinical presentation of subdural empyema

A

Fevers, altered mental status or deteriorating mental status, nausea, vomiting

44
Q

Empiric antibiotic therapy for cranial subdural empyema

A

vancomycin, ceftriaxone (good CNS penetration), flagyl

45
Q

What is an encephalomyelitis

A

inflammation of the spinal cord

46
Q

Definition of encephalitis

A

alteration in mental status for 24h or more, in addition to: fever, focal neurologic deficit, seizure, CSF pleocytosis, abnormal findings on EEG or neuroimaging

47
Q

Diagnosis and treatment of encephalitis

A
  • Neuroimaging to exclude a mass lesion or cerebral edema as a contraindication to a lumbar puncture
  • If no cerebral edema then do LP
  • EEG in its with depressed consciousness, even without seizure activity (non convulsive status epilepticus)
  • No treatment for most, just supportive care
48
Q

HSV-1 encephalitis:

  • Epi and transmission
  • Clinical features
  • Laboratory diagnosis
  • Treatment
A

-Epi and transmission: Reactivation of latent virus
-Clinical features: fever, AMS, temporal lobe seizures
-Lab: HSV Type I PCR on CSF
Treatment: IV Acyclovir

49
Q

VZV encephalitis:

  • Epi and transmission
  • Clinical features
  • Laboratory diagnosis
  • Treatment
A
  • Epi and transmission: can occur at time of acute infection or reactivation, increased risk in HIV
  • Clinical features: cutaneous lesions variably present
  • Lab: VZV PCR on CSF, CSF antibodies (if vasculitis suspected)
  • Treatment: Acyclovir
50
Q

Enterovirus encephalitis:

  • Epi and transmission
  • Clinical features
  • Laboratory diagnosis
  • Treatment
A

Epi and transmission: Typically late summer-fall
Clinical features: fever, altered mental status, variable rash or oral lesions
Lab: Enterovirus PCR on CSF
Treatment: Supportive care

51
Q

West Nile Virus encephalitis:

  • Epi and transmission
  • Clinical features
  • Laboratory diagnosis
  • Treatment
A

Epi and transmission: Mosquito-borne (summer-fall)
Clinical features: fevers, altered mentation with or without muscle weakness (asymmetric flaccid paralysis); seizures rare
Lab: West Nile Virus IgM antibody on CSF (obtain CSF serology)
Treatment: Supportive

52
Q

Rabies Virus encephalitis:

  • Epi and transmission
  • Clinical features
  • Laboratory diagnosis
  • Treatment
A
  • Epi and transmission: bite from an infected animal
  • Clinical features: Paresthesia at site of inoculation, hydrophobia, progressive obtundation
  • Lab diagnosis: Nape of neck skin biopsy for immunohistochemistry; rabies PCR of saliva or CSF (testing coordinated with local health department)
53
Q

What is normally seen on an LP of an HSV encephalitis patient? MRI? EEG?

A

LP:
Lymphocyte Pleocytosis
Erythrocytes (usually if necrosis occurs)

MRI: unilateral or bilateral temporal lobe changes

EEG: periodic lateralizing epileptiform discharges

54
Q

What are the ways VZV infects the CNS?

A
  • You can see a skin rash, but not always
  • Herpes sine zoster, is CNS infection without a rash
  • Infects cerebral arteries causing ischemic strokes
55
Q

CNS presentations of WNV

A

encephalitis, meningitis, myelitis

56
Q

What is WNV testing cross-reactive with?

A

Other flaviviruses!
So be careful if previous exposure to or vaccination from: Japanese encephalitis virus, St. Louis encephalitis virus, yellow fever virus, dengue virus,

57
Q

Autoimmune encephalitis

A

anti-NMDAR encephalitis is confirmed by finding the antibody in serum

Clinical features include: choreoathetosis, psychiatric symptoms, seizures, autonomic instability

58
Q

Most common causes of prion disease and how does it occur

A

CJD is most common and occurs sporadically

59
Q

Describe CJD

A

Occurs sporadically
Most commonly in seventh decade of life
Most common clinical sign is cognition issues
Other neurological signs: spasticity, ataxia, myoclonus, changes in sensory perception
Progressive neurological decline that usually occurs over 6-12 months until death

60
Q

Describe variant CJD

A

Infectious!
Occurs after consumption of infected beef, but can get transmission through blood products or through blood
Signs: ataxia, spasticity, and myoclonus
Place on differential for rapidly progressive dementia
Diagnosis: 14-3-3 protein

ABIM (58 decks)

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