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Neurology > Infections of the Central Nervous system > Flashcards

Infections of the Central Nervous system Flashcards

1
Q

In what ways can infection affect the CNS?

A

Primary CNS infection
- bacterial, viral, fungal or protozoal
- present with CNS symptoms/signs and/or systemic features of illness
Secondary CNS infection
- systemic infection with secondary CNS infection
- (e.g. endocarditis and meningitis)
Systemic infection with secondary (non-infectious CNS complications
- acute confusion with sepsis or CAP
- meningism in urosepsis

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2
Q

When someone presents with a CNS infection, what investigations help differentiate aetiology?

A

LP
Blood cultures
CT/MRI
EEG

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3
Q

Name some bacterial infections of the CNS.

A

Meningitis (-encephalitis)
- community acquired (meningo, pneumo, TB or Listeria)
- healthcare associated (post-neurosurgery or shunt related)
Brain abscess
- seeded as a result of a bloodstream infection
Neurosyphilis
Neuroborreliosis

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4
Q

Name some viral infections of the CNS.

A 
HSV
- herpes encephalitis is getting more common
Varicella Zoster Virus
Enterovirus (D-68)
- causes viral meningitis/encephalitis in very young children
HIV
- as a presenting feature
Mumps
CMV
West Nile
JBE
JCV
These viruses cause encephalitis or meningitis
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5
Q

Name some fungal infections of the CNS.

A 
CRYPTOCOCCUS
- common in immunocomromised groups
Coccidiomycosis
Aspergilloma
The infections cause meningo-encephalitis or mass lesions
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6
Q

Name some protozoal infections of the CNS.

A 
TOXOPLASMOSIS
Helminths
- angiostrongylus
- gnathostoma
Mainly causes mass lesions 
- sometimes eosinophilic meningitis
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7
Q

What is the most important CNS infection?

A

Bacterial meningitis

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8
Q

Why is bacterial meningitis so common in Sub-saharan countries?

A

As this is a preventable disease, these countries probably have poor uptake of the vaccine

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9
Q

What are the main causes of bacterial meningitis?

A 
Streptococcus penumoniae 
Neisseria meningitidus (meningococcal disease)
Haemophilus influenzae 
Listeria
Strep suis
Beta-haemolytic streptoccoal meningitis
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10
Q

In what special cases are people immunised against bacterial meningitis other than Haemophilus, strep pneumoniae or meningococcal?

A

Travel to Sub-Saharan Africa and other high prevalence areas
- ACWY recommended
Asplenic and people with complement deficiency
- meningococcal boosters with Men B and ACWY
- HIB
- Penumococcal
Patients with cochlear implants
- pneumo booster every 5 years

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11
Q

What do you expect to see on clinical examination if the patient has meningitis?

A 
50% of patient have neck stiffness
95% of patients have 2 of
- headache
- neck stiffness
- fever
- reduced consciousness 
Non-blanching rash
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12
Q

What are the risk factors for pneumococcal meningitis?

A 
Middle ear disease
Head injury (CSF leakage)
Neurosurgery
Alcohol
Immunosuppression (HIV)
- 100x increased risk
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13
Q

What are the risk factors for Listeria meningitis?

A

Immunocompromised
Pregnancy
- assume Listeria unless can be excluded

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14
Q

What are the distinguishing clinical features of a pneumococcal meningitis?

A

Neurology

  • 65% focal signs
  • 24% seizures
  • 22% VIII palsy
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15
Q

What are the two main manifestations of meningococcal disease?

A

Sepsis

Meningitis

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16
Q

What predicts a poor outcome in pneumococcal meningitis?

A 
Reduced GCS
CN palsy
CSF WCC <1000mm3
ESR elevation 
Age >60 with systemic complcations
Age <60 with neurologic complications
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17
Q

What predicts a poor outcome in meningococcal meningitis?

A

Age >60
- more likely to present with neurologic complications
Bleeding diathesis
CNS signs

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18
Q

If a person has suspected meningitis, should you do a CT scan before the LP?

A 
Not as a rule 
Yes if they have one of the following risk factors
- Age >60
- Immunocompromised 
- Pre-exisiting CNS disease
- Seizure
- Loss of consciousness/other CNS signs
- Suspected pneumococcal bacteria
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19
Q

If you choose to do a CT scan before the LP in suspected meningitis, what must you give the patient?

A

Blood cultures

Antibiotics

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20
Q

What would the results of the LP show in bacterial meningitis?

A 
Neutrophils 
Lymphocytes 
Very raised protein
LP glucose <50% of blood glucose
Bacteria on culture and PCR
- compare to blood
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21
Q

What would the results of the LP show in viral meningitis?

A

Mainly lymphocytes
Neutrophils if early
Slightly raised protein
Normal glucose

22
Q

What would the results of the LP show in fungal meningitis?

A 
Lymphocytes
Raised protein
LP glucose <50% of blood glucose
India Ink stain shows encapsulated organisms 
CrAG antigen test positive
23
Q

What would the results of the LP show in TB meningitis?

A

Lymphocytes
Raised protein
LP glucose <50% of blood glucose
Mycobacterium TB found on culture and PCR

24
Q

What is the empirical antibiotic therapy for bacterial meningitis?

A

Age <50
- 3rd generation cephalosporin (ceftriaxone)
- maybe IVI Vancomycin if they have come from an area with high rates of resistance
Age >50 or immunocompromised
- 3rd generation cephalosporin (ceftriaxone)
- amoxicillin (increased risk of Listeria)

25
Q

How long should antibiotic treatment for pneumococcal meningitis be?

A

2 weeks

Increase if there are infection related complications

26
Q

How long should antibiotic treatment for Listeria meningitis be?

A

3 weeks
Increase if there are complications
Amoxicillin, +/- gentamicin +/- Cotrimoxazole +/- Rifampicin

27
Q

What is the antibiotic of choice for Listeria infections?

A

Amoxicillin

28
Q

How long should antibiotic treatment for meningococcal meningitis be?

A

Usually for 5-7 days

- penicillin or ceftriaxone

29
Q

What are the problems with use of Corticosteriods?

A 
May close the BBB and prevent antibiotic absorption
Neurotoxocity
Bleeding
Infection 
Hypoglycaemia in diabetics
30
Q

Which patients with bacterial meningitis should get corticosteroids?

A

The patient has pneumococcal disease, and they are from a developed country

  • dexamethasone for 4 days
  • all patients are given this until it is proven not to be pneumococcal in cause
31
Q

When are the benefits of corticosteriod treatment of bacterial meningitis reduced?

A

When presentation is delayed
The patient has untreated HIV
The patient has other life-threatening CNS infections

32
Q

When should a person be given meningococcal prophylaxis?

A

When someone they have come into close contact with has been diagnosed with it

33
Q

What is the chemoprophylaxis treatment for meningococcal prevention?

A

Single dose ciprofloxacin
OR
Single dose rifampicin

34
Q

What is the most prominent differentiating feature of TB CNS infections?

A

Often causes lesions of the cranial nerves

  • occulomotor
  • trochlear
  • abducens
  • glossopharyngeal
35
Q

Why can paradoxical worsening occur when treating someone for pulmonary TB?

A

The treatment of the pulmonary TB unmasks the TB that has disseminated into the brain.
This causes it to start to show signs and symptoms

36
Q

What is the treatment for intra-cerebral TB?

A 
Antibiotics for 1 year
- Rifampicin 
- Isoniazid 
- Pyrazinamide
- Ethambutamol
Steriods
37
Q

What is the key clinical signs to differentiate encephalitis from meningitis?

A

Confusion
Abnormal affect
Seizures

38
Q

What do you expect to see in the CSF in viral encephalitis?

A

Lymphocytes

Normal glucose

39
Q

What is the treatment for viral encephalitis?

A

IV Aciclovir for 2-3 weeks

- HSV, VSV commonly the cause

40
Q

What is the treatment for viral meningitis?

A

Nothing, unless they are immunocompromised

41
Q

What is the diagnostic test for viral encephalitis?

A

Viral PCR on CSF

- tested again in the second week to see if the treatment is working

42
Q

What is progressive focal multifocal leucoencephalopathy?

A

Progressive motor dysfunction

- causes muscular weakness and death

43
Q

In which patients is PMLE most common in?

A

Complication in renal transplants
In the immunocompromised
HIV patients
- when they start therapy

44
Q

What is the cause of PMLE?

A

JC virus

45
Q

How is PMLE treated?

A

No treatment

If the patient is HIV positive, it sometimes disappears with treatment of the HIV

46
Q

What is intra-cerebral toxoplasmosis?

A

Protazoal infection of the CNS with Toxoplasma gondii

- causes multiple enhancing lesions

47
Q

Who is most at risk of intra-cerebral toxoplasmosis?

A

Immunocompromised

HIV patients

48
Q

What are the signs and symptoms of intra-cerebral toxoplasmosis?

A

Headaches
Seizures
Focal CNS signs

49
Q

How is intra-cerebral toxoplasmosis treated?

A

Antibiotic
- Sulphadiazine
- Pyramethamine
Restore the immune function

50
Q

What is the treatment for cryptococcal meningitis?

A

Amphotericin B

Flucytosine

Neurology (13 decks)

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