Infectious Nervous Flashcards
West Nile Virus Encephalitis
fever, headaches, and altered mental status. A prominent finding in WNE is muscular weakness (30 to 50 percent of patients with encephalitis), often with lower motor neuron symptoms, flaccid paralysis, and hyporeflexia with no sensory abnormalities. Rare form.
Most common causes of viral meningitis?
1) Enterococcus (coxsackie, poliovirus, rhinovirus)
2) HSV 2,
3) HSV 1, VZV, HIV, Lyme, VDRL, EBV, LCMV
West Nile Meningitis
Occurs in older, immunocompromised people. Rare form
What is the work up for a lymphocytic predominant meningitis in immunocompetent patient?
Blood: cultures, ESR, ANA, rheumatoid, Sjogren’s, SPEP, angiotensin converting enzyme,
CSF: cytology, antibodies to B. burgdorferi, Brucella, histoplasma, coccidioides, PCR M. tuberculosis.
Enterovirus v. Lyme
EV 6x as frequent as lyme
Median pediatric age 10 Lyme v 5 EV
Prodrome duration 12 d Lyme, 1 day EV
Lyme has facial palsy
fever, HA, nuchal rigidity, facial palsy
Lyme meningitis
fever, HA, nuchal rigidity, sacral pain
HSV 2 meningitis
But most hsv2 meningitis occurs without genital herpes.
Chronic prophylaxis
Acyclovir, valacyclovir
lymphocytic predominant meningitis in HIV patient differential diagnosis?
Virus: enterovirus, HSV 1, 2, 6, 7 VZV, CMV, EBV, HIV, WNV
Bacteria: endocarditis, parameningeal infection, mycoplasma, M tuberculosis, T pallidum
Fungi: Cryptococcus neoformans, H capsulatum, C immitis
Parasites: T. gondii
Noninfectious: carcinomatosis, posttransplant lymphoproliferative d/o, CNS vasculitis, ADEM (Acute disseminated encephalomyelitis)
Drug Reactions: NSAIDS, Cox-2 I, azathioprine, Bactrim, isoniazid, IVIG, OKT-3, intrathecal chemo.
When do you need to do a CT before an LP?
Yale criteria:
Cryptococcal meningitis CD4 count?
100
If WBC
What is IRIS syndrome
Immune reconsitition inflammatory syndrome
esp concerning in aids patient treated for cryptococcus meningitis
weeks after appropriate tx, worsening of sx or new neuro sx.
prevent by delaying HAART therapy.
+CRP with sterile tap
Inflammatory PML:
MS sx: weakness, changes in vision, personality, movement
Fast progressive
caused by JC virus and MS treated with Natulizamab
Multifocal non contrast enhancing lesions on MRI
Prognosis: 1/3-1/2 die in first month
multiple lesions in brain in AIDS patients
Multiple enhancing brain lesions. Usually brain abscesses (rarely encephalitis).
Dx: Serology
If congenital: periventricular calcifications
Rx: pyrimethamine/sulfadiazine and folinic acid
right ear pain followed by weakness of lid closure, eyebrow lifting, and lower face weakness.
No hearing loss, tip of tongue is numb
Bell’s palsy
Most common cause: 2/3 of are VZV, median ag 40, equal gender, recurrance rare
20-30% may have permanent disfiguring facial weakness &/or synkinesis, hyperacusis, loss of taste/tearing.
Tx with prednisone in first 48hr and valacyclovir.
Causes of one time Bell’s palsy
diabetes, HTN, HIV, Lyme, Ramsay Hunt (zoster), sarcoidosis, parotid disorders, Sjogren’s, pregnancy, amyloidosis, intranasal flue vaccine, WNV
Recurrent/Bilateral Facial N. Palsy
lymphoma, sarcoid, Lyme, pontine lesion, m. gravis.
Neurologic signs suspicious for Lyme’s disease
Facial palsy, unilateral or bilateral. Meningeal signs with or without cranial neuritis, Radiculopathy, mononeuropathy multiplex, encephalomyelitis, encephalopathy
Lyme Pearls
2.Diagnostic testing should be done if there
is likelihood of tick exposure
3.Lyme accounts for only 25% su mertime 7th nerve
palsies in endemic areas
4.Onset of headache and meningeal symptoms is
less acute than in viral meningitis
5.Many patients with erythema migrans do not
yet have measurable antibody response
6.ELISA does not provide measure of disease activity
or treatment response and can remain positive for years
7.Early increase B cells, IgG synthesis, bands, possibly
due to chemokineCXCL 13
8.Borrelia burgdorferi is very sensitive to beta-lactam s
and tetracyclines with no sig nificant resistance 9.Persistent symptoms with negative laboratory tests after appropriate treatment are not Lyme disease
Old man with high temp, stiff neck, unrousable, generalized seizure, no papilledema or lateralizing abn.
Dexamethasone (to reduce hearing loss)
Abx: for S. penumo, gnr, listeria,
CT
LP
If low sugar in CSF:
cancer, Bacterial , TB Herpes simplex (sometimes) Fungal (sometimes) Neurosarcoidosis
Necrotic encephalitis, psychiatric symptoms. Mixed poly, lymphocytic encephalitis, RBC 400
HSV encephalitis
Dx PCR`
Left leg weakness over 1 day to 3/5 strength. Areflexic in both legs. Speech arrest. Mild bilateral facial weakness. Normal sensory exam. rapid obtundation. CSF: 125 WBC 50% polys, glucose 75, protein 104
Polio like
West Nile Virus
Dx: IgM
older, immunocompromised people.
facial nerve
Acute confusional states with limbic features
Psychiatric diagnosis, Drugs, Wernicke’s, Seizures/status –ddx, Infection: HSV 1>2, HHV 6, Paraneoplastic syndromes
Encephalitis Causes4
vira: St. Louis, Equine, WNV, Japanese
Bacterial: rocky mt spotted fever, ehrlichiosis, anaplasmosis, lyme, leptospirosis
Amebae: aegleria, acanthamoeba
Non seasonal:
HSV 1, 2, 6, VZV, EBV, CMV, Rabies, H1N1, Toxoplasmosis
