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Neurology > Lecture 23Infections of the Nervous System > Flashcards

Lecture 23Infections of the Nervous System Flashcards

1
Q

Define Meningitis

A

inflammation / infection of meninges

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2
Q

Define Encephalitis

A

inflammation / infection of brain substance

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3
Q

Define Myelitis

A

inflammation / infection of spinal cord

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4
Q

What are the clinical features of Meningitis

A 
Fever
Neck stiffness
Altered mental status
Fever
Photophobia
Nausea
Vomiting
Cerebral dysfunction 
Cranial nerve palsy
Seizures
Petechial skin rash
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5
Q

Differential diagnosis of Meningitis

A 
Bacterial, Viral, Fungal
Sarcoidosis
NSAIDs
Metastatic
Leukaemia 
Lymphoma
Myeloma
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6
Q

Bacterial causes of meningitis

A

o Neisseria meningitidis (meningococcus)

o Streptococcus pneumoniae (pneumococcus)

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7
Q

Viral causes of meningitis

A

Enteroviruses

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8
Q

Clinical features of Encephalitis

A 
Flue like
Progressive headache with fever
•	Progressive cerebral dysfunction
–	Confusion
–	Abnormal behaviour
–	Memory disturbance
–	Depressed conscious level
•	Seizures
•	Focal symptoms / signs
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9
Q

Onset of which type of encephalitis is slower bacterial or viral

A

Viral

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10
Q

Differential diagnosis for encephalitis

A 
HSV
Limbic encephalitis
Hepatic
Uraemic
Hyperglycaemic
Metastatic
Paraneiplastic
Post ictal (after seizure)
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11
Q

What are the 2 main types of auto-immune Encephalitis

A

Anti-VGKC

Anti-NMDA

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12
Q

What is Anti-VGKC

A

(Voltage Gated Potassium Channel)
– Frequent seizures
– amnesia (not able to retain new memories)
– Altered mental state

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13
Q

What is Anti-NMDA receptor

A

– Flue like prodrome
– Prominent psychiatric features
– Altered mental state and seizures
– Progressing to a movement disorder and coma

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14
Q

What investigations are carried out for Meningitis and Encephalitis

A 
Exclude and treat infection
•	Meningitis
–	Blood cultures (bacteraemia)
–	Lumbar puncture (CSF culture/microscopy)
–	No need for imaging if no contraindications to LP 
•	Encephalitis
–	Blood cultures
–	Imaging (CT scan +/- MRI)
–	Lumbar puncture  	
–	EEG
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15
Q

Name contraindications for a lumbar puncture

A
  • Focal symptoms or signs to suggest a focal brain mass

* Reduced conscious level suggests raised intracranial pressure

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16
Q

Name indications for CT brain scanning before lumbar puncture

A 
Focal neurological deficit, not including cranial nerve palsies
New onset seizures
Papilloedema
Abnormal level of consciousness GCS<10
Severe immunocompromised state
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17
Q

Describe the opening pressure, cell count, glucose and protein that would be seen in Bacterial meningitis

A

Increased opening pressure
High cell count (neutrophils)
Reduced glucose
High protein

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18
Q

Describe the opening pressure, cell count, glucose and protein that would be seen in Viral meningitis

A

Normal/increased opening pressure
High cell count (lymphocyte)
Normal glucose (60% of blood glucose)
Protein slightly increased

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19
Q 
66 Female Headache, photophobia, neck stiffness, vomiting, agitated. Treated empirically with IV Ceftriaxone
•	CSF protein 3256 mg/L (150-700)
CSF Glucose 0.0 mmol/L
•	CSF: Appearance cloudy
•	Microscopy: 
•	RBC 0 cells per cubic mm
•	WBC 8856 cells per cubic mm
•	Polymorphs 80%
•	Mononuclear cells 15%
•	Unidentified white cells 5%
What would you find in the gram stain and what would be the diagnosis
A
  • Blood culture Gram stain: Gram positive cocci in chains - looks like streptococci
  • Culture streptococcus pneumoniae sensitive to penicillin
  • Bacterial meningitis
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20
Q

Name the commonest cause of encephalitis in Europe

A

HSV

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21
Q

How is HSV Encephalitis diagnosed

A

PCR of CSF for viral DNA

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22
Q

How is HSV Encephalitis treated

A

Aciclovir

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23
Q

What HSV causes col sores

A

Type 1> 2

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24
Q

What HS causes herpes

A

Type 1 and 2

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25
Q

After primary infection of HSV what happens

A

The virus lays latent in the trigeminal or sacral ganglion

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26
Q

How are enteroviruses spread

A

Faecal-oral route

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27
Q

What are the consequences of enteroviruses

A 
non-paralytic meningitis
CN infections (neurotropic)
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28
Q

Name examples of Enteroviruses (RNA viruses)

A

polioviruses, coxsackieviruses and echoviruses

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29
Q

Other causes of Encephalitis

A 
Arbovirus encephalitides
Brain abscess and Empyema 
HIV
Spirochaetes
Lyme disease 
Neurosyphillis
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30
Q

How is Arbovirus encephalitides transmitted

A

Main vector mosquito or tick

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31
Q

What is a brain abscess

A

Localised area of pus within the brain

32
Q

What is a subdural empyema

A

thin layer of pus between the dura and arachnoid membranes over the surface of the brain

33
Q

Clinical features of brain abscess

A 
•	Fever, Headache
•	Focal symptoms / signs
–	Seizures, dysphasia, hemiparesis, etc
–	Signs of raised intracranial pressure
–	Papilloedema, false localizing signs,
–	depressed conscious level
–	Meningism may be present, particularly with empyema
34
Q

What underlying issues can cause a brain abscess

A

Dental, sinus or ear infection, tumour, subdural haematoma, bacterial endocarditis, penetrating head injury, neurosurgical procedure

35
Q

What investigations are conducted for a suspected brain abscess and Empyema

A

CT/MRI
Blood culture
Biopsy (drainage of pus)

36
Q

What organisms are responsible for brain abscesses

A

Streptococci

Anaerobes (Bacteroides, Prevotella)

37
Q

What is the management of a brain abscess

A
  • Surgical drainage if possible
  • Penicillin or ceftriaxone to cover streps
  • Metronidazole for anaerobes
  • High doses required for penetration
  • Culture and sensitivity tests on aspirate provide useful guide
38
Q

Differential diagnosis for HIV indicator illnesses (brain)

A
  • Cerebral toxoplasmosis - parasitic
  • Aseptic meningitis /encephalitis
  • Primary cerebral lymphoma
  • Cerebral abscess
  • Cryptococcal meningitis
  • Space occupying lesion of unknown cause
  • Dementia
  • Leucoencephalopathy- brain white matter disease
39
Q

Name brain infections in HIV patients with low CD4 counts

A
  • Cryptococcus neoformans
  • Toxoplasma gondii
  • Progressive multifocal leukoencephalopathy (PML)
  • Cytomegalovirus (CMV)
  • HIV-encephalopathy
40
Q

Investigations for HIV indicator illnesses

A
  • Cryptococcal antigen
  • Toxoplasmosis serology
  • CMV PCR
  • HIV PCR
41
Q

What disease involve Spirochaetes in the CNS

A
  • Lyme Disease (Borrelia burgdorferi)
  • Syphilis (Trepomena pallidum)
  • Leptospirosis (Leptospira interrogans)
42
Q

How is Lyme disease spread

A

Vector borne- tick (wooded area)

43
Q

How many stages are there in a Lyme disease infection

A

3

44
Q

Describe stage 1 of Lyme disease

A

• Early localized infection (1-30d)
• erythema migrans
• 50% flu like symptoms (days – 1 week)
– Fatigue, myalgia, arthralgia, headache, fever, chills, neck stiffness

45
Q

Describe stage 2 of Lyme disease

A

• Early disseminated infection (weeks – months)
• One or more organ systems become involved
– Haematologic or lymphatic spread
• Musculoskeletal and neurologic involvement most common
• Neurologic involvement (10-15%) untreated patients

46
Q

Describe stage 3 of Lyme disease

A 
•	Chronic infection 
–	months to years
–	occuring after a period of latency
–	Musculoskeletal and neurologic involvement most common
•	Neurologic involvement
–	As described for stage 2 
–	Subacute encephalopathy
–	Encephalomyelitis
•	Does NOT cause a chronic fatigue syndrome
47
Q

What are the investigations for Lyme disease

A

– Complex range of serological tests
– CSF lymphocytosis
– MRI brain / spine (if CNS involvement)
– Nerve conduction studies / EMG (if PNS involvement)

48
Q

Treatment for Lyme disease

A

• Prolonged antibiotic treatment
– intravenous ceftriaxone
– oral doxycycline

49
Q

What organism causes Neurosyphillis

A

Treponema pallidum

50
Q

How many stages are involved in Neurosyphyllis

A

3

51
Q

How is Neurosyphillis diagnosed

A

CSF lymphocyte increased

Intrathecal antibody prduction

52
Q

How is Neurosyphillis treated

A

High dose penicillin

53
Q

What causes Poliomyelitis

A

Poliovirus 1,2 and 3

54
Q

Describe the effects of Infection with polio irus

A

– infects anterior horn cells of lower motor neurones
• Asymmetric, flaccid paralysis, esp legs
• No sensory features
99% asymptomatic

55
Q

Name important vaccines

A

Polio
Rabies
Tetanus

56
Q

How is tetanus transmitted

A

Transmitted from bit or salivary contamination of open lesion

57
Q

What are the consequences of a rabies infection

A
  • Neurotropic - virus enters peripheral nerves and migrates to CNS
  • Paraesthesiae at site of original lesion
  • Ascending paralysis and encephalitis
58
Q

How is Rabies Encephalitis diagnosed

A

PCR and Serology

59
Q

In the UK Rabies pre-exposure is given to who

A

– bat handlers
– regular handlers of imported animals
– selected travellers to enzootic areas

60
Q

Dsribe rabies post-exposure treatment

A
  • Wash wound
  • Give active rabies immunisation
  • Give human rabies immunoglobulin (passive immunisation) if high risk
61
Q

What organism causes Tetanus

A
  • infection with Clostridium tetani

* anaerobic Gram positive bacillus, spore forming

62
Q

What is the effects of a tetanus infection

A
  • toxin acts at neuro-muscular junction
  • blocks inhibition of motor neurones
  • rigidity and spasm (risus sardonicus)
63
Q

How is Tetanus prevented

A
  • Immunisation (toxoid)
  • given combined with other antigens (DTaP)
  • Penicillin and immunoglobulin for high risk wounds/patients
64
Q

What is Botulism

A

Illness caused by Clostridium botulinum
– Anaerobic spore producing gram positive bacillus
– Neurotoxin
• Binds irreversibly to the presynaptic membranes of peripheral neuromuscular and autonomic nerve junctions
• Toxin binding blocks acetylcholine release

65
Q

What are the modes of infection for Botulism

A

– Infantile (intestinal colonization)
– Food-borne (outbreaks)
– Wound: Almost exclusively injecting or “popping” drug users
Present in soil, dust and aquatic environments

66
Q

Describe the clinical presentation of Botulism

A 
–	Incubation period  4-14 days
–	Descending symmetrical flaccid paralysis
–	Pure motor
–	Respiratory failure
–	Autonomic dysfunction
•	Usually pupil dilation
67
Q

How is Botulism diagnosed

A

– Nerve conduction studies
– Mouse neutralisation bioassay for toxin in blood
– Culture from debrided wound

68
Q

How is Botulism treated

A

– Anti-toxin (A,B,E)
– Penicillin / Metronidazole (prolonged treatment)
– Radical wound debridement

69
Q

What is post infective inflammatory syndromes

A

– Latent interval between the precipitating infection and onset of neurological symptoms
– Autoimmune
– Central nervous system

70
Q

Name an example of post infective inflammatory syndromes

A

Acute disseminated encephalomyelitis (ADEM)

Guillain Barre Syndrome (GBS)

71
Q

How is Creutzfeldt-Jakob Disease (CJD) caused

A

• Transmissible Proteinaceous particle – Prion

72
Q

What are the aetiology of CJD

A 
–	Sporadic CJD
–	New variant CJD
–	Familial CJD (10-15%)
–	Acquired CJD (<5%)
•	Cadeveric Growth Hormone
•	Dura matter grafts
•	Blood transfusion
73
Q

Differential diagnosis for sporadic CJD

A

Alzheimer’s disease
Subacute sclerosing panencephalitis (SSPE)
CNS vasculitis
Inflammatory encephalopathies

74
Q

Prognosis of sporadic CJD

A

– Rapid progression

– Death often within 6 months

75
Q

New variant CJD cause

A 
•	Younger onset <40
•	Linked to Bovine Spongiform Encephalopathy in Cattle
–	Eating infected material
–	Less cases than predicted
–	No new cases last few years
–	May be a genetic susceptibility
76
Q

Investigations for CJD

A

MRI- Pulvinar sign
EEG
CSF

Neurology (44 decks)

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