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Neurology > Meningitis & other IC infections > Flashcards

Meningitis & other IC infections Flashcards

1
Q

What are 7 symptoms of meningitis?

A
  1. fever (high grade)
  2. myalgia
  3. headache
  4. photophobia
  5. neck stiffness
  6. rash (non-blanching)
  7. N&V

NB: meningism = photophobia, neck stiffness, headache

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2
Q

What are the 3 main organisms causing meningitis?

A
  • N.meningitidis
  • strep pneumonia
  • haemophilus influenzae
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3
Q

what else can n.meningitidis cause apart from meningitis (BBB)?

A

can cause meningitis across the BBB or septicaemia

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4
Q

Which age group is haemophilus influenzae likely to effect & cause meningitis?

A

children <5yrs

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5
Q

What 3 cultures should be taken in suspected meningitis?

A
  • blood culture + EDTA for PCR
  • CSF culture + gram stain + PCR
  • Throat swab culture
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6
Q

Is neisseria meningitidis G-ve or positive?

A

gram -ve

they do not retain the violet colour they remain pink

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7
Q

is strep pneumoniae g+ve or negative?

A

g +ve

retains the violet dye after use

g+ve retaian due to the THICK pepdigoglycan cell wall - they lack the outer membrane and have thick cell walls

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8
Q

What is the pathophysiology of meningitis?

A

can get infection of the meningies POST HEAD INJURY –> infection spreads

e.g. pneumococcus (strep p) via nose and staph aureus via compound fracture

a ?infection post-head injury is the ONLY indication for LP on a patient w/a head injury (e.g. otherwise coning risk)

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9
Q

Apart from bacteria what other organsims should you consider for meningitis?

A
  • worry about HSV encephalitis
  • Tuberculosis
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10
Q

Which is the most common cause of meningitis out of meningococcus or pneumococcus (s.pneumonie causing acute pneumonia)?

A

pneumococcus! - 25%

while meningococcus = 10%

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11
Q

at 0-3 months the common causative agents for meningitis are different to the usual n.meningitidis, s.pneumonia and Hib.

What organisms are the commest for meningitis causing 0-3m?

A

Group B strep - MOST COMMON CAUSE IN NEONATES

E.coli

listeria monocytogenes

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12
Q

listeria monocytogenes is a cause of meningitis for neonates, what other groups does it become one of the top causative agents for?

A

if >60 years

and

immunosupressed

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13
Q

if Hib is most common in children <5y/o which bacteria are most causative for meningitis between 6 yrs - 60 yrs?

A
  • Neisseria meningitidis
  • Streptococcus pneumoniae
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14
Q

What are the most common bacteria causing meningitis over 60yrs?

A
  • Streptococcus pneumoniae
  • Neisseria meningitidis
  • Listeria monocytogenes
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15
Q

What is the most common causative agents for bacterial meningitis from 3m-6y/o

A
  • Neisseria meningitidis
  • Streptococcus pneumoniae
  • Haemophilus influenzae
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16
Q

What does a non-blanching rash indicate?

A

actually indicates meningococcal septicaemia

  • from DIC, bacteria release toxin –> cytokine storm –> CLOT then BLEED
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17
Q

What are 2 signs O/E for meningitis?

A

Kernigs sign = pain and resistance on attempting to extend the leg at the knee with thigh flexed @ hip

Brudzinski sign = neck flexion causes knee flexion

overall: stretching meninges = pain produced

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18
Q

How can you tell chronic meningitis?

A

whether the chronic meningitis is malignant, TB or fungal –>

tends to pick off the lower CNs one by one e.g. the larynx/pharynx contol ones e.g. CN9, 10,11,12

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19
Q

What complications can you get of meningitis?

include infective, pressure & other neurological?

A

deafness (most common)

  • other neurological: epilepsy, paralysis
  • infective: sepsis, intracerebral abscess
  • pressure: brain herniation, hydrocephalus
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20
Q

how do:

  • malaria,
  • encephalitis,
  • septicaemia,
  • subarachnoid,
  • dengue,
  • tetanus

all relate to meningitis?

A

they are differentials for they syx of meningitis

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21
Q

TB can cause meningitis. What Ix should you do to rule out TB in meningitis cases?

A

CXR

mantoux

gastric washings (sputum)

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22
Q

What cultures/swabs both bacterial and viral should be done in meningitis/infections?

A

blood

rash scrapings

throat

stool/rectal

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23
Q

What bloods should be done for ?meningitis?

A
  • FBC,
  • U&Es,
  • LFT,
  • glucose,
  • clotting,
  • viral serology (EBV, HIV)
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24
Q

What imaging should be done for ?meningitis?

A
  • CTH,
  • CXR
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25
Q

What tests can be done on lumbar puncture to indicate that there is infection?

A
  • measure opening pressure - will be raised
    • (normal = 7-18)
  • do MC&S
    • (Ziehl-neelsen stain - mainly mycobacteria)
  • PCR
26
Q

What would the appearance, glucose, proteins & WCC in CSF of bacterial infection be?

A

cloudy

low glucose (<0.5 of plasma)(eaten)

high protein >1g/l

WCC 10-5,000 polymorphs or neurtophils (has the most WCC out of viral or TB as they cap at around 1,000 neut)

27
Q

What would the appearance, glucose, proteins & WCC in CSF of viral infection be?

A

clear/cloudy

60-80% of plasma glucose

normal or raised protein

max 1,000 lymphocytes or from 15-1,000

NB: low glucose maybe seen in herpes encephalitis & MUMPS

28
Q

What would the appearance, glucose, proteins & WCC in CSF of TB infection be?

A

unlike other bacteria CSF you may see a slightly cloudy fibrin web

again, glucose would be low - <50% plasme conc (eaten) & high protein e.g. >1g/L

but lymphocytes would be 10-1,000 max (other bacterial can go up to 5,000.

29
Q

What are the contraindications for lumbar puncture?

NB: spinal cord ends @ level of vertebrae L1-L2 (–>s2)

while limbar punctures are usually perfored between L3 & L5 e.g. cauda eqina level to avoid damage to spinal cord.

A
  1. Raised ICP/risk incipient herniation
  2. shock/CVS compromise
  3. respiratory insufficiency (e.g. in a baby you have to curl them up into a ball for LP- TF making it even harder for them to breathe)
  4. extensive or spreading purpura or local superficial infection at LP site
  5. bleeding disorders, low platelets
  6. dont do LP if it will DELAY abx starting
30
Q

What are the INDICATIONS for LP?

A
  • fever without focus <3months old, or if older
  • meningitis/encephalitis suspicion
  • suspected SAH or CT normal
  • diagnostic workup of certain malignancies, seizures, metabolic disorders, neurological conditions (e.g. MS, GBS)
31
Q

What are the complications of LP?

A
  • post dural puncture headache (common)
  • local back pain
  • infection
  • spinal haematoma
  • subarachnoid epidermal cyst
  • apnoea
32
Q

Neck stiffness, photophobia and headahce are signs of meningitis/encephalitis. What signs in addition to these would you see in neonates w/meningitis/encephalitis?

A
  • poor feeding
  • irritability
  • hypotonia
  • altered cry
  • opisthotonus
  • bulging fontanelle
33
Q

What GCS signs indicated raised ICP/incipient herniation risk?

A
  • GCS <9 or
  • GCS that fluctuates by 3 or more points
    *
34
Q

What is cushings triad?

A

raised systolic BP, dc pulse and dc respiration

There is CNS ischaemia –> increase sympathetic e.g. raises BP but the baroreceptor senses the raised BP (trying to overcome the high pressure in brain/cranial vault) so slows HR to bradycardia

irregular respirations are from reduced perfusion of the brainstem from swelling/possible brainstem herniation

(the opposite of shock e.g. low bp & high pulse and resp)

35
Q

What does “abnormal dolls eye movements” show?

e.g. where the eyes should move in the direction opposite to that of head movement the eyes now move in the direction of head movement

A
  • shows brainstem abnormality

(as part of raised ICP/risk incipient herniation)

(negative dolls eye reflex signifies severe brain damage or brain death)

36
Q

Raised ICP/risk incipient herniation is a contraindication for LP

what else besides fluccutating/reduced <9 GCS, cushings reflex & abnormal dolls eye shows signs of raised ICP?

A
  • Focal neurological signs
  • abnormal posture or posturing
  • papilloedema
  • unequal, dilated or poorly responsive movements
  • seizures - within 30m or prolonged >30mins siezures
37
Q

What is the managment of meningitis without septicaemia?

A
  • ABCDE
  • DEXAMATHASONE 4-10mg/6h IV
  • Abx =
    • Benzyl penicillin 1.2g IM/IV in 1o care
    • broad spec: IV cefotaxime 2g/6h slow IV
    • then refer to local guidelines once MC&S back
  • Fluids
  • cerebral monitoring - neuro obs
  • notify public health and contact prophylaxis
38
Q

What should you give if you suspect viral encephalitis?

A

worry about HSV encephalitis

so

aciclovir!

39
Q

for someone with meningitis we need to notify public health and give prophylaxis to contacts.

What do we give?

A

give rifampicin or ciprofloxacin

to household contacts in droplet range or those who have kissed the pts mouth

40
Q

What are the features of encepalitis e.g. herpes simplex (HSV) encephalitis?

A
  1. fever
  2. headache
  3. psychiatric symptoms
  4. seizures
  5. vomiting
  6. focal features of HSV = aphasia e.g. the virus characteristically affects temporal lobes
  • NOT peripheral lesions e.g. cold sored have no relation to HSV encephalitis
41
Q

Which HSV causes encephalitis in adults & where does it impact?

A

HSV-1 is responsible for 95% of cases in adults

HSV typically affects TEMPORAL and INFERIOR-FRONTAL lobes

Rx: with IV aciclovir

NB: if treatment is started promptly the mortality is 10-20%; if untreated the mortality approaches 80%

42
Q

What CSF signs are there of encephalitis?

A

lymphocytosis and elevated protein in CSF

43
Q

apart from CSF what Ix do you do for encephalitis?

A
  • PCR for HSV
  • Bloods:
    • cultures,
    • PCR,
    • toxoplasma IgM titre
      • (causes encephalitis in adutlts- eating cat/dog parasite egs in soild/water/food; IgM indicates its recent infection),
    • malaria film
  • CTH contrast enhanced - for medial temoral and inferior frontal changed e/g. petichial haemorrhages (normal in 1/3 patients) –>
  • MRI is better
  • EEG
44
Q

What does this EEG pattern mean?

lateralised periodic discharges at 2 Hz

A

encephalitis

45
Q

A patient presents with toxaemia, fever, meningism, leucocytosis, riased ICP, localising signs and also a penetrating wound to the head. What condition does this indicate?

A

due to it being those symptoms which could be meningitis/encephaltis + local signs + underlying cause including penetrating wound or could be direct spread e.g. from middle ear or mastoid or blood borne spread

–> intracranial abscess.

46
Q

How do you Ix an intracranial abscess?

A
  • X-ray (to see if frontal sinus/ethmoid sinus infection or mastoid has spread)
  • CXR ( to look for septic embolus from lung or systemic circulation in R->L cardiac shunt & for MCA territory)
  • CT/MRI
47
Q

How do you Rx an intracranial abscess?

A
  • aspirate
  • abx into abscess cavity
  • high dose systemic antibiotics,
  • anticonvulsant therapy –> 1/3rd patients develop epilepsy
48
Q

What follow up should be given for intracranial abscess?

A
  • serial CT scan follow ups
  • aspiration may need to be repeated
  • abscess capsule may need to be excised if it fails to respond to aspiration
49
Q

A patient presents with seizures and this CTH what is this?

A

neurocysticerosis

a form of cysticercosis e.g. the most common worm infection of CNS (developing countries)

can form giant cysts in brain

Px: seizures (meningism & fever are not typical)

50
Q

Meningitis does not usually require imaging - normally is clinical and CSF diagnosis

You should only image is it is a non-straight forward course, worried about ddx

or worried about complications… such as what?

what are the complications of meningitis?

A
  • ↑ICP/hydrocephalus - inflamed meninges are adhesive –> block CSF flow
  • Spread of infection causing cerebritis (brain parenchyma due to bacterial whereas encephalitis = inflam due to virus/PNP/AI)
  • Collection causing subdural empyema/ cerebral abscess
  • Ischaemia due to infection coating vessels
  • CN due to inflammation spread
51
Q

What are the most common things causing encephalitis?

cerebritis is normally infection due to bacteria/non viral pathogens/2ndry to another cause

A

HSV & Varicella

they can be non-infective e.g. limbic encephalitis - autoimmune, paraneoplastic

52
Q

A patient presents confused and comatose with low GCS. What could this indicate?

A

encephalitis

can lead to LT complications e.g. memory loss, seizures

53
Q

What is imaging used for in encephalitis?

A

imaging is only supportive - it cannot differentiate between infective & non-infective causes

otherwise Dx is done on clinical diagnosis

54
Q

What does initial imaging of encephalitis show vs 4 months later?

A

initial imagins = enhancement and swelling (px: confused, comatose/low GCS)

4 months later = scarring, volume loss, dilation of ventricles (fits with the LT comps. memory loss & seizures)

55
Q

Where is the characteistic location of enceptalitis ?HSV?

A

medial temporal lobe

insula

cingulate gyrus

56
Q

What do these images show and how do you know?

A
  • irregular mass
  • surrounded by cerebral oedema
  • doesnt affect grey/white equally like a vascular event would
  • diffusion characteristics allow distinguishment from tumour - as diffusion not restricted in a tumour –> its restricted in Pus

TF…

this is a cerebral abscess!

57
Q

What is an extra axial infected collection called?

A

extra axial means external to brain parenchyma

–> subdural empyema

NB: abscesses are usually parenchymal

other infected collections = sinus filling, epidural abscess.

58
Q

Who can JC virus reactivation happen in and what does it cause?

A

causes multiple lesions in immunocompromised/HIV

59
Q

HIV pt presenting with 4wk history of:

Dysarthria (DBM, non-dominant hemisphere)

Somnolence/sleepiness (thalamic, brainstem)

Right arm weakness (L hemisphere)

what could this be?

A

JC virus reactivation –> it causes multiple lesions

60
Q

this happens from Prior infection in HIV/imimunocompromised

Usually older patients

Signal abnormality in the cortex and basal ganglia

–> Characteristic hockey stick appearance in the pulvinar of the thalami

A

= viral CJD

Creutzfeldt-Jakob disease

Neurology (7 decks)

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