Neuro ID Flashcards
Name the major etiologies of viral meningitis?
herpes viruses, enteroviruses, lymphocytic choriomeningitis virus, mumps, HIV, adenovirus, arbovirus, parainfluenza virus 2 and 3. (HELM HAP)
Key basics of enterovirus?
fecal oral spread, summer/fall seasonality, risk factor of chronic enteroviral meningoencephalitis agammaglobulinemia (CEMA), Rituximab. PCR better than CSF culture.
scattered maculopapular rash enterovirus with meningitis?
echovirus 9, RNA virus, MCC aspetic meningitis in children, naturally found in GI tract.
herpangina with enterovirus meningitis?
coxsackievirus A
pericaridtis/pleuritis with enterovirus meningitis?
Coxsackievirus B
rhomboencephalitis with enterovirus?
enterovirus 71
keys of mumps virus?
male>females 5-9 years old, can have +/- parotitis by ~ 5 days. CSF culture 30-50%, PCR better.
Describe mollaret’s ?
Recurrent benign lymphocytic meningitis cuased by HSV-2 with at least 10 episodes lasting 2-5 days followed by spontaneous recovery
What is LCMV?
lymphocytic choriomeningits virus, transmitted to humans by contact with rodents or their excreta.
Clinical features of herpes simplex encephalitis?
most severe of all human viral infections, no seasonality, majority caused by HSV-1. See fever, personality changes, dysphasia, and autonomic dysfunction
what would you expect to see on EEG/brain biopsy in herpes simplex encephalitis?
EEG - periodic lateralizing epileptiform discharges (PLEDs), brain biopsy - intranuclear inclusions/inflammation with widespread hemorrhagic necrosis.
what would you expect to see on MRI in herpes simplex encephalitis?
MRI - bilateral asymmetrical involvement of the limbic system, medial temporal lobes, insular cortices and inferolateral frontal lobes. The basal ganglia are typically spared, helping to distinguish it from a middle cerebral artery infarct.
The treatment dosage for HSV encephalitis?
30mg/kg/day in q8 hours for 14-21 days. No added benefit of 3 months of oral valacyclovir.
basics of HHV6?
worry about it in immunocompromised patients. CSF PCR has high sensitivity but PPV low. Treat with ganciclovir or foscarnet.
Describe B virus?
macaques bite or scratch with the vesicular eruption at the site, the neurologic disease in 3-7 days. Give prophylactic valacyclovir, treat with acyclovir, valacyclovir or ganciclovir.
describe the transmission of west nile virus?
mosquito vector, bird reservoir hosts, incidental infections with humans, horses.
MRI findings for CMV encephalitis?
subependymal gadaloinium enhacement and non-specific white matter changes
how would you diagnose CMV?
CSF PCR?
treatment of CMV encephalitis?
ganciclovir + foscarnet
what are the WNV clinical syndromes?
80% - no symptoms. 20% fever; the severe disease is meningitis, meningoencephalitis, poliomyelitis - like flaccid paralysis
how would you diagnose WNV encephalitis?
8-14 days Serum IgM antibody, CSF IgM>90%, CSF PCR<60%, T2/FLAIR MRI showing hyperintensity within deep brain structures, including the thalami, basal ganglia and midbrain structures 5; the latter includes the red nucleus, cerebral peduncle and substantia nigra
what are the 3 diseases measles virus can cause?
acute disseminated encephalitis with MRI showing asymmetric demyelination 2-4 weeks after exposure, inclusion body disease, subacute sclerosing pan-encephalitis (6-10 years later)
when do you see symptoms of measles?
1-6 months after exposure.
what are the two forms of rabies?
encephalitic (furious - 80%) agitation, hydrophobia and paralytic (dumb - 20%) (ascending paralysis, early muscle weakness, later cerebral involvement
what are the two big noninfectious etiologies of encephalitis?
Acute disseminated encephalomyelitis (ADEM) and anti-N-methyl-D-aspartate receptor (Anti-NMDAR) encephalitis
describe ADEM? Tx?
encephalitis with either post-infectious (URI, viral, hep C, HIV) or post-immunization 2-4 weeks. Tx with steroids
what are the MRI findings in ADEM?
bilateral asymmetric T2 hypersensitivity in subcortical and deep white matter.
Describe Anti-NMDAR encephalitis?
Neuronal antibody associated encephalitis with psych, cognitive, seizures, LOC associated with ovarian teratoma
Describe the CSF studies associated with Anti-NMDAR encephalitis?
Mild pleocytosis (median WBC 23), normal glucose and protein. antibodies to NR 1 subunit of the NMDAR in CSF and serum
what is associated with the development of NMDAR antibodies?
viral causes of encephalitis (HSV)
MRI findings of anti-NMDAR encephalitis?
abnormal FLAIR or T2 hyperintensity can be seen in the medial temporal lobe, cerebral/cerebellar cortex, basal ganglia, and brainstem 1,2. Typically there is no abnormal enhancement or hemorrhage 8.
Treatment of anti-NMDAR encephalitis?
First-line usually corticosteroids + IVIG. second is plasma exchange. Females should be evaluated for ovarian teratoma.
meningococal meningitis epidemiologic feature?
children and young adults. THose with terminal complement deficiencies (c5-C8, C9 and properdin deficincies)
streptococcal meningitis epidemiologic feature?
neonates with PROM, low birth weight. Adults with chronic disease
Epidemiologic features of listeria meningitis?
consumption of cole-slaw, raw vegetables, milk, cheese, ice-cream, processed meats, cantaloupes, diced celery.
Epidemiologic features of gram negative bacillary meningitis?
isolated from CSF of patients following head trauma/neurosurgical features. Associated with disseminated strongyloidiasis in hyperinfection syndrome
what are the gram negative bacilli that cause meningitis?
Serratia, pseduomonas, acinetobacter baumannii, Klebsiella, E.Coli, salmonella (SPAKES)
what are the serotypes associated with meningococcal meningitis?
serogroups A, B, C, Y, and W135
which meningococcal meningitis serotype associated with epidemics?
epidemics caused by serogroups A and C
Epidemiologic features of Haemophilus influenza Meningitis?
concurrent pharyngitis or otitis media in >50% of cases. Capsular type b strain in >90% of serious infections
Bacterial meningitis associated with CSF shunts and drains?
Staph epidermidis, Diptheroids (P. Acnes)
Risk factors for Streptococcus suis?
Vietnam, eating undercooked pig blood, pig intestine. Pig exposure.
what suggest disseminated disease with coccidioidal meningitis?
serum complement-fixing antibody titers >1:43 to 1:64
what CSF findings suggest coccidioidal meningitis?
prominent eosinophilia, elevated CSF proteins, + CSF complement-fixing antibodies with CSF coccidiosis antigen
what does naegleria fowleri cause?
acute amebic meningoencephalitis
amebic meningoencephalitis illness script?
children/young adults during warm weather with contact with fresh/brackish water after 5-7 days has sudden fever, photophobia, headache, stupor and coma.
CSF findings for acute amebic meningoencephalitis?
neutrophilic meningitis with RBC and low glucose. Wet mount may reveal trophozoites
Ilness script for angiostrongylus cantonensis meningitis?
asian countries + jamaica; rat lungworm, is a parasitic nematode (worm) that is transmitted between rats and mollusks, 6-30 days after ingestion, headache, nstiff neck, parathesias, and vomiting. CSF with eosinophils
Common parasitic causes of eosinophilic meningitis?
T-BAG; taenia solium, baylisacaris procynois, angiostrongylus cantonenesis, gnathostoma spinigerum
Empiric antibiotic for purulent meningitis <1 month
Ampicillin + cefotaxime
Empiric antibiotic for purulent meningitis 1-23 months
Vancomycin, 3rd generation ceph
Empiric antibiotic for purulent meningitis 2-50 years?
Vancomycin + 3rd gen Ceph
Empiric antibiotic for purulent meningitis older than 50
vancomycin, ampicillin, 3rd gen ceph
Empiric antibiotic for purulent meningitis for immunocompromised
vancomycin + ampicillin + (cefepime or merropenem)
Empiric antibiotic for purulent meningitis basilar skull fracture?
vancomycin + 3rd generation cephalosporin
Empiric antibiotic for purulent meningitis head trauma or after neurosurgery?
vancomycin + ceftazidime or cefepime or merropenem
Empiric antibiotic for purulent meningitis CSf shunt or drain
vancomycin + ceftazidime or cefepime or merropenem
antimicrobial therapy for bacterial meningitis - Strep pneumo
Vancomycin + 3rd generation cephalosporin
antimicrobial therapy for bacterial meningitis - Neisseria meningitidis
3rd generation cephalosporin
antimicrobial therapy for bacterial meningitis - Haemophilis influenza
3rd generation cephalosporin
antimicrobial therapy for bacterial meningitis - Listeria monocytogenes
ampicillin or Pen G
antimicrobial therapy for bacterial meningitis -Enterobacteriaceae
3rd generation cephalosporin
antimicrobial therapy for bacterial meningitis - pseudomonas
ceftazidime or cefepime
antimicrobial therapy for bacterial meningitis - acinetobacter baumanii
meropenem or colistin or polymyxin
antimicrobial therapy for bacterial meningitis -strep agalactiae
ampicillin or Pen G
antimicrobial therapy for bacterial meningitis - Listeria monocytogenes
ampicillin or Pen G
antimicrobial therapy for bacterial meningitis - MRSA
Vancomycin
antimicrobial therapy for bacterial meningitis - MSSA
nafcillin or oxacillin
antimicrobial therapy for bacterial meningitis -Mycobaterium TB
RIPE
antimicrobial therapy for bacterial meningitis -cryptococus neoformans
ampho B + 5-Flucytosine
antimicrobial therapy for bacterial meningitis - candida species
ampho b
antimicrobial therapy for bacterial meningitis - coccidioides immitis?
fluconazole
antimicrobial therapy for bacterial meningitis - naeglieria fowleri
ampho B + rifampin + doxycycline +/- miltefosine +hypothermia protocol
antimicrobial therapy for bacterial meningitis - naeglieria fowleri
ampho B + rifampin + doxycycline +/- miltefosine +hypothermia protocol
what is the role of dexamethasone for bacterial meningitis?
attenuates subarachnoid space inflammatory response response resulting from antimicrobial-induced lysis
when is dexamethasone indicated in adults meningitis?
pneumococcal meningitis
when is dexamethasone indicated for infants and children meningitis?
Indicated in haemophilis unfluenza type b meningitis and considered for pneumococal meningitis
dose of dexamethasone for meningitis?
0.15mg/Kg q6 hours x 4 days with or just before antimicrobial dose
In addition to antifungal treatment, what other adjunctive treatment would be necessary for cryptococcal meningitis?
reduction in ICP with serial LP/CSF shunts. Dexamethasone associated with more harmful events and disability.
what are the 3 predisposing conditions for brain abscess?
continguous focus of infection, hematagenous spread, or cyrptogenic.
empiric antibiotic therapy for bacterial brain abscess in otitis media or mastoiditis predisposing condition?
metronidazole + 3rd gen Ceph
empiric antibiotic therapy for bacterial brain abscess in for sinusitis predisposing condition?
vanc + metro+ 3rd gen ceph
empiric antibiotic therapy for bacterial brain abscess in dental sepsis predisposing condition
pen + metronidazole
empiric antibiotic therapy for bacterial brain abscess in penetrating trauma or post- NS predisposing condition?
vanc + 3rd gen ceph
empiric antibiotic therapy for bacterial brain abscess in patient with lung abscess, empyema, bronchiectasis predisposing condition
pen + metronidazole + sulfonamide
empiric antibiotic therapy for bacterial brain abscess with bacterial endocarditis predisposing condition
Vancomycin
empiric antibiotic therapy for bacterial brain abscess in unknown predisposing condition
Vanc + metronidazole + 3rd/4th gen ceph
empiric antibiotic therapy for bacterial brain abscess in transplant patient predisposing condition?
add voriconazole, plus bactrim + vanc, metro, 3rd/4th gen ceph
empiric antibiotic therapy for bacterial brain abscess in HIV infected patient predisposing condition?
add pyrimethamine + sulfadiazine. COnsider RIPE for possible TB
Antimicrobial therapy of brain abscess with an organism of actinomyces sp?
pen G
Antimicrobial therapy of brain abscess with an organism of bacteroides fragilis?
metronidazole
Antimicrobial therapy of brain abscess with an organism of enterobacteriaceae?
3rd gen ceph
Antimicrobial therapy of brain abscess with an organism of fusobacterium?
metronidazole
Antimicrobial therapy of brain abscess with an organism of pseudomonas?
ceftrazidime or cefepime
Antimicrobial therapy of brain abscess with an organism of staph aureus?
naf or vanc
Antimicrobial therapy of brain abscess with an organism of streptococci?
pen G
Antimicrobial therapy of brain abscess with an organism of nocardia asteroides?
bactrim or sulfadiazine
Antimicrobial therapy of brain abscess with an organism of mycobacterium TB?
RIPE
Antimicrobial therapy of brain abscess with an organism of aspergillus?
voriconazole
Antimicrobial therapy of brain abscess with an organism of candida
amphotericin +/- 5 flucytosine
Antimicrobial therapy of brain abscess with an organism of mucorales?
amphotericin
Antimicrobial therapy of brain abscess with an organism of scedosporium spp
voriconazole
what is cavernous sinus thrombosis?
clot in the cavernous sinuses either aspetic or septic (most common) by commonly staph (60-70%)or strep (17%), dx with MR venogram?
most common clinical features of septic cavernous sinus thrombosis?
periorbital edema (73%), headache (52%), double vision, oculomotor palsies
Risk factors for cavernous sinus thrombosis?
paranasal sinusitis, facial or dental infection
General management of septic cavernous sinus thrombosis?
culture and drainage of infected sinuses, vanc + flagyl + 3rd/4th gen cephalosporin. ?anticoagulation/?steroids
Risk factors for cranial subdural empyema and cranial epidural abscess?
Streptococci (25-45%), staphylococci (10-15%), GNB 3-10%
Management of cranial subdural empyema?
best to worst mortality: craniotomy, craniectomy, burr hole
most common epidemiology of spinal epidural abscess?
hematenous dissemination (50%), unidentified source (20-40%), continugous focus (33%)
Organism associated with a spinal epidural abscess?
Staph and strep mostly
clinical stages of a spinal epidural abscess?
back pain and tenderness, radicular pain and paresthesias, transverse myelitis, then complete paralysis
Empiric management of spinal epidural abscess?
anti staphylococcal agent + gram negative bacilli
Normal CSF findings?
OP 6-20; CSF<5cm lymphocyte predominant, CSF protein<60 (40mg (>40%)
Bacterial CSF findings?
15-50cm, neutrophil predominant, WBC>1K, CSF glucose decreased <40, CSF protein elevated 80-500
Viral CSF findings?
6-30cm, WBC <1K, CSF protein <200, CSF glucose>45
TB CSF findings?
OP 15-50, CSF WBC 50-300, mononuclear, CSF protein 50-300, glucose <45
When would you give penicillin only for strep pneumo meningitis?
If penicillin MIC<0.06 or add ampicilin.
what is the treatment for strep pneumo meningitis?
Pen MIC<0.06, penicillin only. If Pen MIC>0.12, Ceftriaxone MIC<1.0, ceftriaxone. If Pen MIC>0.12 and Ceftriaxone MIC>1.0, vancomycin + ceftriaxone/cefotaxime. If ceftriaxone MIC>4.0, consider adding rifampin.
what is the treatment for Neisseria meningitides meningitis?
If PCN MIC<0.1, pen G or ampicillin. If 0.1-1.0, 3rd generation cephalosporin
what is the treatment for haemophils influenza meningitis?
Beta lactamase negative - ampicillin. Beta lactamase postiive - 3rd generation cephalosporin
Name the types of enterovirus?
Echovirus, enterovirus, coxsackie, poliovirus, rhinovirus
