Neuro: infections Flashcards
typical s/s for meningitis
fever intense HA sensitivtiy to light musc rigidity---nuchal \_\_\_\_\_\_\_\_\_\_\_\_ severe: -ams -seizures -death
RF for bac meningitis
- sinusitis
- otitis
- surgery
- systemic infections
- head trauma
- CA
- ETOH
- immunodef states
how do bac usually gain access to CNS in bac meningitis?
-list the progression of infection steps
colonizing the mucous mems of NASOPHARYNX
- -local tissue invasion
- bacteremia
- infection in subarachnoid space
- can spread to meninges via sinuses or defects in skull*
CM bac meningitis
fever ams vom HA neck stiffness photosensitivty seizures confusion
classic triad of CM for bac men
fever over greater than 38C or 100.8 F
nuchal rigidity
HA
PE findings for bac men
neck stiffness on passive flexion–
Thigh flexion on neck flexion–BRUDZINSKI SIGN
resistnace to passive extension of knee w. hip flexion–KERNIG SIGN
what is Brudzinski sign
leg raise/flexion on neck extension/bending
lift head up (neck flexion)… the PT’s hips involuntarily flex
what is kernig sign
knee extension (hip flexion) causes pain in the neck (K=kernigs and K=knee)
*cant extend knee when the hip is flexed
DX of bac men
prompt LP and CSF examination
CSF findings for bac men
- opening pressure?
- appearance
- protein
- glucose
- WBC
- gram stsin
opening pressure: increase appereance: turbid protein: increased glucose: decrease WBC: over 80% are neutrophils... generally elevated Gram stain: positive
CSF findings for viral men
- opening pressure?
- appearance
- protein
- glucose
- WBC
- gram stsin
- opening pressure–normal or slightly incr
- appearance–clear
- protein–normal or slightly incr
- glucose–normal
- WBC–mostly lymphocytes
- gram stsin–normal
CSF findings for fungal men
- opening pressure?
- appearance
- protein
- glucose
- WBC
- gram stsin
- opening pressure–normal
- appearance–fibrin web
- protein–increased
- glucose–decreased
- WBC–mostly lymphocytes
- gram stsin–normal
MCC for bac meningitis in: Neonate: Children >3Mo-12yrs Children 10-19 Adults up to 50 Adults 50+
Neonate–GBS–S. agalactiae****
- E. coli
- H. influ
- listeria
Children >3Mo-12yrs—Strep pneumo
Children 10-19—>N. meningitidis
Adults up to 50—>Strep pneumo or N. Meningitis
Adults 50+–> Listeria, SP, or NM
Empirix TX for neonatal bac meingitis?
Ampicillin + Gentamicin
Empirix TX for Bac men in children >3Mo-10yrs
Vancomycin and Ceftriaxone
Empiric tx for Bac men in children 10-19
Vancomycin and Ceftriaxone
emp tx for bac men in adults up to 50
Vancomycin and Ceftriaxone
emp tx for bac men in adults 50+
Vancomycin and Ceftriaxone and Ampicillin (bc we want to cover listeria)
TX for bac men
- based off age group, empiric ABX
- Dexamethasone–red mortality and sequalae (NO in neonates)
* ***steroids bc meningitis causes inflammation and steroids are anti-inflammatory
Why is there extra precautions in regards to N. meningitis?
because it is VERY VERY CONTAGIOUS!
- MC in pts who are 10-20**
- *Droplet precaution is used
PTs who are 10-20 w. bac men most likely have which bac?
N. meingitis
V contagious
for close contacts with prolonged exposure to PT with bac men due to NM… what is the prophylaxis tx?
Ciproflaxacin 500mgx1
OR
Rifampin 600 PO q 12H for 2
vaccines avail for which strains of bac for bac men?
which age group is vaccined for which one?
- H. influenzae–>2-15 MO
- N. meningitidis–>11-12 YO..booster at 16YO
- S. pneumoniae—>adults 65+ AND 2-15MO
is the head CT scan done before or after LP for bac men?
PRIOR TO LP!!
-bc we want to r/o mass effect before doing LP
CM in babies with meingitis?
bulging fontanelles
what is it mean by ASEPTIC meningits?
microbe causing meningitis doesnt culture on bac media… so viral, fungal, etc
College student living in close proximity with other students.. we want to think?
bac meningitis
what must we make sure the PT does not have prior to doing a LP?
INCR ICP
**check for papilloedema
also, get a CT if unsure if there is brain swelling
which two diseases cause high protein in CSF?
bac meningitis (also fungal)
and
GBS
how to differntiate GBS and bac meningitis CSF results?
GBS—- will have NORMAL glucose
BM—decr glucose!!
(both have incr protein)
Aseptic meningits… assume dx when?
any meningitis with neg bac cultures
MCC of aseptic/viral men
Enterovirus
- coxsackievirus
- echovirus
CM for viral men?
*classic s/s but can be milder
PE for virla men
same as bac
+Brudzinski
+Kernig
+meningeal signs
how to differentiate b/w viral men and encephalitis?
VIRAL MEN: has NOOO focal deficits (hemiparesis, sensory, CN palsies) and NO AMS
ENCEPH: has focal deficits and AMS!!!!!
DX for viral men
*diagnosis of exlucsion AFTER r/o bacterial *
—-VIA LP!
CSF: will be normal, WBC mainly lymphocytes, and protein normal
TX for viral men
- supportive mainly—antipyretics, IV fluids, analgesics
* most cases are self limiting
Do you need droplet precaution in viral men
NO!
infection or inflammation of brain parancyhmia or brain itself
Encephalitis
etiology for encephalitis
-infectious agents
-metabolic
-mitochrondiral dysfunction
brain tumor
incr ICP
prolong exposure toxin
trauma
poor nutrition
lack of oxygen to brain
hallmark of encephalopathy ?
AMS
MCC viral encephalopathy?
HSV-1
Leukocyte aggregation in the perivascular space
or
Perivascular “cuffing”
+
lymphocytic infiltration and macrophage proliferation involving gray matter regions
viral encephalitis
CM of viral enceph
AMS Seizures HA neck stiffness photosensitivty fever chills N/V
PE findings for viral enceph
focal neuro deficits–hemiparesis, CN palsies, sensory deficits
meningeal signs:
-neck stiffness on passive flexion
-+Brudzinski (often not present)
+Kernig (often not present)
What is IMP to do with a PT who has focal neuro deficits prior to LP? and WHY
HEAD CT because we want to make sure there is NO tumor
then after -CT… move onto LP
CSF findings with viral enceph
other DX tools for dx
Lymphocytes (like aseptic men) pressure is normal-slightly increased -glucose normal -protein is normal-slighthy incr RBC can be present (good way to differentiate b/w meningitis too)
***MRI–temporal involvement is characteristics of HSV
TX for herpes enceph
IV Acyclovir
*empirically started if PT has no obvious causes for encephalitis
+
supportive measures
Prodrome to viral enceph?
flu-like s/s for few days:
- mild HA
- sore throat
- red appetite
- myalgias
- progress to AMS, drowsiness and coma
cerebral s/s from hepa enceph caused by ?
ammonia toxicity—since liver is damaged–body cannot properly rid of ammonia
CM for hepat enceph
- somnolence
- agitation
- nystagmus
- Asterixis
- seizures
how to test for Asterixis
Ask PT to put hands out infront of them….. and hands will show tremor
Asterixis define
flapping tremor of outstretched, dorsiflexed hands or feet
-result from impaired postural control
DX for hepatic enceph
blood tests: show incr amonia levels, prolonged PT & PTT–b/c liver is not creating the clotting factors you need so PT is at risk for bleeding
CSF: shows elevated glutamine** (AA)
TX for hepatic enceph
Coagulopathy tx–fresh frozen plasma or Vit K
Lactulose: decreased pH and incr ammonia absop
Rifaximin–redu ammonia forming bacteria in colon
*severe: liver transplant
What is the outcome related to in hepatic enceph?
related to LIVER function and not really neuro function
MC manifestation from West Nile encephalitis
what can also develop?
RARE!!!! because mot ppl who get bitten by infected mostiquo will show no s.s
Meningoencephalitis
Acute paralytic poliiomyelitis can also dev
-acute focal or generalized ASYMMETRIC weakness or by a rapidly ascending quadriplegia
TX for west nile virus encephalitis
Supportive
Acute, focal or generalized asymmetric weakness or rapid ascending quadriplegia present?
Think acute paralytic poliomyelitis
Paralytic shellfish poisoning–what is the toxin
Saxitoxin–blocks NA channels–blocks APs—in motor and sensory nerve and muscle
CM of paralytic shellfish poisoning
rapidly progressive acute peripheral neruopathy
sensory s/s
ASCENDING paralysis
**can lead to resp paralysis—-death
how long does it take from ingesting of saxitoxin to s/s
30 mins
Rapidly progressing acute periphereal neuropathy with sensory s/s
paralysis is in ascending fashion
Paralytic shellfish poisoning
TX for shellfish poisoning?
No antitoxin
-but with proper supportive care…PT can recover
Arsenic poisoning—classic CM
rapidly evolving sensorimotor polyneuropathy
SYMMETRIC
often with GI distrubances + crampy ABD pain
RASH ON PALMS ON HAND **
sensory s/s are painful
*motor impairment is more in toes and legs vs arms
DX for arsenic pois
measure arsenic content of HAIR —pubic hair works best bc less contaminated with external substances
urine to—-only ACUTE phase tho
TX for arsenic pois
No tx
*neuro recovery dep on sevreity of poisoning
organophosphate pois——can be from what items
pesticides
insecticides
active ingredient in nerve gas
cholinergic crisis… think of??
organophosphate pois
What is blocked during organophos pois
ACHE inhibitoin—- so ACHE cannot be b/d into ACH
what is usually first s/s of organophos pois? then followed by? next???
crampy muscle pain —followed by distal numbness and paresthesias—-then followed by leg weakness–decr in tendon reflexes–
TX of organophosphate pois
decon skin with BLEACH or SOAP/H2O
Admin ATROPINE 2-6mg every 5mins
Pralidoximine 1G every hour up to 3 hours
*IV OR IM FOR BOTH
TX for neruopathies: none…might go away over time. central deficits can be permanent
Lead poisoning–common or not
-affects CNS or PNS
common
Affects both CNS and PNS
in kids, what is the major neurologic feature of lead poisoning?
Acute encephalopathy
what nerve is typically affected with lead pois
*causes what kind/ pattern/ of disturbances?
RADIAL
*causes asymmetric progressive motor disturbances
CM lead pois
anemia constipation colicky abdominal pain (colicky=pains comes/goes) gum discoloration neuropathy
tx for lead poisoning?
none
Botulism toxin can cause? and how?
neuromuscular paralysis by preventing release of ACH at NMJ
typical CM for botulism toxicity
diplopia facial weakness dysphagia nasal speech diff breathing when diapragm aff
weakness
flaccid paralysis
resp arrest
MC cause of botulism tox
home canning
other causes of botuism tox
- vacuum and smoked oacked foods
- honey—-infants
- iv drug users
- wounds
when does weakness s/s begin after exposure to botulism toxin?
12-72 hours after ingestion of toxin
6-8 hrs in infants
weakness in what body part s/s for botulism occurs when in disease progression?
LAST in the limbs
classic pupilary CM for botulism tox
fix
dilated
unreactive
*blurry vision
prodromal s/s for botulism tox
GI symptoms
N/V
ABD pain
diarrhea
what s/s occur after the GI prodromal s/s for botulism tox?
diplopia, dry mouth, dilated and fixed pupils, descending and decreased muscle strength (flaccid paralysis) and decr DTR
infant presnts: lethargic, feeding difficulty, hypotonia and weak cry
floppy baby syndrome due to botulism toxicity
if you get C botulism through wound: what are s/s
weakness
fever
leukocytosis
Dx for botulism
clinical
how to CONFIRM dx of botulism?
stool wound or serum assay
Managemtn for Botullism:
- foodborne
- wound
- if >1yr old–>antitoxin is first line
if <1 yr old—>human derived botulism immune globulin - Antitoxin and ABX… PCN first lone
