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Infections of the central nervous system

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Infections of the central nervous system

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  1. Infections of the central nervous system Anna Piekarska MD, PhD

  2. Contents 1. Bacterial meningitis 2. Non purulent bacterial meningitis 3. Viral meningitis 4. Viral encephalitis 5. Differential diagnosis between bacterial and viral CNS infections

  3. Clinical features of bacterial meningitis • Headache over 12-36 h • Fever over 38°C • Meningism • Nusea and vomiting • Alteration of consciousness • Hematology and biochemistry of the blood is abnormal

  4. Diagnosis of bacterial meningitis • Lumbar punction • CSF examination • CSF culture • CT or MR are not necessary

  5. Indications to the lumbar punction Headache + Fever + Meningism

  6. Lumbarpunction

  7. Contindications to the lumbar punction • Suspected severe intracranial hypertension (brain abscess or tumor) particularly located in the posterior fossa. • There is a suspicion that their neurologic presentation may be secondary to an intracranial mass lesion with accompanying mass effect. • These include patients with the following characteristics: • age older than 60 years, • immunocompromised state, • new-onset seizure, • altered consciousness, • papilledema, and/or focal neurologic deficit.

  8. Contrindications to the lumbar punction • Clinical practice: • Bradycardia • High blood pressure • Bradypnea or apnea • Dilated pupils • Ophtalomolgical examination is not necessary

  9. (relative) Contrindications to the lumbar punction • Haemophilia • Local skin infection in LP space • Skin abscess • Bedsores

  10. Typical Cerebrospinal Fluid Findings

  11. Diagnosis of bact. meningitis • Typical CSF changes • Cells: > 200 (1000)/1ul, > 50% granulocytes • Protein: >0,5 g/l • Glucose: < 2/3 serum level (even 0) • CT and MRI findings are not necessary in the first days

  12. Management of bact. meningitis • Specific antibacterial treatment • Steroidal antinflammatory drug: dexamethason • Anti- cerebral oedema drugs: • 20% Mannitol • Furosemid • Analgetics and antiemetics

  13. Roules of antibacterial treatment of BM • A: Antibacterial spectrum • B: Barrier - Penetration to the CNS • C: Concentrations - High doses • D: Drugscombination • E: Elongation of thetraetment

  14. Bacterial meningitis • List of pathogens • Gram – positive: • Streptococcusspp. • Staphylococcusspp. • Gram – negative: • Neisseriameningitidis • Haemophilusinfluenze • E.coli • Pseudomonasaeruginosa • Proteusspp. • Klebsiellapneumoniae

  15. Epidemiology of bact. meningitis • Newborns • Gram-negative • Children 1m- 2 y • Haemophilus influenzae type b • Strept. / Neisseria • Adults with immuodepresion

  16. Antibiotics in BM • Penicillin 24 MU/d + Ceftriaxon 2,0- 4,0g/g • Ceftriaxon 2,0-4,0g/d + Amikacin 1,5g/d • P/C or C/A + Metronidazol 1,5g/d • Chloramfenicol 3,0g/d • Meropenem 1,5- 3,0g/d • Vancomycin 3,0g/d • Trimetoprim+ sulfametoxazol 960 mg 2x/d as supporting treatment

  17. Impact of vaccination on BM etiology in USA 1986 1995

  18. Complications of BM • Early • Death • Sepsis and septic shock • Brain abscess • Hydrocephalus • Late • Permanent neurological sequeles: • deafness, • focal neuroligical signs • Psychotic symptoms: • Loss of memory • Afasia • Altered personality • Behavior disorders

  19. Comlications of BM

  20. Brain abscessas a complication of BM

  21. Hydrocephalusas a complication of BM

  22. Brain haemorrhageas a complication of BM

  23. Bacterial non-purulent neuroinfections • Tuberculosis • Listeriosis • Borreliosis • Leptospirosis • Syphylis • Brucellosis

  24. Tuberculous meningitis, clinical features • Reactivation in immunodepresiv patients • Prodromal history varying from few weeks to 3 months • Clinical symtoms: • Fever • Headche • Cranial nerve palsies (esp. ocular nerve) • Confulsions • Meningeal signes

  25. CSF parameters in meningitis

  26. Tuberculous meningitis, treatment • Antituberculous agents for 12 months: • 3-4 drugs for 2 months • RMP and INH for 8-10 months • Corticosteroids • Prognosis: • Survival rates: 10-84% • Permanent neurological sequeles is about 30% (esp. hydrocephalus)

  27. Listerial meningitis • Epidemiology: • Neonates – mater to child infection • Older children • Immunosuppressed adults: • Corticosteroid or anticancer therapy • Organ transpalnt recipients • No AIDS patients • Transmission: • Refrigerated food: milk, soft cheeses, vegetables

  28. Listeriosis, clinical features • Acute meningitis • Brainstem encephalitis with: • focal neurological findings, • miningism sings may exist • Diagnosis: • Blood or CSF culture • Tratment: • Amoxycillin (ampicillin) 3g/day plus gentamicin 2-5 mg/kg/day i.v. • Chloramfenicol 2-3 g/day i.v.

  29. Lyme borreliosis • Causative spirochete: Borrelia burgdorferi • Vector: ticks • Meningoradiculitis can occur 2-6 month after initial infection • Often presenting as aseptic meningitis or encephalomeningitis • Clinical features: • Headache • Fever • Meningism sings • Dysfunction of the affected spinal nerve roots • Erythema migrans in history

  30. Lyme borreliosis • Diagnosis: augmentation of titreBorreliaantibody in CSF and serum • Treatment: • Ceftriaxon 2,0g/dayi.v. for 3 weeks • Cerebraloedematreatment: • 20% Mannitol

  31. Neurosyphilis • The meningoencephlitis form is rarely seen in secondary syphilis • Symptoms: • Headache • Nusea and vomiting • Focal signs (about 50% incidence) • Diagnosis • CSF and serum reveals a positive VDRL • Treatment • Penicillin G 12-24 milion units/day i.v. for 10 day • Follow-up serology • Every 3 months first year • Then every 6 months for 2 years

  32. Leptospirosis • LPS is seen in summer months, usually in association with water and animal (mouss, rat) exposure • LPS involve the CNS as aseptic meningitis in 9-68% of LPS cases • Symptoms • Headache • Muscular pain and tenderness • Nusea and vomiting • Renal faillure

  33. Leptospirosis • Diagnosis • Isolation of the organism from the: • Urine • Blood • CSF • Treatment • Penicillin 10 milion units/day • Or tetracycline 2-4 g/day

  34. Viral meningitis • List of pathogens • Echovirus • Coxackievirus • Poliovirus • Herpes simplex virus t.1 or 2 • Arbovirurses • Complications of other infections: • Mumps virus • Varicella zoster virus • Rubella virus • Epstein- Barr virus • Influenza virus type A or B

  35. Epidemiology of viral meningitis • Children and young adults • Intrafamiliar spread is common • Late summer • Echoviruses: serotypes 6,9,11,19,30 • Coxackie A9, B4, B5

  36. Clinical features of viral meningitis • Headache over 12-36 h • Nusea and vomiting • No alteration of consciousness • Meningism • Hematology and biochemistry of the blood is normal

  37. Diagnosis of viral meningitis • Typical CSF changes • Cells: 40-250/1ul, all lymphocytes • Protein: 0,45- 0,9 g/l • Glucose: normal • CT and MRI findings are not necessary

  38. Lymphocytosis can occur in CSF in: • Viral infections of CNS • Tuberculous meningitis • Listeriosis • Leptospirosis • Lyme borreliosis • Lymphocytic leukaemia • Partly treated bacterial meningitis • Intracranial abscess

  39. Poliomyelitis • Enteroviral infection that causes damage ad death of anterior horn cells • Fecal-oral transmission • Epidemiology: • Young children and teenagers • In developed countries is sporadic becouse of vaccination • Patient excrete the virus up to 6 weeks after disease onset

  40. Pathogenesis of polio • Poliovirus enters the body through the alimentary tract or the ortopharynx • Viraemic phase • Virus enters the meninges and spinal cord • Infection kills anterior horn cells leading to lower motor neurone degeneration

  41. Clinical features of polio • Incubation 1-3 weeks • Over 90% of cases are inapparent or mild • Non-paralytic poliomyelitis • Paralytic poliomyelitis (more extensive in older age group) • Fever, diarrhea • Meningism • Myalgia and lower motor neuron lesion after 2-5 days with fasciculation, • Reflex and movement are lost, • Paralysis is asymetric • Sensation is normal

  42. Diagnosis of polio • CSF reveals> 500 cells/ 1ul (lymphocytes) • PCR- based detection of polio RNA in CSF • Cell culture of stool, throat or CSF • Demonstration of AB production in CSF • Demonstration of rising titers of serum AB

  43. Polio Cells  in 1 week Protein is N in 1 week Protein  in 2 week Asymetric group of muscles Motoric lost Non-spastic paralysis Sensetion is normal Guillain-Barr syndrome Cells N Protein is  in 1 and 2 week Symetric muscles Sensation lost Differential diagnosis of polio

  44. Management of enteroviral meningitis • No specificantiviraltreatment • Analgesics and antiemetics • Lumbarpunctureimprove the headache • Anti- cerebraloedemadrugs: • 20% Mannitol • Furosemid