Peripheral Neuropathies CNS and Spinal Infections

1. Peripheral NeuropathiesCNS and Spinal Infections Thomas Vu Resident Weekly Conference June 5th, 2019

2. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

3. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

4. Central vs Peripheral

7. Central vs Peripheral

8. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

9. Guillain-Barre Syndrome

10. Guillain-Barre Syndrome • Immune-mediated (antibody formation against) peripheral nerve myelin sheath or axonal destructive polyneuropathy • Worse in weeks 2-4 • Often preceded by infectious process Campylobacter, Zika, CMV, EBV, Mycoplasma • Ascending symmetric weakness/paralysis, areflexia/hyporeflexia • Can affect diaphragm, respiratory compromise • Autonomic dysfunction • Many variants

11. Quiz

12. Guillain-Barre Syndrome Diagnostics • Historical • Required: progressive weakness more than 1 limb, areflexia • Several other suggestive findings (timeframe, CN involvement, etc.) • LP • CSF Protein elevated (>45) • WBC <10, predommononuc • *Cytoalbuminologic dissociation (elevated protein, nl or low wbc) • Electromyogram, N. Conduction Treatment • Airway, breathing • Protection decreases aspiration, other complications • Vital Capacity (nl 60-70ml/kg), NIF • Single breath count 1-25 • Avoid succinylcholine for intubation (depolarizing agent), risk hyperkalemic response • IVIG – risk of VTE, aseptic meningitis (more widely used) • Plasmapheresis – risk hemodynamic instability

13. Guillain-Barre Syndrome Diagnostics • Historical • Required: progressive weakness more than 1 limb, areflexia • Several other suggestive findings (timeframe, CN involvement, etc.) • LP • CSF Protein elevated (>45) • WBC <10, predommononuc • *Cytoalbuminologic dissociation (elevated protein, nl or low wbc) • Electromyogram, N. Conduction Treatment • Airway, breathing • Protection decreases aspiration, other complications • Vital Capacity (nl 60-70ml/kg), NIF • Single breath count 1-25 • Avoid succinylcholine for intubation (depolarizing agent), risk hyperkalemic response • IVIG – risk of VTE, aseptic meningitis (more widely used) • Plasmapheresis – risk hemodynamic instability

14. Guillain-Barre Syndrome Diagnostics • Historical • Required: progressive weakness more than 1 limb, areflexia • Several other suggestive findings (timeframe, CN involvement, etc.) • LP • CSF Protein elevated (>45) • WBC <10, predommononuc • *Cytoalbuminologic dissociation (elevated protein, nl or low wbc) • Electromyogram, N. Conduction Treatment • Airway, breathing • Protection decreases aspiration, other complications • Vital Capacity (nl 60-70ml/kg), NIF • Single breath count 1-25 • Avoid succinylcholine for intubation (depolarizing agent), risk hyperkalemic response • IVIG – risk of VTE, aseptic meningitis (more widely used) • Plasmapheresis – risk hemodynamic instability

16. Quiz

17. Transverse Myelitis • Inflammatory disorder, complete transverse section of spinal cord • May present like a compressive lesion of spinal cord • s/p viral illness • SX: back pain, low grade fever, autonomic disturbance, paraplegia, transverse sensory level • Tx: High Dose Steroids Miller-Fisher Variant: ophthalmoplegia, sensory ataxia, areflexia Descending Paralysis Accounts for 5% of cases of GBS RECTAL TONE: PRESERVED DIMINISHED

18. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

19. Quiz

20. Bells Palsy/Unilateral Facial Palsy • Bells/Idiopathic • Several assoc viral invections • CN VII (Facial N), +/- ear pain, CN V/VIII/XI/X association • Facial droop, effaced wrinkles, inability close eyes; can recur • Exclude - Ear infection (OM, Mastoiditis) - CVA (can raise eyebrows/forehead sparing; some can present with forehead involvement if affects abducen so test EOM) • Tx: Prednisone 1mg/kg 7dEyelid/Patch to care against corneal abrasions/keratitis, ocular lubricants • Most recover w/in 3 weeks; 15% permanent paralysis; 7d f/u PCP or ENT • Ramsey Hunt • Unilateral, severe pain, vesicular eruption on face; can be associated with nausea, vertigo, hearing loss  Tx: Steroids + Antivirals (Famiciclovir 500mg PO TID or Valacyclovir 1g PO TID x7d) • Lyme • Consider facial palsy if history of erythema migrans, tick bite, arthritis • Can be bilateral, multifocal polyradiculopathy  Tx: Doxycycline 100mg bid 1month

21. Bells Palsy/Unilateral Facial Palsy • Bells/Idiopathic • Several assoc viral invections • CN VII (Facial N), +/- ear pain, CN V/VIII/XI/X association • Facial droop, effaced wrinkles, inability close eyes; can recur • Exclude - Ear infection (OM, Mastoiditis) - CVA (can raise eyebrows/forehead sparing; some can present with forehead involvement if affects abducen so test EOM) • Tx: Prednisone 1mg/kg 7dEyelid/Patch to care against corneal abrasions/keratitis, ocular lubricants • Most recover w/in 3 weeks; 15% permanent paralysis; 7d f/u PCP or ENT • Ramsey Hunt • Unilateral, severe pain, vesicular eruption on face; can be associated with nausea, vertigo, hearing loss  Tx: Steroids + Antivirals (Famiciclovir 500mg PO TID or Valacyclovir 1g PO TID x7d) • Lyme • Consider facial palsy if history of erythema migrans, tick bite, arthritis • Can be bilateral, multifocal polyradiculopathy  Tx: Doxycycline 100mg bid 1month

22. Bells Palsy/Unilateral Facial Palsy • Bells/Idiopathic • Several assoc viral invections • CN VII (Facial N), +/- ear pain, CN V/VIII/XI/X association • Facial droop, effaced wrinkles, inability close eyes; can recur • Exclude - Ear infection (OM, Mastoiditis) - CVA (can raise eyebrows/forehead sparing; some can present with forehead involvement if affects abducen so test EOM) • Tx: Prednisone 1mg/kg 7dEyelid/Patch to care against corneal abrasions/keratitis, ocular lubricants • Most recover w/in 3 weeks; 15% permanent paralysis; 7d f/u PCP or ENT • Ramsey Hunt • Unilateral, severe pain, vesicular eruption on face; can be associated with nausea, vertigo, hearing loss  Tx: Steroids + Antivirals (Famiciclovir 500mg PO TID or Valacyclovir 1g PO TID x7d) • Lyme • Consider facial palsy if history of erythema migrans, tick bite, arthritis • Can be bilateral, multifocal polyradiculopathy  Tx: Doxycycline 100mg bid 1month

23. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

24. Quiz

26. Mononeuropathies

27. Mononeuropathies – Carpal Tunnel SyndromeTinel’s sign Phalens maneuver

28. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

29. Neuromuscular Junction Disorders

30. Quiz

31. Neuromuscular Junction Disorders

32. Acute Peripheral Neuropathies • Central vs Peripheral • Guillain-Barre Syndrome • Bells Palsy/Unilateral Facial Paralysis • Mononeuropathies • Neuromuscular Junction Disorders • Subacute/Chronic Peripheral Nerve

33. Subacute/Chronic Peripheral Nerve • HIV • Can present like polymyositis • Susceptible to Guillan Barre Syndrome • CMV Radiculitis • Lumbosacral nerve roots • Diabetic Peripheral Neuropathy • All types can be improved with tight glycemic control • Tx: TCAs, Anticonvulsants, Topical Capsaicin • Duloxetine, Venlafaxine, Amitriptyline, Pregabalin, Gabapentin, Valproic Acid, Tramadol, Oxycodone

34. CNS & Spinal Infections

35. CNS & Spinal Infections • Bacterial Meningitis • Viral Meningitis • Fungal CNS Infections • Viral Encephalitis • Brain Abscess • Epidural Abscess

36. CNS & Spinal Infections • Bacterial Meningitis • Viral Meningitis • Fungal CNS Infections • Viral Encephalitis • Brain Abscess • Epidural Abscess

37. Bacterial Meningitis

38. Quiz

39. Bacterial Meningitis Causative agents • Strep pneumo 58% • GBS 18% • Neiseria meningitidis 14% • Haemophilus influenza 6.7% • Listeria 3.4% • E coli, Mycobacterium Neonatal <3mos • GBS • E Coli • Listeria Infants >3mos • Strep • Neiseria • Haemophilus

40. Bacterial Meningitis

41. Bacterial Meningitis

42. Bacterial Meningitis • BBB permeability increases, vasogenic edema • Disruption cell membrane, cytotoxic dema • Vasculitis, ischemia, thrombosis

43. Bacterial Meningitis • #1 Headache 79-94% • Fever 77-85% • Stiff neck ~88% • Altered MS 78%Most = 2 of 4 above; absence does not exclude • Seizures, focal neuro • Increased ICP = papilledema, CN palsy (CN 3, 4, 6, 7) • Meningeal irritation - Brudzinski- Kernig • Skin – petechiae, splinter hemorrhages, pustules (most commonly N. meningitides)

44. Bacterial Meningitis

45. Bacterial Meningitis

46. Bacterial Meningitis Diagnostics LP- Contraindicated: Platelets <20k INR>1.5 Cellulitis overlying site

48. Bacterial Meningitis Treatment • NEVER DELAY ABX FOR NEUROIMAGING OR TO PERFORM LP Adult Antibiotics/Viral- Ceftriaxone 2g • + Vancomycin 15mg/kg • + Ampicillin 2g (if >50yo, Listeria) • + Acyclovir (if HSV suspected) LP within 2 hours of abx Steroids - Dexamethasone 10mg (adults) • Presumptive pneumococcal • Adults -> Reduces CSF inflammation, risk of M/M, • Children -> hearing loss, other neuro seqelae

49. Quiz

50. Bacterial Meningitis Bacterial Meningitis