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CNS Infections

CNS Infections. Sarah McPherson Aug. 15, 2002. 14 yo male presents with headache ane fever X 24 hrs. Previously well. Seen in doctor’s office and sent to ED after a witnessed focal seizure involving the right arm. Other history unremarkable O/E: Hr 100, BP 110/70, Temp 39.5

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CNS Infections

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  1. CNS Infections Sarah McPherson Aug. 15, 2002

  2. 14 yo male presents with headache ane fever X 24 hrs. Previously well. Seen in doctor’s office and sent to ED after a witnessed focal seizure involving the right arm. Other history unremarkable O/E: Hr 100, BP 110/70, Temp 39.5 normal mental status, no nuchal rigidity normal neuro exam What would you do????

  3. Clinical presentation of meningitis • Classic triad of bacteral meningitis (< 2/3 of presentations): • fever, nuchal rigidity, altered mental status • also present as headaches, seizures (focal or generalized, weight loss, night sweats, septic shock • physical exam: • Kernig’s (unable to extend knee when pateint suline with hip flexed) • Brudinski’s (flex neck and the hips also flex OR flex hip on one side and see similar movement of the other hip)

  4. Infectious Bacterial: S. pneumo N meningitidis L monocytogenes H flu S. aureus E coli GBS Viral: HSV enterovirus HIV varicella Infectious fungal: cryptococcus coccidioides candida blastomyces Parasites: toxopasma Rickettsia: Rocky Mountain spotted fever Causes of meningitis

  5. Drugs NSAID trimethoprim isoniazid Systemic disease Serum sickness vasculitis SLE sarcoidosis Causes of meningitis

  6. Diagnosis • The LP: Cell count: < 5 WBC, < 1 PMN gram stain: no organism xanthochromia: none CSF-serum glucose: 0.6:1 protein: 15-45 mg/dl

  7. Diagnosis • When should you CT before LP??? • Profoundly altered mental status • papilledema • focal neuro deficit • minimal or absent fever • recent head trauma • recent onset seizure

  8. Diagnosis • What if you have a VP shunt??? • Infection rates 2.6-10% mostly in first few months after insertion • mostly infected by skin flora (S aureus, coag - staph, propionobacterium) • needle aspirate the reservoir (~25% better than LP at identifying pathogen)

  9. Back to the Case... • CT head normal • LP: • 40 WBC • 3 PMN • 3 RBC • CSF glucose low (normal serum glucose) • protein elevated • negative gram stain What now???

  10. Definitive therapy • Bacterial Meningitis: • 3rd generation cephalosporin • add Vanco if in area where drug resistant S. pneumo is prevelant • add ampicillin to cover Listeria (< 3 months, > 50 years)

  11. Definitive therapy • What if your gram stain shows gram-negative coccobacilli??? • The controversy of pre-treatment with steroids...

  12. Steroids... • Shown to decrease neurologic and audiologic sequelae in children > 2 months of age with H. flu infections • benefit to adult patients or infections other than H. flu is less clear • Recommendation: treat children with gram negative coccobacilli on gram stain with 0.15 mg/kg of Dexamethasone just before giving antibiotics and then q6h X 4 days

  13. Another Case 22 yo girl presents with purpuric rash, nuchal rigidity, temp 39.1, HR 110, BP 95/60, with altered mental status How would this presentation alter your approach? ABC’s first, blood cultures, Antibiotics then LP

  14. Aseptic meningitis • Typically present as fever and nuchal rigidity, may have headache, N&V • CSF may show increased WBC with increased lymphocytes; normal to slightly elevated protein; normal gram stain

  15. Aseptic meningitis • Management: • supportive • relief of headache, fever, and dehydration • medical • if WBC on gram stain most clinicans will start on empiric antibiotics pending C&S • if evidence of primary HSV infection, acyclovir (oral 200 5X/day for 10 days)

  16. 70 yo man presents with fever 38.5 X 6 hr, headache, altered LOC and aphasia, HR 85, BP 105/80 • CT shows edema of the right temporal lobe • LP 30 WBC, increased protein, normal gram stain

  17. Viral encephalitits • Rare • typically present with fever, headache, altered LOC, behavioral or speech disturbnce, focal neuro deficits, seizures • CSF: mononuclear cell pleocytosis; elevated protein; normal gram stain; PCR for HSV, CMV, HHV-6, enterovirus (99% sens and 94% spec for HSV) • CT, MRI, EEG may be helpful

  18. Herpes Encephalitis • Neonatal • CNS involvement in majority infants with herpetic disease in the newborn period • CSF PCR is the gold standard • treatment : Acyclovir 30mh/kg/d divided q8h • with antiviral decreased mortality from 50% to 15% (pts with CNS involvement) • 2/3 will have long term neurologic sequelae despite treatment

  19. Herpes Encephalitits • HSE • most common cause of focal encephalitis • 50% are > 50 yoa • without antiviral mortality > 80% • Treatment: Acyclovir 10 mg/kg q8h • Prognosis: • if GCS < 6 outcome is poor • if treatment is started in < 4 days from onset of symptoms survival increases from 72 to 92% • with acyclovir 30% normal or minimal neuro impairment, 9% moderate, 53% dead or severe impairment

  20. West Nile Virus • First isolated in 1937 in Uganda • first isolated in the Us in 1999 • now found in Ontario, Quebec, Manitoba and possibly SK • transmitted by mosquito • in an area hwere West Nile is circulating ~ 1% of mosquitos will carry it and there is an ~1% risk of infection after bite from a + mosquito • symptoms: fever, headache, myalgia, arthralgia, lymphadenopathy, maculopapular or roseloar rash on trunk or extremitites, nuchal rigidity, seizure, altered LOC, muscle weakness • increased fatality in elderly pop’n • treatment supportive • of hospitalized patients mortality ranges from 3-15%

  21. 45 yo man with HIV presents with headache and fever neuro exam normal, temp 38.2, normal vitals What next????

  22. Normal CT head but when infused shows ring enhancing lesion • DX? Toxoplasmosis • Rx? Admission, pyrimethamine 200 mg po then 50 -100 mg qd plus clindamycin 900 iv q6h

  23. CNS infection in the HIV patient • CNS infection occurs in 75-90% of patients with AIDS • infections are the predominant cause of new neuro symptoms/signs toxoplasma gondii: • most common cause of focal encephalitits • DX: contrast enhanced CT or MRI showing ringed lesion; LP for Ab to toxo Ag • Rx: pyrimethamine + clinda or sulfadiazine

  24. CNS infection in the HIV patient Cryptococcus neoformans • causes focal lesion or diffuse encephalitits • Dx: India ink stain, fungal culture,cryptococcal Ag in CSF • Rx: Ampho B iv HSV M. tuberuculosis Nocardia all the bacteria that nonimmunosuppressed patients have

  25. The HIV patient with any new neuro symptoms/signs +/- fever • Enhanced CT head • LP for all the normal stuff + India ink stain, fungal culture, viral PCR’s, Toxo Ab, Crypto Ag, Acid fast stain

  26. 25 yo women presents with back pain X 2 days. She has no other concerns. O/E afebrile, hemodynamically stable, normal neuro exam, you notice track marks on her arms. She admits to ongoing IVDU. What would you do next? What are your concerns?

  27. Epidural Abscess • Risk factors: • IVDU • recent spinal or epidural anaesthesia • systemic infection • Clinical features: • back pain • focal neuro deficits • fever (83% of the time) • all IVDUers with back pain should be considered infectious until proven otherwise (osteo vs epidural abscess)

  28. Epidural Abscess • Dx: CT, if negative and clinical suspicion is high then need an MRI • Rx: • emergent surgical debridement • 3rd generation cephalosporin + Flagyl

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