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CNS Infections

CNS Infections. J. Ned Pruitt II Associate Professor of Neurology Medical College of Georgia. Case 1. A 35 yo man is brought to the ER after 5 days of fever and chills. His wife relates that he has been very confused today and she called 911 after a seizure.

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CNS Infections

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  1. CNS Infections J. Ned Pruitt II Associate Professor of Neurology Medical College of Georgia

  2. Case 1 • A 35 yo man is brought to the ER after 5 days of fever and chills. His wife relates that he has been very confused today and she called 911 after a seizure. • PMHx is unremarkable except for a splenectomy at age 14 after a traumatic injury. • Meds – prn tylenol in the last week. • NKDA • Vaccinations are up to date.

  3. Case 1 • Exam – Ill appearing man. Temp 39 C. Lethargic and can answer simple questions but can give no meaningful history. Neck is stiff to flexion and extension. A fine petechial rash is on his chest and upper arms.

  4. Case 1 – What next? • More examination or history? • Labs? • Radiology? • Medications?

  5. CNS Infections • Meningitis • Bacterial, viral, fungal, chemical, carcinomatous • Encephalitis • Bacterial, viral • Meningoencephalitis • Abscess • Parenchymal, subdural, epidural

  6. CNS Infections • Signs and symptoms • Fever • Headache • Altered mental status -lethargy to coma • Neck stiffness – meningismus – flex/ext • Increased intracranial pressure – papilledema, nausea/vomiting, abducens palsies, bulging fontanelle in infants

  7. Exam in suspected CNS Infection • Mental Status • Cranial nerve and fundiscopic exam • Meningeal Signs • General exam – rashes, lymphadenpathy • Labs – CBCD, BMP, PT/PTT, bHCG, blood cultures, UA C&S • Radiology – CT head - uncontrasted if no focal signs, contrast if mass suspected

  8. LP Increased intracranial pressure is expected – but LP contraindicated if a mass is present or if epidural spinal abscess is suspected Left lateral decubitus position L3-L4 interspace or L4-L5 interspace Think about your studies before the LP

  9. LP • Tube #1 – glucose and protein • Tube #2 – cell count and differential • Tube #3 – gram stain and rountine culture, cyrptococcal antigen, AFB stain and culture • Tube #4 – VDRL, or viral studies (PCR)

  10. CSF Characteristics

  11. Key CSF Features • CSF is not liquid gold – get enough to get your answer • CSF Glucose is 2/3 of serum glucose • Important in diabetic patients • Traumatic LPs – • CSF pro increases by 1 for every 1000 rbcs • Tube #1 and Tube#4 for rbcs when SAH is in the differential not as a routine • Very high CSF Protein levels will make CSF yellow • Send a full tube of CSF for cytology not just a few cc’s

  12. Case 1 • CT of head negative. • LP - OP (opening pressure) 250mm, glucose 17, protein 92, Rbcs 3, Wbcs 280 with 89% pmns, 11% lymphocytes • Gram stain - + for Gram neg organisms

  13. Bacterial Meningitis • Streptococcus pneumoniae • Hemophilus influenzae • Listeria moncytogenes • Group B streptococcus • Niesseria meningitidis

  14. Bacterial Menigitis • Age less than 3 months- • Group B strep • L. Monocytogenes • E. coli • Strep pneumoniae

  15. Bacterial Meningitis • 3 Months to 18 years – • N. meningitidis • S. pneumoniae • H. influenzae

  16. Bacterial Meningitis • Age 18 to 50 years • S. pneumoniae • N. meningitidis • H. influenzae

  17. Bacterial Meningitis • Over age 50 years • S. pnemoniae • L. monocytogenes • Gram (-) bacilli

  18. Treatment of Bacterial Meningitis • PCN G or 3rd generation cephalosporin and consult ID • Steroids – Dexamethasone IV q6 for 4 days

  19. Viral Meningitis Very common Often caused by enteroviruses Treatment is supportive

  20. Viral Encephalitis • Encephalitis (Meningoencephalitis) • Altered mental status and seizures • Herpes Simplex virus – medial temporal lobe • Acyclovir • Management of seizures • Very high morbidity and mortality • PCR diagnosis of CSF • West Nile, St Lousi E, EEE, CMV

  21. Chronic Meningitis • Immunocompromised patients • Cryptococcus neoformans • HIV • M. tuberculosis • M. avium • Carcinomatous meningitis • Lung, breast

  22. Case 1 • Meningitis caused by N. Meningitidis • Treatment with 3rd generation cephalosporin for 10 days • Dexamethasone • Prophlaxis with Rifampin for contacts

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