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INFECTIOUS DISEASES PART II

INFECTIOUS DISEASES PART II. BERNADETTE R. ESPIRITU, M.D. FPSP AP-CP. INFECTIOUS DISEASES OF THE CNS. Important ANATOMIC FEATURE of the CNS that affects the pathophysiology of INFECTIONS is that: The BRAIN is surrounded by MENINGES & bathed in CSF.

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INFECTIOUS DISEASES PART II

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  1. INFECTIOUS DISEASESPART II BERNADETTE R. ESPIRITU, M.D. FPSP AP-CP

  2. INFECTIOUS DISEASES OF THE CNS • Important ANATOMIC FEATURE of the CNS that affects the pathophysiology of INFECTIONS is that: The BRAIN is surrounded by MENINGES & bathed in CSF

  3. CNS INFECTIOUS DISEASES • CSF PROVIDES BOTH: • Culture Medium for the infecting organism • Rapid means of disseminating infection throughout the system once the outer defenses have been breached

  4. MENINGITIS • Inflammatory state of the: leptomeninges subarachnoid space • It is usually the result of infection

  5. MENINGITIS CHEMICAL MENINGITIS • caused by release or insertion of irritative substance into the CSF • Pleocytosis (Increase # of PMNs) • Increased CHON • Normal sugar content • Organism can neither be seen nor cultured

  6. MENINGITIS • CARCINOMATOUS MENINGITIS - Infiltration of the subarachnoid space by tumor cells and eventually spread to the entire neuraxis - no inflammatory response

  7. INFECTIOUS MENINGITIS CLASSIFICATION • ACUTE PYOGENIC - Usually Bacterial • ACUTE LYMPHOCYTIC - Usually Viral • CHRONIC MENINGITIS - Bacterial or Fungal

  8. ACUTE PYOGENIC MENINGITIS CAUSATIVE ORGANISM • E. coli:Neonate w/ neural tube defect • H. influenza: Infants & Children • Neisseria meningitides • adolescents & young adults • most common cause: epidemic meningitis • Oral commensal & transmitted through the air • Pneumococcus: • very young or the very old and following trauma

  9. ACUTE PYOGENIC MENINGITIS GROSS: • cloudy or frankly purulent CSF • Location of the exudate varies: • H. influenza – basal • Pneumococcal – over the cerebral convexities near the sagittal sinus • Fulminant meningitis – extend into the ventricles

  10. ACUTE PYOGENIC MENINGITIS MICRO: • PMNs fill the entire subarachnoid space & around the leptomeningeal blood vessels (less severe cases) • Fulminant – inflammatory cells infiltrate the walls of the leptomeningeal veins that can lead to venous occlusion – hemorrhagic infarction of the underlying brain • Arteritis – uncommon unless meningitis is prolonged

  11. ACUTE PYOGENIC MENINGITIS • CLINICAL MANIFESTATIONS: • General signs of infection • Signs of meningeal irritation • headache • photophobia • irritability • clouding of consciousness • neck stiffness

  12. ACUTE PYOGENIC MENINGITIS • LABORATORY DIAGNOSIS: • SPINAL TAP • Cloudy or purulent CSF • Increased pressure • 90,000 / mm3 PMNs • Increased CHON level • Markedly reduced sugar content

  13. ACUTE PYOGENIC MENINGITIS • LAB DIAGNOSIS • CSF SMEAR – Increase number of WBC (smear) • CSF CULTURE – ID causative org

  14. ACUTE PYOGENIC MENINGITIS • FATAL • RECOVERY: Fibroblastic proliferation in the meninges that produced adhesive arachnoiditis • If obliteration sufficiently impede CSF flow– HYDROCEPHALUS– Pneumococcal meningitis

  15. ACUTE PYOGENIC MENINGITIS • HYDOCEPHALUS due to Pneumococcal Meningitis: Large quantities of the capsular polysaccharide of the organism produce glutinous exudate that encourages arachnoid fibrosis  obliteration  impede CSF circulation

  16. ACUTE PYOGENIC MENINGITIS • MENINGITIS IN IMMUNOSUPPRESSED • Klebsiella or anaerobic organism

  17. ACUTE PYOGENIC MENINGITIS

  18. ACUTE PYOGENIC MENINGITIS

  19. ACUTE PYOGENIC MENINGITIS

  20. BACTERIAL MENINGITIS

  21. BACTERIAL MENINGITIS

  22. BACTERIAL MENINGITIS

  23. BACTERIAL MENINGITIS

  24. ACUTE LYMPHOCYTIC MENINGITIS • CAUSATIVE AGENTS (viruses) • Mumps • ECHO viruses • Coxsackie virus • Epstein-Barr virus • Herpes simplex II

  25. ACUTE LYMPHOCYTIC MENINGITIS • CLINICAL MANIFESTATION - Same as bacterial meningitis with meningeal irritation but is LESS FUMINANT & the CSF findings are markedly different • Self-limiting • No life-threatening complications

  26. ACUTE LYMPHOCYTIC MENINGITIS • LABORATORY DIAGNOSIS • Lymphocytic Pleocytosis • CHON elevation is moderate • Sugar content is nearly always normal

  27. ACUTE LYMPHOCYTIC MENINGITIS (VIRAL MENINGITIS)

  28. ACUTE LYMPHOCYTIC MENINGITIS

  29. ACUTE LYMPHOCYTIC MENINGITIS

  30. VIRAL MENINGITIS

  31. VIRAL MENINGITIS Typical owl-eye intranuclear inclusions are seen in cytomegalovirus encephalitis together with distention of the Cytoplasm by viral particles

  32. CHRONIC MENINGITIS • CAUSATIVE AGENTS • Mycobacterium TB • Treponema pallidum (Syphilis) • Brucella spp • Fungi • Coccidioisis • Candida • Cryptococcus neoformans

  33. TB MENINGITIS GROSS: • Subarachnoid space contains gelatinous or fibrinous exudate that is most obvious around the base of the brain extending to the lateral sulci • Focal densities visible along the course of the cerebral vessels

  34. TB MENINGITIS MICRO: • Exudate consists of lymphocytes, plasma cells, macrophages & fibroblasts

  35. TB MENINGITIS MICRO: • Focal densities are tubercles with giant cells & caseation necrosis • Arteries in the subarachnoid space may show obliterative endarteritis with inflammatory cells in their walls and marked intimal thickening • Fibrous adhesive arachnoiditis around the base of the brain

  36. TB MENINGITIS • CLINICAL MANIFESTATION • headache • malaise • mental confusion • vomiting

  37. TB MENINGITIS • COMPLICATIONS • Hydrocephalus • Obliterative endarteritis causing arterial occlusion & infarction of the underlying brain • Cranial nerves may be affected

  38. TB MENINGITIS • LABORATORY DIAGNOSIS • Moderate CSF either entire mononuclear pleocytosis or mixture of PMNs and mononuclears = 1000 cells per mm3 • CHON level is elevated • sugar is moderately reduced / normal

  39. TB MENINGITIS

  40. TB MENINGITIS

  41. TB MENINGITIS

  42. TB MENINGITIS

  43. CRYPTOCOCCAL MENINGITIS • Frequent in debilitated or immunocompromised hosts • Trivial inflammatory response despite the large number of organism GROSS: • Found in the subarachnoid space • Distends the Virchow-Robin spaces producing characteristic “soap bubbles”

  44. CRYPTOCOCCAL MENINGITIS • CLINICAL MANIFESTATION • Course is fulminant & fatal in 2 weeks • indolent over months or years

  45. CRYPTOCOCCAL MENINGITIS • LABORATORY DIAGNOSISMucoid encapsulated yeasts can be visualized in the CSF by: india ink • INDOLENT CASES: • Few cells • Very high CHON - > 500 mg/dl • Pathognomonic cryptococcal antigen

  46. CRYPTOCOCCAL MENINGITIS

  47. CRYPTOCOCCAL MENINGITIS

  48. VIRAL HEART DISEASE • CAUSATIVE AGENTS • Coxsackie A & B viruses • Echoviruses • Poliovirus • Influenza A & B viruses • HIV

  49. MYOCARDITIS • Inflammatory involvement of the heart muscle • leukocytic infiltrate • necrosis or degeneration of myocytes • Occurs at any age • May induce cardiac failure & sudden death by arrythmia

  50. MYOCARDITIS • DIAGNOSIS • Fever • Sudden appearance of ECG changes indicative of diffuse myocardial lesion • Autopsies – 1-4% • Infants & pregnants are vulnerable • Follows some days to few weeks after the primary viral infection somewhere

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