1 / 98

CNS Infections

CNS Infections. Mazin Barry, MD, FRCPC, FACP, DTM&H Assistant Professor and Consultant Division of Infectious Diseases King Saud University. Meningitis. Learning Objectives. Be familiar with clinical presentation of disease Appreciate different causative organisms Approach to management

lrymer
Download Presentation

CNS Infections

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CNS Infections Mazin Barry, MD, FRCPC, FACP, DTM&H Assistant Professor and Consultant Division of Infectious Diseases King Saud University

  2. Meningitis

  3. Learning Objectives • Be familiar with clinical presentation of disease • Appreciate different causative organisms • Approach to management • Utilization of antimicrobial therapy • How to prevent disease • Role of Steroids • Case discussion

  4. Variable causes and outcome • Acute Benign Forms of Viral Meningoencephalitis • Rapidly Fatal Bacterial Meningitis with Local Progressive mental deterioration and death • Different etiological organisms • Time of starting appropriate therapy

  5. Definitions • Meningitis – inflammation of the meninges • Encephalitis – infection of the brain parenchyma • Meningoencephalitis – inflammation of brain + meninges • Aseptic meningitis – inflammation of meninges with sterile CSF • Meninges?

  6. Meninges • Meningitis: inflammation of the pia mater and the arachnoid mater, with suppuration of the cerebrospinal fluid

  7. CAUSES OF MENINGITIS

  8. Encephalitis/Encephalopathy • Herpes simplex: PCR, Acyclovir • Arboviruses: e.g dengue • Rabies • Rare: Listeria, cat scratch disease, amebic

  9. Aseptic Meningitis • CSF: pleocytosis 100s, Norm G &P, Neg Culture • Enteroviruses: most common cause 80% • HSV-2, and other viruses • HIV • Partial Rx Bacteria • Drugs: MTZ, TMP-SMX, NSAIDs, carbamazapine, IVIG • Rare: leptospirosis

  10. Symptoms of Bacterial Meningitis • High grade sudden fever • Severe Headache • Altered level consciousness, irritability, photophobia • Vomiting • Seizures • Stiff neck • Bulging fontanel in infants

  11. Signs • Vital signs: Fever • Nuchal rigidity • Kerning's sign: while patient is lying supine, with the hip and knee flexed to 90 degrees pain limits passive extension of the knee • Brudzinski's sign: flexion of the neck causes involuntary flexion of the knee and hip • Papilledema • Neurological defecit • Don’t forget source of infection: ears, sinsuses, chest..etc • Petechiae, ecchymosis

  12. Video

  13. Signs • Absence of all 3 signs of the classic triad of fever, neck stiffness, and an altered mental status virtually eliminates a diagnosis of meningitis • Changes in mental status are more common in bacterial than viral meningitis • Kernig and Brudzinski signs have low sensitivity but high specificity

  14. Most useful Sign • Jolt accentuation maneuver: ask patient to rapidly rotate his or her head horizontally: Headache worsens • Sensitivity of 100%, specificity of 54%, positivelikelihood ratio of 2.2, and negative likelihood ratio of 0for the diagnosis of meningitis JAMA July 1999 Does this adult patient have acute meningitis?

  15. Complications • Hydrocephalus • Seizures • SIADH • Subdural effusions & empyema • Septic sinus or cortical vein thrombosis • Arterial ischemia / infarction (inflammatory vasculitis) • CN Palsies (esp deafness) • Septic shock / multi-organ failure from bacteremia (esp meningococcus & pneumococcus) • Risk of adrenal hemorrhage with hypo-adrenalism (Waterhouse-Friderichsen syndrome)

  16. Investigations • CBC, Creat, lytes: Na • Blood Culture • CXR • CT Head • CSF analysis Remember to be careful: •  ICP may increase risk of herniation • Cellulitis at area of lumbar puncture • Bleeding disorder

  17. CSF analysis • Appearance, opening pressure • Cell count with differential • Glucose, protein • CSF appearance • Gram stain • Culture • TB AFB smear PCR and culture • Brucella serology and PCR • HSV PCR • Cryptococcus antigen

  18. Bacterial Meningitis

  19. Bacterial Pathogens Neonates • Group B Streptococci 49%, E coli, enterococci, Klebsiella, Enterobacter, Samonella, Serratia, Listeria Older infants and children • Neisseria meningitidis, S. pneumoniae, M.tuberculosis, H. influenzae

  20. Causes of Bacterial meningitis in Adults • Streptococcus pneumonia………….37% • Neisseria meningitides…..13% • Listeria monocytogenes….10% • Other strept.species……….7% • Gram negative……………….4% • Haemophillus influenza……4% • TB, Brucella

  21. Keep in mind • Global emergence and prevalence of Penicillin- Resistant Streptococcus pneumonia • Dramatic Reduction in invasive Hemophillus influenza disease secondary to use of conjugate Haemophillus Type B- vaccine. • Group B – Streptococci: previously in neonate, now emerging as disease of elderly

  22. Bacterial Meningitis - Empiric Treatment (Gram stain Neg) • Remember MENINGEAL DOSES • Ceftriaxone 2gm IV Q12h • High CSF levels • Vancomycin 500-750mg IV Q6h (highly penicillin resistant pneumococcus) • Dexamethasone (0.15mg/kg IV Q6h) for 2-4 days : 1st dose 15-20 min prior to or con-comitant with 1st dose Abx to block TNF production • Ampicillin (for Listeria)

  23. Management Algorithm for Adults Suspicion of bacterial meningitis YES new onset seizure, papilledema, altered level of consciousness, or focal neurological deficit or delay in performance of diagnostic L.P NO YES Blood c/s & Lumbar puncture B/C stat Dexamethasone + empirical Abx Dexamethasone + empirical Abx CSF is abnormal -ve CT-scan of the head YES +ve CSF gram stain Perform L.P NO YES Dexamethasone + empirical Abx Dexamethasone + targeted Abx

  24. Case-1 • 34 years old man returning from Hajj • Fever, severe headache, neck stiffness, vomiting for two days • Found confuzed by family: ER • Temp 38.4, HR 110, BP 100/70 • Obtunded, Nuchal rigidity, Kerning’s and brudzinski’s signs • Petechiae

  25. Investigations • CSF examination: Opening pressure: 260 mm H20 & cloudy WBC: 1500/ ml: 96% polymorphs Glucose: 24mg / dl Protein: 200 mg

  26. Gram stain

  27. This led to.. • Vaccination: Pre Hajj vaccination in 90’s • serogroups A, C

  28. N. meningitidis W135 & Hajj • In UK alone 2000: 45 cases 8 (18%) deaths • In 2001 34 cases 10 (29%) deaths • Pre hajj: Quadrivalent conjugate meningococcal vaccine: A, C, Y, W135 (menactra) • Up to 3 years in adult : Does not affect nasopharyngeal carriage and does not provide herd immunity

  29. Meningococcus • Fulminate meningococcemia with purpura: • Overwhelming sepsis, DIC • Meningitis with rash (Petechiae) • Meningitis without rash • Mortality 3 - 10 %

  30. Treatment & Chemoprophylaxis • Droplet Isolation: 48h post Abx • Treatment: Ceftriaxone or Pen G 7 days • Eradicate nasopharyngeal carriage: house hold contact Health care providers who examined patient closely • Rifampin 600 mg for 2 d or Ciprofloxacin 500mg once or Ceftriaxone 125mg I.M once

  31. Chemoprophylaxis Systemic Review NNT=200 to prevent one case in 30 days BMJ

  32. CASE 2 • 26 year old Saudi female presents with fever, cough and headache for the last 3 days. Examination revealed ill – looking woman with sign of consolidation over lower lungs

  33. CASE 2 • Six hours after admission, her headache became worse and rapidly became obstunded. • CSF: WBC: 3000 : 99% PML Sugar: Zero Protein: 260 mg/dl.

  34. Gram stain

  35. Epidemiological Features ofPneumococcal meningitis • The most common Cause • Highest mortality 20 – 30% • May be associated with other Focus: Pneumonia, Otitis Media, Sinusitis • Head Trauma & CSF Leak • spleenectoy and Sickle cell disease • Global emergence of Penicillin – Resistant

  36. CSF Leak

  37. Treatment of Pneumococcus meningitis • Steroids (pre 1st dose Abx) for 4 days • Pen G MIC less than 0.1mcg/mL: Pen G 4 million U Q 4h or Ampicillin 2gm IV Q4h • Pen G MIC 0.1-1: Ceftriaxone 2gm IV Q12h • Pen G Equal to or more than 2: vanco 500-750mg IV Q6h and ceftriaxone

  38. Treatment & prevention of Pnemococcusmeningitis • Penicillin G (MIC< 0.1mcg/ml) • Ceftriaxone 14 days • Vancomycin if Highly penicillin resistance (MIC>=2mcg/ml) • Steroids (pre Abx) • Vaccination: • Pneumococcal polysaccharide vaccine (Pneumovax): 23 purified capsular polysaccharide antigens (serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F) • Pneumococcal conjugate vaccine (Prevnar 13): Valent conjugatevaccine for children

  39. Pneumococcal conjugate vaccine (PCV) • 13 serotypes • Children 6 weeks through 17 years of age for the prevention of invasive disease caused by 13 Streptococcuspneumoniae strains (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F) • Children 6 weeks through 5 years for the prevention of otitis media caused by 7 of the 13 strains (4, 6B, 9V, 14, 18C, 19F, and 23F) • Adults 50 years of age and older for the prevention of pneumococcal pneumonia and invasive disease caused by the 13 vaccine strains

More Related