Fishing for a Diagnosis - “Nervous” infections

1. Fishing for a Diagnosis -“Nervous” infections Neurology Grand Rounds 08 January 2009 Antony Thomas Consultant Neurologist UHCW & Alexandra hospital Redditch

2. Best Wishes for a Happy, successful, peaceful and prosperous New Year to all.

3. RC • 23 years, Right handed, sheep farmer • Well until 8/05/08 • Occipital headache: severe • Nausea, vomiting • Blurred vision, double vision • Dribbling • “behaves as drunk” slurred speech, dizziness and unsteady • Weak right face with failure to close right eye

4. RC • A&E @ WRH 10/05/08 • CT Head: ? Normal • Sent home • Readmitted at WRH 14/05/08 with deterioration, worsening headache, slurring, decreased swallow, diplopia • MR Brain: abnormal

9. Transferred to Neurosurgery UHCW 16th • Pyrexial • GCS 15, no papilledema • Right V1 sensory impairement • Right eye abduction weakness • Bilateral nystagmus R>L • Right Facial weakness LMN • Bulbar paresis, dysarthria, right sided tongue weakness • Mild right sided weakness and minimal sensory impairement • Right sided cerebellar signs • Rest of the systemic examination unremarkable

10. Investigations • Leukocytosis, Neutrophilia, Monocytosis • Impaired LFT • Deteriorating Renal functions • CRP normal  85 172 • Autoantibodies: negative • HIV: Negative • Serum ACE: normal

11. Microbiology @ Worcester Telephone call Blood culture (14/05 sample): grown Listeria Started on antibiotics after repeating cultures Amoxicillin 2G Q4H Gentamicin

12. Progress • Respiratory distress • Poor cough, inadequate gag • Throat suction: thick yellowish secretions • Hypoxic, hypercapneic • Chest crackles more on right lower base • CXR: Right lower lobe opacity

14. Transfer to ITU Intubated and ventilated ARDS: on oscillator Hydrocortisone Co-trimoxazole added Repeat MR Brain: similar findings

17. BLOOD CULTURE REPORT POSITIVE  :Gram positive  bacilli   Erythromycin S   Fusidic Acid R   Gentamicin S   Penicillin        R   Trimethoprim  S   Vancomycin   S                    Listeria monocytogenes  isolated 

18. Progress Cardiorespiratory arrest x 2 Succesful CPR Amiodarone Gradually improved CXR got better

20. Progress • Unfortunately………………… • Desaturating • More ventilatory requirements • Worsening respiratory, liver and renal functions • Pupil unequal and dialated • R.I.P

21. Listeria Monocytogenes • Meningo-encephalitis: common • Immunocompromised & debilitated individuals • In new born, well known and often fatal • CSF – pleocytosis (initially polymorphonuclear) • Rarely normal CSF • Rhombencephalitis

23. Listeria • Early CT scan normal • Multiple abscesses in the brain • Monocytosis

24. CNS Infections • Meninges and subarachnoid space can be infected by viruses, bacteria, spirochaetes and fungi • Virus and bacteria: seasonal variation • Classic case unmistakable • But subtle presentations can lead to fatal delay in diagnosis

25. Typical acute meningitis • Pyrexia • Severe headache • Phtophobia • Rapid development of neck stiffness • Kernig’s sign, Brudzinski sign • If untreated  vomiting, drowsiness and eventually coma

26. Meningitis Entero ((Echo,polio, coxsackie) HSV2 Lymphocytic choriomeningitis VZ Mumps HIV Encephalitis HSV VZ CMV EBV HIV Mumps Measles Rabies Arbo Viral causes

27. Typical Cerebrospinal Fluid Findings in Various Types of Meningitis Test Bacterial Viral Fungal Tubercular Opening pressure Elevated Usually normal Variable Variable WBC≥1,000 per mm3 <100 per mm3 Variable Variable Cell differential Predominance of Predominance of Predominance Predominance PMNs* lymphocytes†of lymphocytes of lymphocytes Protein Mild to marked Normal to elevated Elevated Elevated elevation CSF-to-serum glucose Normal to marked Usually normal Low Low ratio decrease CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes. *—Lymphocytosis present 10 percent of the time. †—PMNs may predominate early in the course.