Upload
paulo-josue-sablad
View
218
Download
0
Embed Size (px)
Citation preview
8/6/2019 CNS Infection 11
1/75
CNS infectionCNS infectionSupischa theerasasawatSupischa theerasasawat
8/6/2019 CNS Infection 11
2/75
ContentContent RoutsRouts Classification by organ involvementClassification by organ involvement
MeningitisMeningitis
EncephalitisEncephalitis
MyelitisMyelitis
Classification by pathogenClassification by pathogen BacteriaBacteria
VirusVirus
TBTB
FungusFungus
SpirocheteSpirochete
ParasiteParasite
8/6/2019 CNS Infection 11
3/75
4 routes which infectious agents can enter
the CNS
INFECTIONS
hematogenous spread
i) most common- usually via arterialroute
- can enter retrogradely(veins)
direct implantationi) most often is traumatic
ii) iatrogenic (rare) vialumbar puncture
local extension(secondary to establishedinfections)
i) most often frommastoid and frontalsinuses, infected tooth
PNS into CNSi) viruses
- rabies
- herpes zoster
8/6/2019 CNS Infection 11
4/75
DefinitionsDefinitions
MeningitisMeningitis
Inflammation of the leptomeningesInflammation of the leptomeninges
Usually caused by bacteriaUsually caused by bacteria EncephalitisEncephalitis
Inflammation of the brain itselfInflammation of the brain itself
Caused by many types of organismsCaused by many types of organisms
MyelitisMyelitis
Inflammation of the spinal cordInflammation of the spinal cord
8/6/2019 CNS Infection 11
5/75
Meningitis classified
acute pyogenic
usually bacterial meningitis
aseptic usually acute viral meningitis
chronic
usually TB, spirochetes, cryptococcus
8/6/2019 CNS Infection 11
6/75
Characteristic CSF formulasCharacteristic CSF formulas
8/6/2019 CNS Infection 11
7/75
Imaging should precede lumbar punctureImaging should precede lumbar puncture
newnew--onset seizuresonset seizures
an immunocompromised statean immunocompromised state
signs that are suspicious for spacesigns that are suspicious for space--occupying lesionsoccupying lesions
moderatemoderate--toto--severe impairment ofsevere impairment of
consciousnessconsciousness
8/6/2019 CNS Infection 11
8/75
EncephalitisEncephalitis
Acute fluAcute flu--like prodome, high fever, severelike prodome, high fever, severe
headache, N/V,headache, N/V, altered consciousnessaltered consciousness,,
seizure and focal neurological signsseizure and focal neurological signs
Limbic encephalitis (temporal lobeLimbic encephalitis (temporal lobe
involvement)involvement)
Rhombenencephalitis (lower cranial n.Rhombenencephalitis (lower cranial n.
involvement, myoclonus, autonomicinvolvement, myoclonus, autonomic
dysfunction, lock in syndrome)dysfunction, lock in syndrome)
8/6/2019 CNS Infection 11
9/75
BacteriaBacteria
8/6/2019 CNS Infection 11
10/75
Examples of BacteriaExamples of Bacteria
Streptococcus pneumoniaeStreptococcus pneumoniae
Neisseria meningitidisNeisseria meningitidis
Haemophilus influenzaeHaemophilus influenzae
8/6/2019 CNS Infection 11
11/75
PathogenesisPathogenesis
8/6/2019 CNS Infection 11
12/75
Microorganism vary with age of the patient
a) neonatesi) E. coli
ii) Strep. pneumonia
iii) Listeria monocytogenes
b) adolescents and young adultsi) Neisseria meningitidis (most
common)
ii) Haemophilus influenza- immunizations have markedly
reduced this pathogen
8/6/2019 CNS Infection 11
13/75
Signs & Symptoms of MeningitisSigns & Symptoms of Meningitis
Headache >Headache > 9090%%
Fever >Fever > 9090%%
Stiffness of neck >Stiffness of neck > 8585%% VomitingVomiting 3535%%
SeizuresSeizures 3030%%
WeaknessWeakness 1515%%
8/6/2019 CNS Infection 11
14/75
Spinal tab yields
cloudy or frankly purulent CSF ( 100-
10,000 WBC)
increased pressure (4
0% presure>400mmH2O)
o neutrophils (80-95%)
8/6/2019 CNS Infection 11
15/75
Respiratory isolation for 24 hours is indicated for patients with suspected
meningococcal infection
8/6/2019 CNS Infection 11
16/75
8/6/2019 CNS Infection 11
17/75
8/6/2019 CNS Infection 11
18/75
8/6/2019 CNS Infection 11
19/75
Adjunctive dexamethasone therapyAdjunctive dexamethasone therapy
DexamethasoneDexamethasone does not improvedoes not improve thethe
outcomeoutcome in all adolescents and adults within all adolescents and adults with
suspected bacterial meningitis; asuspected bacterial meningitis; a
beneficial effect appears to be confined tobeneficial effect appears to be confined to
patients with microbiologically provenpatients with microbiologically proven
disease, including those who havedisease, including those who have
received prior treatment with antibioticsreceived prior treatment with antibiotics
n engl j med 357;24 www.nejm.org december 13, 2007
8/6/2019 CNS Infection 11
20/75
Neurocritical careNeurocritical care
In patients with a high risk of brain herniation, considerIn patients with a high risk of brain herniation, considermonitoring intracranial pressure and intermittentmonitoring intracranial pressure and intermittentadministration of osmotic diuretics to maintain anadministration of osmotic diuretics to maintain an
intracranial pressure of 6060 mm Hgmm Hg
Initiate repeated lumbar puncture, lumbar drain, orInitiate repeated lumbar puncture, lumbar drain, orventriculostomy in patients with acute hydrocephalusventriculostomy in patients with acute hydrocephalus
Electroencephalographic monitoring in patients with aElectroencephalographic monitoring in patients with ahistory of seizures and fluctuating scores on thehistory of seizures and fluctuating scores on theGlasgow Coma ScaleGlasgow Coma Scale**
8/6/2019 CNS Infection 11
21/75
Airway and respiratory careAirway and respiratory care
Intubate or provide noninvasive ventilation inIntubate or provide noninvasive ventilation in
patients with worsening consciousness (clinicalpatients with worsening consciousness (clinical
and laboratory indicators for intubation includeand laboratory indicators for intubation include
poor cough and pooling secretions, apoor cough and pooling secretions, a RR of >RR of >3535per minute, arterial oxygen saturation of
8/6/2019 CNS Infection 11
22/75
Circulatory careCirculatory care
In patients with septic shock, administer lowIn patients with septic shock, administer lowdoses of corticosteroids (if there is a poordoses of corticosteroids (if there is a poorresponse on corticotropin testing, indicatingresponse on corticotropin testing, indicatingadrenocorticoid insufficiency, corticosteroidsadrenocorticoid insufficiency, corticosteroids
should be continued)should be continued) Initiate inotropic agents (dopamine) to maintainInitiate inotropic agents (dopamine) to maintain
blood pressure (blood pressure (mean arterial pressure,mean arterial pressure, 7070--100100mm Hg)mm Hg)
Initiate crystalloids or albumin (Initiate crystalloids or albumin (55%) to maintain%) to maintainadequate fluid balanceadequate fluid balance
Consider the use of a SwanGanz catheter toConsider the use of a SwanGanz catheter tomonitor hemodynamic measurementsmonitor hemodynamic measurements
8/6/2019 CNS Infection 11
23/75
Other supportive careOther supportive care
Initiate nasogastricInitiate nasogastrictube feeding of atube feeding of astandard nutritionstandard nutrition
formulaformula Initiate prophylaxisInitiate prophylaxis
with protonwith proton--pumppumpinhibitorsinhibitors
MaintainMaintainnormoglycemic statenormoglycemic state((serum glucose level,serum glucose level,4040C, use cooling byC, use cooling byconduction orconduction orantipyretic agentsantipyretic agents
8/6/2019 CNS Infection 11
24/75
Complications during the Clinical CourseComplications during the Clinical Course
and Outcomesand Outcomes
8/6/2019 CNS Infection 11
25/75
8/6/2019 CNS Infection 11
26/75
Waterhouse-Friderichsen
syndrome
results from meningitis-associated
septicemia
- hemorrhagic infarction of the adrenal glands- cutaneous petechiae
- common with menigococcal and
pneumococcal meningitis
8/6/2019 CNS Infection 11
27/75
ACUTE FOCAL SUPPURATIVE
INFECTIONS
Brain abscess
Subdural Empyema
Extradural Abscess
8/6/2019 CNS Infection 11
28/75
Brain abscess
may arise from a variety of routes [often
from primary infected site in the heart
(acute bacterial endocarditis), lungs, tooth
decay, bones]
Strep and Staph are the most common
bacteria
cerebral abscesses are destructive lesions
8/6/2019 CNS Infection 11
29/75
central liquefactive necrosis surrounded by
fibrous cap
- edema in surrounding area common sites (in descending order)
- frontal lobe
- parietal lobe- cerebellum
8/6/2019 CNS Infection 11
30/75
present with progressive focal deficits
- signs ofo ICP
- CSF undero pressure
- WBC and protein o
- glucose normal
rupture of abscess can cause ventriculitis,
meningitis and venous sinus thrombosis surgery and antibiotics have decreased lethality
to less that 10%
8/6/2019 CNS Infection 11
31/75
Subdural Empyema
bacteria and fungus can spread to
subdural space p subdural empyema
arachnoid and subarachnoid spaces usuallyunaffected
thrombophlebitis may develop in
bridging veins p venous occlusion and
infarct
8/6/2019 CNS Infection 11
32/75
Clinical
febrile
headache
neck stiffness untreated may develop lethargy
and coma
CSF profile similar to abscess
8/6/2019 CNS Infection 11
33/75
Extradural Abscess
commonly associated with osteomyelitis
usually arise from adjacent site of infection
sinusitis or a surgical procedurewhen occurring in spinal epidural
space p spinal compression
neurosurgical emergency
8/6/2019 CNS Infection 11
34/75
VirusesViruses
8/6/2019 CNS Infection 11
35/75
Examples of VirusesExamples of Viruses
Herpes Simplex VirusHerpes Simplex Virus
8/6/2019 CNS Infection 11
36/75
PathogenesisPathogenesis
Depending on the virus, the pathogenesisDepending on the virus, the pathogenesis
consists of a mixture of direct viralconsists of a mixture of direct viral
pathology or postpathology or post--infectious inflammatoryinfectious inflammatory
or immuneor immune--mediated responsemediated response
8/6/2019 CNS Infection 11
37/75
AcuteAseptic (Viral Meningitis)
refers to absence of any recognizable
organism
generally viral clinical course is less fulminant
compared to bacterial
8/6/2019 CNS Infection 11
38/75
Spinal tab yields
CSF glucose near normal
protein only moderately elevated
lymphocytic pleocytosis usually self limiting
most common is the enterovirus
8/6/2019 CNS Infection 11
39/75
NSAID
antibiotics
CSF is sterile glucose normal (CSF)
pleocytosis with neutrophils
o CSF protein
Drug-inducedaseptic meningitis
8/6/2019 CNS Infection 11
40/75
Viral encephalitis
parenchymal infection meningeal inflammation and sometimes spinal cord
involvement (encephalomyelitis)
most characteristic features perivascular and parenchymal mononuclear cell
infiltration
intrauterine viral infections may cause congenitalmalformations (rubella)
slowly progressive degenerative disease may occurmany years after viral illness postencephalitic parkinsonism
8/6/2019 CNS Infection 11
41/75
Clinical
generalized neurologic deficits
- seizures
- confusion
- delirium- stupor and coma
CSF usually colorless
- slightly o pressure
- initially a neutrophilic pleocytosis, which rapidly
- converts to lymphocytes
- proteins are o
- glucose is normal
8/6/2019 CNS Infection 11
42/75
Herpes virus in CNSHerpes virus in CNS
EncephalitisEncephalitis HSVHSV--11//22, VZV, CMV, VZV, CMV
Acute meningitisAcute meningitis HSVHSV--22, VZV, VZV
Recurrent meningitisRecurrent meningitis HSVHSV--22MyelitisMyelitis HSVHSV--22, VZV, CMV, EBV, VZV, CMV, EBV
CombinedCombined EBVEBV
VentriculitisVentriculitis VZV, CMVVZV, CMVBrainstem encephalitisBrainstem encephalitis HSVHSV--11//22, VZV, VZV
polymyeloradiculitispolymyeloradiculitis CMVCMV
8/6/2019 CNS Infection 11
43/75
8/6/2019 CNS Infection 11
44/75
HSV type 1 (HSV-1)
occur at any age
most common in children and young
adultsmost common S & S are mood and
memory change
most often begins in the temporal lobes
and orbital gyri of frontal lobes
8/6/2019 CNS Infection 11
45/75
HSV type 2 (HSV-2)
in adults as meningitis
~ 50% of neonates develop severe
encephalitis to mothers having active primary genital HSV infections
8/6/2019 CNS Infection 11
46/75
Varicella-Zoster virus (Herpes Zoster)
childhood chickenpox
reactivation in adults (i.e., shingles) painful vascular skin eruptions
usually is self limited, however may be a persistent postherpetic neuralgia syndrome
- ~ 10% of patients
overt CNS manifestations are rare however, when present do produce
more severe signs
- granulomatous arteritis
8/6/2019 CNS Infection 11
47/75
Cytomegalovirus
occurs in fetuses and immunosupprressed
most common opportunistic viral pathogen in
patients with AID
S affects 15-20% of patients
localize in paraventricular subependymal
regions of the brain
severe hemorrhagic necrotizing
8/6/2019 CNS Infection 11
48/75
ClinicalClinical
CMV encephalitisCMV encephalitis AcuteAcute--subacutesubacute
confusionconfusion
DisorientationDisorientation
Memory lossMemory loss
Cranial n. palsyCranial n. palsy
FeverFever
CSFCSF HypoglycorrhachiaHypoglycorrhachia
MononuclearMononuclearpleocytosispleocytosis
CMVCMVpolyradiculomyelitispolyradiculomyelitis Sacral painSacral pain
paraesthesiaparaesthesia
Sphincter dysfunctionSphincter dysfunction
Subacute onset ofSubacute onset ofascending flaccidascending flaccidparaparesisparaparesis
CSFCSF HypoglycorrhachiaHypoglycorrhachia
PMN pleocytosisPMN pleocytosis
8/6/2019 CNS Infection 11
49/75
DiagnosisDiagnosis
CMV PCR +CMV PCR +
8/6/2019 CNS Infection 11
50/75
TreatmentTreatment
GanciclovirGanciclovir 55 mg/kg bidmg/kg bid 33 wk + foscarnetwk + foscarnet
6060 mg/kg qmg/kg q 88 h until improvedh until improved
Maintenance ValMaintenance Val--GCVGCV 900900 mg OD
+mg OD
+foscarnetfoscarnet 9090--120120 mg IV ODmg IV OD
8/6/2019 CNS Infection 11
51/75
TBTB
8/6/2019 CNS Infection 11
52/75
TBTB
headaches
malaise and confusion
vomitingCSF:
moderate pleocytosis
- PMN and MN proteins markedly o
glucose slightly q or normal
8/6/2019 CNS Infection 11
53/75
Subarachnoid space p fibrous exudate
most often at base of brain
often obliterating the cisterns
encasing cranial nerves
development of a single intraparenchymal
mass p tuberculoma
may cause significant mass effect
8/6/2019 CNS Infection 11
54/75
Clinical
most serious is arachnoid fibrosis and
- hydrocepahlus
obliterative endarteritis- arterial occlusion and infarction
spinal cord roots may be involved
8/6/2019 CNS Infection 11
55/75
8/6/2019 CNS Infection 11
56/75
TreatmentTreatment
2IRZE(S) + 10 IR
8/6/2019 CNS Infection 11
57/75
TreatmentTreatment
33 IRZS +IRZS + 66IRZIRZ
Dexamethasone IVDexamethasone IV 00..44 MKDMKD 11 wk thenwk then 00..33
MKDMKD 11 wk thenwk then 00..22 MKDMKD 11 wk thenwk then 00..11
MKDMKD 11 wkwk then oralthen oral 44 mg/d tapemg/d tape 11 mg/dmg/d
withinwithin 44 wkwk
8/6/2019 CNS Infection 11
58/75
SpirocheteSpirochete
8/6/2019 CNS Infection 11
59/75
Neurosyphilis
tertiary stage ~ 10% of untreated patients
major forms of meningovascular neurosyphilis are
paretic, and tabes dorsalis meningovascular neurosyphilis is chronic meningitis
involving base of the brain, spinal leptomeninges andcerebral convexities. Obliterative endarteritis (Heubnerarteritis)
paretic neurosyphilis caused by invasion of the brain byT. pallidum. Progressive loss of mental and physicalfunctions with mood alterations
Tabes dorsalis is a result of damage by the spirochete tothe sensory nerves in dorsal roots, causing locomotor
ataxia and sense of position, loss of pain sensation
8/6/2019 CNS Infection 11
60/75
DiagnosisDiagnosis
CSF reactive FTACSF reactive FTA--ABS or TPHAABS or TPHA
8/6/2019 CNS Infection 11
61/75
TreatmentTreatment
Penicillin G IVPenicillin G IV 44 mU qmU q 44 hh 1414d thend then
benzathine penicillin Gbenzathine penicillin G 22..44 mU IM xmU IM x33
8/6/2019 CNS Infection 11
62/75
FungiFungi
8/6/2019 CNS Infection 11
63/75
Example of a FungusExample of a Fungus
Cryptococcus neoformansCryptococcus neoformans
8/6/2019 CNS Infection 11
64/75
ClinicalClinical
FeverFever
HeadacheHeadache
Stiffness of neck positiveStiffness of neck positive Sign of increase ICPSign of increase ICP
8/6/2019 CNS Infection 11
65/75
DiagnosisDiagnosis
Indian inkIndian ink
Cryptococcal AgCryptococcal Ag
8/6/2019 CNS Infection 11
66/75
8/6/2019 CNS Infection 11
67/75
TreatmentTreatmentdiseasedisease protocalprotocal dosedose durationduration
HIV neg.HIV neg. 11 AmphotericinAmphotericin 00..77MKDMKD
+flucytosine+flucytosine 100100MKDMKD
+fluconazole+fluconazole 400400mg/dmg/d
22 wkwk
1010 wkwk
22 AmphotericinAmphotericin 00..77MKDMKD
+flucytosine+flucytosine 100100MKDMKD
1010 wkwk
HIV pos.HIV pos.
inductioninduction
AmphotericinAmphotericin 00..77MKDMKD
+flucytosine+flucytosine 100100MKDMKD+fluconazole+fluconazole 400400mg/dmg/d
22 wkwk
1010 wkwk
maintanancemaintanance FluconazoleFluconazole 400400 mg/dmg/d
8/6/2019 CNS Infection 11
68/75
ParasitesParasites
8/6/2019 CNS Infection 11
69/75
Examples of ParasitesExamples of Parasites
Toxoplasma gondiiToxoplasma gondii
8/6/2019 CNS Infection 11
70/75
8/6/2019 CNS Infection 11
71/75
ClinicalClinical
Subacute tSubacute t00 chronic feverchronic fever
HeadacheHeadache
Focal neurodeficit correlate withFocal neurodeficit correlate withanatomical site involvement (anatomical site involvement (basal gangliabasal ganglia
and corticomedullary junctionand corticomedullary junction))
8/6/2019 CNS Infection 11
72/75
DiagnosisDiagnosis
DefiniteDefinite tissue biopsytissue biopsy
AntiAnti--toxplasma IgGtoxplasma IgG
Clinical compatible+ imagingClinical compatible+ imaging
8/6/2019 CNS Infection 11
73/75
8/6/2019 CNS Infection 11
74/75
TreatmentTreatment
PyrimethaminePyrimethamine 200200
mg thenmg then 5050--7575 mg +mg +
sulfadiazinesulfadiazine 11--11..55g qg q
66 h + folinic acidh + folinic acid 1515mg OD at leastmg OD at least 66
weeksweeks
Pyrimethamine +Pyrimethamine +
folinic acidfolinic acid
ClindamycinClindamycin 600600 mg qmg q
66 hh AzithromycinAzithromycin 900900--
12001200 mg ODmg OD
Cotrimoxazole (Cotrimoxazole (55
mg/kg TMP) bidmg/kg TMP) bid
8/6/2019 CNS Infection 11
75/75
Secondary prophylaxisSecondary prophylaxis
PyrimethaminePyrimethamine 2525--5050 mg + sulfadiazinemg + sulfadiazine
00..55--11g qg q 66 h + folinic acidh + folinic acid 1515 mg ODmg OD
PyrimethaminePyrimethamine 2525--5050 mg + clindamycinmg + clindamycin
600600 mg qmg q 66 h + folinic acidh + folinic acid 1515 mg ODmg OD
Stop CDStop CD44 >> 200200 >> 66 mo.mo.