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8/11/2019 Pedia - CNS Infection, Seizures, NMD [Agrava]
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Highlight = Memorize per Dr. Agrava
Table of ContentsInfections of the CNS ................................... 2
DefinitionsBacterial Meningitis
EtiologyNewborn period2 months 12 years
Neisseria meningitidesHaemophilus influenza type bRisk FactorsPathophysiology of Bacterial Meningitis .................... 3Clinical ManifestationsLumbar PunctureContraindications for LP
5 Absolute, 1 relative CINormal CSFTypical CSF Findings in Meningi tis ............................ .......... 4T602-1(partial) CSF Findings in Meningitis
Techniques in DiagnosisNeurodiagnostic Procedures
Treatment ................................................................. 5Recommendations for Empiric antibiotic Therapy in Bacterial
MeningitisPathogen-specific therapy for Meningitis
Complications of Bacterial MeningitisPrognosis
Poor PrognosisPrevention ................................................................ 6
N. meningitidesH. Influenzae Type BS. Pneumoniae
Tuberculous MeningitisPathophysiologyClinical Features of TB MeningitisRadio diagnostic criter ia ............. .............. ............... .. 7Diagnosis
ClinicalCT ScanLumbar puncture
InvestigationOther Forms of CNS TBManagement ............................................................. 8Treatment
Viral Meningoencephalitis ................................... 9VE Etiology
Enteroviruses
Mumps virusArbovirusesHerpes Family
Pathology and pathogenesisTissue sectionsPredilection
Clinical manifestationDiagnosis
Tb Diagnostic proceduresLaboratory findings ............................................................ 10
TreatmentPrognosis
Possible ComplicationsEosinophilic meningitis
EtiologyOthersNoninfectious causes include
Clinical ManifestationsDiagnosisTreatmentPrognosis
Brain Abscess .................................................. 11CausesPathology
Location and sourceClinical manifestationDiagnosis
CT with contrast and MRITreatment
Surgery is indicatedPrognosis
Seizures in Chi ldhood ................................ 12EpidemiologyEvaluation of the First Seizures
HistorySeizure typeExamination
Febrile seizures ................................................ 13FS Recurrent Seizures
Factors assoc with !recurrence risk!Risk of developing epilepsy
FS Treatment
Unprovoked SeizuresUS First seizure
Recurrent SeizuresRS Etiology
Diagnostic Evaluation of First SeizuresFebrileUnprovokedRecurrent
Intl Classification of Epileptic Seizures .................. 14Epileptic syndromesPartial seizures
SIMPLE partial seizuresCOMPLEX partial seizures
AutomatismComplex partial seizures with 2generalizationDiagnosis
Benign Partial Epilepsy w/Centrotemporal Spikes(BPEC)
Clinical FeaturesDiagnosisTreatment
Rasmussen EncephalitisGeneralized Seizures ......................................... 15
Absence seizuresAbsence TypicalAbsence Atypical
Generalized Tonic-clonic SeizuresGeneralized Seizures Precipitating factors
Myoclonic Epilepsies of ChildhoodBenign myoclonus in infancyTypical myoclonic epilepsy of early childhoodComplex Myoclonic Epilepsies of ChildhoodJuvenile Myoclonic Epilepsy (Janz syndrome)Progressive Myoclonic Epilepsies
Infantile spasms ...................................................... 16CryptogenicSymptomaticTheories
Landau-Kleffner Syndrome (LKS)LKS DxLKS Tx
Mechanism of SeizuresTwo hypotheses
Use of EEG in diagnosing EpilepsyProlonged EEG monitoring with simultaneous closed-circuit video recording
Treatment of Epil epsy ........................ ................ 17Pharmacologic
Indications for anticonvulsant drug monitoringProminent risk factorsNon pharmacologic
Ketogenic dietSurgery for epilepsyVagal nerve stimulation
Neonatal Seizures ............................................. 18Focal seizuresMultifocal clonicTonic seizuresMyoclonic seizuresSubtle seizures
NS EEG ClassificationClinical sz w/ consistent EEG eventClinical sz w/ inconsistent EEG eventElectrical sz w/ absent clinicalseizures
NS Etiologic DiagnosisDiagnostic ExamsF593-3 An approach to the child with a suspected convulsive
dsoCauses by AgeInborn errors of metabolism ................................................19Unintentional injection of local anestheticBenign familial neonatal seizuresFifth-day fitsPyridoxine dependency
Drug withdrawal seizuresStatus epilepticusSE Major subtypes
Febrile seizureIdiopathic status epilepticusSymptomatic status epilepticus
SE PathophysiologyGeneral Principles in the Management of StatusEpilepticusSE Treatment
First line drugSecond line Drugs
Conditions that MimicSeizures ............................ 20Benign paroxysmal vertigoNight terrorsBreath holding spells
Cyanotic spellsPallid spells
Paroxysmal kinesigenic choeoathetosisShuddering attacks
Benign paroxysmal torticollis of infancyHereditary chin tremblingNarcolepsy & CataplexyRage attacks or episodic dyscontrol syndromeMasturbationPseudoseizuresSyncope .................................................................. 2
Simple syncopeCough syncopeProlonged QT syndrome
Neuromuscular Diseases.............................. 22Evaluation and Investigation
Components of the motor unitsInnervation
Nervous systemClinical Manifestations
Neuropathic or MyopathicLaboratory Findings
Serum Creatinine kinase (CK) levelsOtherDistinguishing Features of Dsos of Motor System ............... 23
Patterns of Weakness and Localization in Floppy InfantsDevelopmental Dso of Muscle ............................. 24
DiseasesDisease
Transmission LocusMuscular Dystrophies
Duchenne & Beckers Muscular Dystrophy .............. 25Duchenne muscular dystrophyBecker muscular dystrophyD&B Clinical M anifestationLab Findings ...................................................................... 26
DiagnosisGenetic Etiology and PathogenesisTreatmentNutritional State
Emery-Dreifuss Muscular DystrophyClinical ManifestationsDiagnosisTreatment
Myotonic Muscular Dystrophy (Steinert dse)MMD TypesClinical Manifestations
Periodic Paralyses (Potassium-Related) .................... 27PP Treatment
Congenital Myotonic DystrophyLab FindingsDiagnosis ........................................................................... 2
Treatment
Myotonic chondrodystrophy (Schwartz-Jampel dse)Myotonia congenital (Thomsen disease)Paramyotonia
Guillain-Barr SyndromeClinical Manifestations
Bulbar Involvement 50%GBS vs. Polio
GBS VariantsMiller-Fisher SyndromeChronic Relapsing/Unremitting Polyradiculoneuropathy .... 29
Congenital Guillain-Barr syndromeLab Findings and Diagnosis
CSF studiesOther
TreatmentPrognosis
Endocrine and Toxic MyopathiesThyroid Myopathies
HyperthyroidismHypothyroidismTreatment
HyperparathyroidismSteroid-Induced MyopathyHyperaldosteronism (Conn syndrome)
Chronic Growth Hormone ExcessToxic Myopathies .................................... ......... 3
Malignant HyperthermiaDSO of NM Transmission & of Motor Neurons
NMJ dso: Myasthenia GravisJuvenile MGTransient MGCongenital MGDiagnosis
Anterior Horn Cell: Spinal Muscular Atrophy (SMA)Perinatal SMA (Type 0)Infantile SMA (Type1, Werdnig-Hoffman Dse)Juvenile SMA (Type 2)Adult SMA (Type 3, Kugelberg-Welander Dse)DiagnosisTreatment
Course: Pediatrics
Week: 7
Lecturer: Dr. Agrava
Topic: CNS Infections
Seizures and Neuromuscular
Diseases
Source: Lecture
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Infections of the CNS
DEFINITIONS
BACTERIAL MENINGITIS
Etiology
o
Newborn period
2 months 12 years
!
o
o
! o o
o o o
Neisseria meningitides
o
o
o o
Haemophilus influenza type b
o
!
Risk Factors
o o
Risk Factors for Common Orgs
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Pathophysiology of Bacterial Meningitis
o
o
o
! !
o !!
o
"
"
" "
o
o
"
"
! !
!
o !
" o !
o
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Clinical Manifestations
Neonates Infants Older Children and Adults
Very non-specific
Fever or hypothermia
Seizures
Lethargy or irritability
Vomiting, poor feeding or feeding intolerance
Respiratory distress, apnea
Diarrhea
Fever - 50%
Seizures - 40%
Poor feeding
Abdominal distention
Respiratory distress
Bulging anterior fontanelle - 30%
Altered sensorium
Classic Triad:
Fever
Headache
Nuchal rigidity
Lumbar Puncture
Contraindications for LP
5 Absolute, 1 relative CI !
Normal CSFPRETERM TERM INFANTS/CHILD
WBC (cell/mm3)Mean
-2SD%PMN
9.0
0-25.457.2%
8.2
0-22.461.3%
0
0-70
Glucose (mg/dl)
MeanRange
5024.63
5232-119
>4040-90
CSF glucose/Blood glucose
MeanRange
7455-105
8144-248
5040-60
Protein (mg.dl)
MeanRange
11565-150
9020-170
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Typical CSF Findings in Meningitis
o
Bacterial Viral Fungal Tuberculous
Opening pressure Normal or High Normal Normal or High Usu High
WBC count (cells/mm3) 1,000 10,000 80
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Subdural effusion !focal seizures; note thickened sulci = pus
Meningitis; thickened; whitish material is exudate
TreatmentRecommendations for Empiric antibiotic Therapy in Bacterial Meningitis
Pathogen-specific therapy for Meningitis
Complications of Bacterial Meningitis
Prognosis !"
Poor Prognosis #
!
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Sensorineural hearing loss
o o
o
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PreventionN. meningitides H. Influenzae Type B S. Pneumoniae
o
o
TUBERCULOUS MENINGITIS
Pathophysiology #
! $
Rupture of these encapsulated foci results in spread of infection intothe subarachnoid space
Clinical Features of TB Meningitis
Inferior brain surface showing exudate in basal cisterns
Stage
INon-specificsymptoms -fever, lethargy
Stage
2Confusion,cranial nerveparesis,`meningism!arteritic
Complications:hemiparesis,ataxia,dysarthria
Stage
3Coma localising,flexing orextending topain,opisthotonos
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Radio diagnostic criteria
!
Normal vs Tuberculous Meningitis
Enhancement in basal exudates of Tb meningitis as shown in CT Scan
DiagnosisClinicalCT Scan
Lumbar puncture
o
" o
Investigation
o "
Other Forms of CNS TB
o
4yo/F, prolonged fever, ataxia, vomiting, headache; thought it was atumor in the cerebellum but it was actually caseation necrosis
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VIRAL MENINGOENCEPHALITIS
o
o
VE Etiology
Enteroviruses
Mumps virus
Arboviruses
Herpes FamilyG"=."3 3$2.)"H I$=53 ,-." J :G6K;J<
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Pathology and pathogenesis
Tissue sections
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Predilection $ $
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Clinical manifestation
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Diagnosis
Tb Diagnostic proceduresO)"',=&"#'".7()&%=(2 :OO9<
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Laboratory findings>6R
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Treatment
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Prognosis
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Possible Complications
o ! o
EOSINOPHILIC MENINGITIS
Etiology
Others
Noninfectious causes include:
Clinical Manifestations !
o
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o o
o o
o o o o
Diagnosis
o
o
Treatment
o
! ! "
Prognosis
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BRAIN ABSCESS
Causes
Pathology
o
Location and source
Clinical manifestation
o
o o
o
Diagnosis
o $
o o
o
CT with contrast and MRI
o
o
Large multiloculated frontal lobeabscess showing ring enhancement andmidline shift as seen on CT scan
Hypoechoic 6.7 x 5.2 cm.Oval ParietoTemporal Lesion
Treatment
!
!
! !
Surgery is indicated
o !
Prognosis
o o o
o o o o o
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BacterialMeningitis
Tuberculous Meningitis Viral Encepahlitis
S/sx
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FEBRILE SEIZURES
o o
FS Recurrent Seizures
Factors assoc with !recurrence risk
!Risk of developing epilepsy
FS Treatment
o
o o o
o
UNPROVOKED SEIZURES
o
US First seizure
RECURRENT SEIZURES
RS Etiology !
!
o
!o o o o
o
DIAGNOSTIC EVALUATION OF FIRST SEIZURES
Febrile Unprovoked Recurrent
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