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Suwannna setthawatcharawanich MDSuwannna setthawatcharawanich, MD.
Department of Medicine, PSU
OutlineOutline
Basic anatomy relates to CNS infection
Clinical syndrome of CNS infection
Route of CNS infection
CSF in CNS infection
Principle of management
Structures of brain and spinal cordStructures of brain and spinal cord1. Meninges
Dorsal root gg.
2. Venous drainage of the brain2. Venous drainage of the brain
3. Arterial system of the brain
4. Ventricular system
Syndrome of CNS infections1. Meningitis (inflammation of meninges: dura, arachoid, pia)
2. CNS parenchymap y
2.1 Diffuse CNS parenchyma: encephalitis
2.2 Focal or multifocal CNS parenchyma: 2.2 Focal or multifocal CNS parenchyma
abscess, cerebritis, cerebellitis, myelitis
3 Paramenigeal lesions: then propagate to CNS3. Paramenigeal lesions: then propagate to CNS
epidural, subdural, thrombophlebitis, adjacent organ
Terminology: organ-itis, abscess, granulomaVentriculitis meningitis arteritis thrombophlebitisVentriculitis, meningitis, arteritis, thrombophlebitis,Cerebritis,…. etc.Epidural abscess, brain abscess, granuloma of ..
How to approach patient with CNS infection
Does the patient have CNS infection?Does the patient have CNS infection?
What is the location of infection?
What is the nature (organism)?What is the nature (organism)?
How to manage patient with CNS infection?
How to approach patient with CNS infection
Does the patient have CNS infection?
Fever + clinical syndrome + duration
Differential diagnosis?
Cardinal symptoms / signs of CNS infections
ไข + ปวดหว + focal S / S + meningeal signไข ปวดหว focal S / S meningeal sign+
conscious changeconscious change
encephalitis meningitisabscess
ไข + ปวดหลง + para/quadri + back pain/tendernessl i / iplegia/paresis
S i l bSpinal abscess
Differential diagnosis of meningitis (ไข + ปวดหว + คอแขง)
1. Meningism: childhood, adolescence, fever with headache,
LP normal, improved after LP
2. Drug induced meningitis: asso. with systemic sign of allergy
CSF: PMN, protein ,, p ,
NSAIDs (ibuprofen, sulindac), azathioprine, INH, cotrimoxazole, penicillin, IVIGcotrimoxazole, penicillin, IVIG
3. Vasculitis & CNT
4 Chemical meningitis: substance in subarachnoid space4. Chemical meningitis: substance in subarachnoid space
contrast agent, MTX, spinal block, ruptured cyst (dermoid,
id id i h i ) epidermoid, craniopharyngioma) CSF: lymphocytic purulent profile
5 C i i i i l fil5. Carcinomatous meningitis: low sugar profile
Differential diagnosis of encephalitisDifferential diagnosis of encephalitis1. Drug induced encephalitis: asso. with systemic sign of allergy
CSF PMN t i CSF: PMN, protein ,
NSAIDs (ibuprofen, sulindac), azathioprine, INH,
cotrimoxazole, penicillin, IVIG
2. Vasculitis & CNT
3. Chemical induced: substance in subarachnoid space
contrast agent, MTX, spinal block
CSF: lymphocytic purulent profile
4. Dementia
5. Delirium from other causes6. Multiple brain metastasisp
Differential diagnosis of abscess or granuloma1.Stroke
2.Brain tumor
3.Trauma 4.Vasculitis (CNT). ( )
Differential diagnosis of spinal cord infection
1 Myelitis from other causes:1. Myelitis from other causes:radiation, post-infection, substance, multiple sclerosis
2 St k 2. Stroke 3. Tumor 4. Vasculitis 5 T 5. Trauma
How to approach patient with CNS infection
Does the patient have CNS infection?
S d f CNS i f ti
What is the location of infection?
Syndrome of CNS infection
Source/route of infection
Cardinal symptoms / signs of CNS infections
ไข + ปวดหว + focal S / S + meningeal signไข ปวดหว focal S / S meningeal sign+
conscious changeconscious change
encephalitis meningitisabscess
ไข + ปวดหลง + para/quadri + back pain/tendernessl i / iplegia/paresis
S i l bSpinal abscess
Syndrome of CNS infection1. Acute meningitis syndrome
2. Subacute/chronic meningitis syndromeg y
3. Acute encephalitis syndrome
4 Ch i h liti d4. Chronic encephalitic syndrome
5. Space - occupying lesion syndrome
6. Toxic - mediated syndrome
Clinical syndrome + duration
Route of infectionf f1. Hematogenous
1 1 Arterial: septicemia septic emboli ----> meningitis abscess mycotic aneurysm 1.1 Arterial: septicemia, septic emboli ----> meningitis, abscess, mycotic aneurysm
1.2 Venous: face, scalp infection -----> emissary v. ----> cerebral thrombophlebitis
2 Lymphatics intra abdominal pelvic infection > spinal or epidural abscess2. Lymphatics: intra-abdominal, pelvic infection ----> spinal or epidural abscess
3. Direct penetration
3 1 I f i f dj i i di i i i li i 3.1 Infection of adjacent organ: otitis media, sinusitis, osteomyelitis
3.2 Trauma, surgery, LP
3.3 Communication between subarachnoid space and outerpart
e.g. CSF rhinorrhea, otorrhea, Pilonidal sinus
3.4 Olfactory epithelium: Amoeba, Herpes simplex
4. Neurotropic spread: rabies
How to approach patient with CNS infection
Does the patient have CNS infection?
What is the location of infection?
Host?
What is the nature (organism)?Host?
CSF analysis
Host
Immunocompetent ImmunocompromisedImmunocompetent Immunocompromised
NewbornNewborn ElderlyChronic diseases
DM, cirrhosis,SLE, RF, etc.
Ch thChemotherapy Prolong antibiotics
Community vs Hospital acquired
Urgent LP ปลอดภยไหม ตองทา CT สมองกอนไหม
Contraindication for LP
1. Absolute:
1 1 ICP from mass lesion1.1 ICP from mass lesion
( papilledema and/or localizing sign)
1.2 Skin infection at LP area
2 Relative: 2. Relative:
2.1 Bleeding tendency
2.2 Septicemic state
CSF examination :
- Lumbar puncture- Cervical puncture, cisternal punctureCervical puncture, cisternal puncture- Ventricular puncture
1 Opening pressure/ closed pressure1. Opening pressure/ closed pressure2. Physical appearance Mi i b b t b3. Microscopic exam: wbc, rbc, cryptococcus, ameba
4. Protein, sugar/blood sugar5. Gram stain, indian ink, AFB, mod. AFB6. Culture: aerobe, TB, fungusg7. Others: ADA, bacterial Ag, cryptococcal Ag, viral
titer, VDRL, PCRtiter, VDRL, PCR
Normal CSF finding1. Clear, colorless. lear, colorless
2. Pressure 15-20 mmHg
El l 3. Electrolyte: Na 137-145, K 2.7-3.9,
Cl 116-122, CO2 20-24
4. Protein 20-50 mg%
5 S 40 70 % 2/3 BS5. Sugar 40-70 mg%, 2/3 BS
6. Cell < 5 /ml, all monocuclear cell 7. No abnormal cell
f F f dType of CSF findings
1 Purulent profiles: 1. Purulent profiles:
2. Lymphocytic - normal glucose
3. Lymphocytic - low glucose
E i hili4. Eosinophilic
CSF profiles Purulent Lymph-glc(N) Lymph-glc(low) Eop y p g ( ) y p g ( )
Appearance cloudy clear xanthochrom cloudyPressure ++ +/N +++/++++ ++/+++Pressure ++ +/N +++/++++ ++/+++Cell (wbc) +++ + ++ ++/+++
predominantly PMN Lymph Lymph EoProtein ++ + +++ ++Protein ++ + +++ ++Sugar --- N -- -
+; mild increased ++ moderate +++ severe+; mild increased, ++ moderate, +++ severe-; mild decrease, -- moderate, --- severeN; normal
Purulent CSF: PMN, low sugar, high prot, slightly ICP
1. Bacterial meningitis*** :
g g p g y
g
Streptococcal pneumoniae
H hil i flHemophilus influenzae
Neiseria meningitidis etc.
2. Amoebic meningoencephalitis (naegleria fowleri)
3 Chemical meningitis contrast media ruptured 3. Chemical meningitis: contrast media, ruptured
dermoid/epidermoid cyst
4. Drug induced meningitis: NSAID, penicillin,
cotrimoxazole IVIG cotrimoxazole, IVIG
2. Lymphocytic - normal glucose CSF:
1 V l h l
y p y gnormal ICP, normal or slightly increased protein
1. Viral meningitis/encephalitis*** :
Adenovirus, echovirus, herpes virus, etc.p
2. Post-viral/post-vaccinal meningoencephalitis
3 Spir ch t rick ttsi l3. Spirochate/rickettsial
4. Bacterial meningitis: partially treated,
Listeria monocytogenes
5 Parameningeal infection5. Parameningeal infection
6. Vasculitic disease
3. Lymphocytic – low glucose CSF: high prot, high ICP
1. TB meningitis***2. Fungal meningitis***: cryptococcus neoforman etc.3. Carcinomatous meningitis: CA, lymphoma, leukemia3. Carcinomatous meningitis CA, lymphoma, leukemia4. Viral: mumps, Herpes Simplex, Lymp choriomeningitis
4 Eosinophilic CSF:4. Eosinophilic CSF: high ICP, N/slightly high prot, sometime low sugar
1. Angiostrongylus catonensis & Gnathostoma spinigerum**
usually more than 20%
2 Other parasitic infection: usually no more than 20%2. Other parasitic infection: usually no more than 20%
NB. CSF eosinophilia: present Eo in the CSF
(trauma, blood, gas)
3. Tumor
Diagnosis of meningitisg g
1. Clinical syndrome of meningitis
Clinical: fever + headache + neck stiffnessAcute vs chronic
2. Source of infection
Clinical: history, physical exam
3. Laboratory
CSF exam, CT/MRI head, other fluid stain/culture, other
lab chem: hemoculture CBC antibody titer etclab chem: hemoculture, CBC, antibody titer, etc.
How to approach patient with CNS infection
Does the patient have CNS infection?Does the patient have CNS infection?
What is the location of infection?
What is the nature (organism)?What is the nature (organism)?
How to manage patient with CNS infection?
M t f CNS i f tiManagement of CNS infection
Prompt treatment is neededp
1. Specific treatment: depend on organismconsider surgical role if neededconsider surgical role if needed
2. Symptomatic treatment3. Be careful of complicationp
1. Acute meningitis syndrome1. Acute meningitis syndrome
ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน
+/- photophobia, CN palsy, other focal S&S, consciousness
Systemic exam. May reveal cluses: herpetic ruption, parotitis,
orchitis, eschar, purpura + shock
urgent LPurgent LP
CCauses:1. Bacteria*** 2. Virus***3. Spirochate/ ricketsia 4. Amoeba3. Spirochate/ ricketsia 4. Amoeba5. Parasite: Angio, Gnatho 6. Chemical/drug induced7. Immunological 8. Miscellaneous9. Meningism
Treatment1. Antibiotics: พจารณา host, clinical, community or hospital acquired
ceftriaxone 2 gm iv q 12 hr, 7-14 d รอผล culturef g q ,
และ sense
กรณ gram positive: ให AB 7-10 d gram negative ให AB 14-21 d กรณ gram positive: ให AB 7 10 d, gram negative ให AB 14 21 d
และตอง LP ซากอนหยด AB โดยม CSF: cell < 50, all mononuclear
Bacterial meningitis: ตองหา source/route of intectionBacterial meningitis: ตองหา source/route of intection
2. กรณ virus: symptomatic : analgesic: paracet, NSAID
ใ 1 ป อาการจะคอยๆดขนใน 1 สปดาห
3. กรณ eosinophilic meningitis: symptomatic: analgesic
ถาม s/s of increased intracraial pressure: LP for release
pressure + corticosteroid oral form, ใหคาแนะนาในการปองกนการตด
ซา เชนการกนอาหาร
2. Subacute/chronic meningitis syndrome2. Subacute/chronic meningitis syndromeไข + ปวดหว + คอแขง ในเวลาเปนสปดาห - เดอน
+/- photophobia, CN palsy, other focal S&S, consciousness
papilledema
Systemic exam. May reveal clues: PPE, Hairy leukoplakia,
umbilicated papule, cachexia p p ,
Diagnosis: Hx + PE +/- CT + CSF exam
CausesCauses1. TB meningitis***2. Cryptococcal meningitis***3. Carcinomatous meningitis: CA, hematologic malignancy4. Neurosyphilis5 V liti di5.Vasculitic diseases6. Sarcoidosis
T tm tTreatment1. กรณ TB meningitis: ให 2IRZE ตามดวย 10IR ตดตามอาการในระหวางใหยา บาง
รายอาจมอาการแยลงไดเลกนอย พจารณาให steroid 1 mg/kg/d 2-4 wk เมอ
1. ม neurological deficit: hemiparesis, paraparesis, etc.
2. decreased consciousness
3. S/S of increased intracranial pressure
4. prominent encephalitic component
5. CSF protein > 500 mg%, or other evidence of spinal blockp g p6. visual failure secondary to chiasmatic arachnoiditis
2. กรณ cryptococcal meningitis:ให amphopericin B 0.25-1mg/kg/dyp g p p g g
total course 1-1.5 gm หลงจากนน ถา normal host หยดยาได ถา AIDS ให
fluconazole 200 mg/d life longfluconazole 200 mg/d life long
3. Acute encephalitis syndrome3. Acute encephalitis syndromeไข + สบสน/อาละวาด/ซม +/- ปวดหว +/- คอแขง
Diagnosis: Hx + PE + CSF exam +/- CT scanCauses:
1. Viral encephalitis***
2. Post viral/post vaccinal encephalitisp p
3. Spirochate, ricketsia
4 Mycoplasma pneumoniae4. Mycoplasma pneumoniae
5. Amoeba
6 Cerebral malaria6. Cerebral malaria
7. Rabies
T tm tTreatment1. Symptomatic : analgesic, anticonvulsant, etc.
2. In case of Herpes simplex encephalitis: positive temporal
lobe lesion in imaging and/or suggestive CSF ( slightly low sugar, lymphocyte, red blood cell) ให acyclovir 10 mg/kg iv
q 8 hr 7-10 d
3. Cerebral malaria:
quinine IVq
plasma exchange in case of hyerparasitemia + impairedconsciousness (parasitemia > 10%) (p )
4. Chronic encephalitis syndrome4. Chronic encephalitis syndrome1. Virus: HIV, SSPE(subacute sclerosing panecphalitis, etc.
2. Spirochate: neurosyphilis
3. Prion: CJD(crufeldt Jacob disease), Kuru( ),
5. Toxic - mediated syndrome1. Tetanus
2. Botulism
3. Pertussis
6. Space - occupying lesion syndrome6. Space occupying lesion syndrome ปวดหว (abscess, cerebritis, granuloma)
ไข + + neurological deficit + papilledema
ปวดหลง (spinal abscess, myelitis, epidural abscess)( p , y , p )
C / CSDiagnosis: Hx + PE + CT/MRI + CSF examCauses:
1. Brain abscess, spinal abscess
2. Brain granuloma
3. Brain cyst
4. Subdural empyemapy
5. Epidural abscess
TreatmentTreatment1. Brain abscess: antibiotics, surgery
2 Spinal abscess: in case of epidural abscess emergency2. Spinal abscess: in case of epidural abscess emergency
surgery, in case of intra-spinal abscess antibioticsand/or surgeryand/or surgery
3. Myelitis:ขนกบวาเปนจากอะไร ถาเปนจาก TB ใหการรกษาแบบTB + steroid,
li i i i i i l ll ถาเปน myelitis จาก virus, post vaccination, post viral, allergy to
contrast media ใหการารกษาตามอาการ, ถาไมพบสาเหตทเกยวของ อาจเปน multiple
sclerosis ให methylprednisolone 250 mg iv q 6 hr 3 d ตามดวย oral
prednisolone 60 mg/d 11 d then tape off
suggestion: refer if no neurologist, neurosurgeon,
MRI in the hospital,กอน refer ตองดผปวย เตรยมเครองชวยเหลอใหด,พรอม
เพราะผปวย myelitis อาจ progress ในระหวาง refer ได
Complication of CNS infection1. Edema: ---> ICP2. Hydrocephalus: obstructive or communicating3. Cortical thrombophlebitis: focal S&S,
consciousness, seizure,4. Cerebral vasculitis: focal S&S, seizure,
behavior change etcbehavior change, etc.5. Syndrome of inappropriate secretion of
nti diuretic h rm neanti-diuretic hormaone6. Cranial neuropathy7. Seizure8, Other: subdural effusion, abscess, ventriculitis,
syringomyelia, pituitary insufficiency
Case1ป 25 ป ผปวยหญง อาย 25 ป รบราชการ บานอย จ. ตรง
CC. ไข ซม 1 วนPI. 2 วนกอนมารพ. ไขสง บนปวดศรษะ กนอาหารไดนอย นอนเกอบตลอดเวลา
อาเจยนบางครง
1 วน ซม ปสสาวะราด อาเจยน ญาตจงพามารพ.PH. SLE 1 ป รกษามาตลอด ลาสดไดยา prednisolone 30 mg/dPE. T 39 C BP 100/70 mmHg P100 /min RR 26/minSystemic exam: unremarkableN l i l E V MNeurological exam: E2V2M5
Sensation, cerebellar : can’t evaluateMotor: move all four limbs (localize pain)Motor: move all four limbs (localize pain)CN : doll’s eye ---> positive, normal fundiReflex : 1+ allStiffness of neck : positive
คาถามคาถาม
1. พยาธสภาพอยทใด
2. พยาธสภาพนาจะเปนอะไร
3. แนวทางตรวจทางหองปฎบตการคออะไร
4. เชอททาใหเกดโรคคออะไร
Meninges, acute meningitis
LP : turbid open pressure 22 mmHgLP : turbid, open pressure 22 mmHg
cell 21,000/mm3 PMN 98%
sugar 15 mg% BS 80 mg% protein 98 mg%sugar 15 mg% BS 80 mg% protein 98 mg%
Gram -ve rod
Case4.ผปวยหญง อาย 20 ป นกศกษา บานอยจ สงขลาผปวยหญง อาย 20 ป นกศกษา บานอยจ. สงขลา
CC. พฤตกรรมเปลยนแปลง 1 วนPI 3 วนกอนมารพ มไข ไมไอ ไมมนามก บนปวดศรษะ ดซมๆ แตยงชวยตวเองไดPI. 3 วนกอนมารพ. มไข ไมไอ ไมมนามก บนปวดศรษะ ดซมๆ แตยงชวยตวเองได
1 วนกอนมารพ. พดจาสบสนไมคอยรเรอง ตอนเยนชกทงตว 1 ครง และซมลง ญาตจงพามารพ ญาตจงพามารพ.
PH. แขงแรงดPE T 38 5 C PR 100/ i BP 130/70 H RR 24/ iPE. T 38.5 C PR 100/min BP 130/70 mmHg RR 24/min
Systemic exam: unremarkable
Neurological exam: E3V4M6
Motor: move all four limbs actively
CN: normal, normal fundi
Other: unremarkable
Reflex: 2+ all, stiffness of neck- negative
คาถามคาถาม
1. พยาธสภาพอยทไหน2. พยาธสภาพนาจะเปนอะไร3. แผนการตรวจทางหองปฎบตการคออะไรฎ
4. เชอททาใหเกดโรคนาจะเปนอะไร
Brain parenchyma, acute encephalitisp y , p
LP: slightly turbid, open pressure 22 mmHg closed pressure 20 mmHg
cell 100/mm3 mono 100%cell 100/mm mono 100%
protein 80 mg% sugar 60 mg% BS 80 mg%
Gram stain - no organismGram stain - no organism
The Solution Focus Making thing p itive d e n’t mean a nny tl k it mean Making things positive doesn t mean a sunny outlook; it means making the choice to see problems as opportunities. Every problem and difficult situation is embedded with a solution the adventure and difficult situation is embedded with a solution - the adventure lies in finding the solution.
ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน
Acute meningitis
อาการอนทพบได คอ
g
อาการอนทพบได คอ
+/- photophobia, CN palsy, other focal S&S,
consciousness
Systemic exam may reveal clues:Systemic exam. may reveal clues:
herpetic eruption, parotitis, orchitis, eschar,
purpura + shock
H d h d?Headache caused?
Meningitis
1 A t i iti1. Acute meningitis
2. Subacute/chronic meningitis2. Subacute/chronic meningitis
ไข + ปวดหว + คอแขง ในเวลาเปน สปดาห - เดอน
Subacute/chronic meningitis
Causes1. TB meningitis***2. Cryptococcal meningitis***3. Carcinomatous meningitis: CA4. Neurosyphilisyp5.Vasculitic diseases6. Sarcoidosis
Type of CSF findings
Purulent profiles1. Purulent profiles
2. Lymphocytic - normal glucosey p y g
3. Lymphocytic - low glucose
4. Eosinophilic
Syndrome of CNS infectionA t i iti d1. Acute meningitis syndrome
2. Subacute/chronic meningitis syndrome
3. Acute encephalitis syndrome
4 Chronic encephalitic syndrome4. Chronic encephalitic syndrome
5. Space - occupying lesion syndrome
6. Toxic - mediated syndrome
Case 2 ผปวยชาย อาย 30 ป อาชพคร บานอย จ.พทลง ผปวยชาย อาย 30 ป อาชพคร บานอย จ.พทลงCC. ไข ซม 1 วนPI. 4 สปดาหกอนมารพ. มไขตาๆ บนปวดศรษะทวไป กนอาหารไดนอยลงPI. 4 สปดาหกอนมารพ. มไขตาๆ บนปวดศรษะทวไป กนอาหารไดนอยลง
กนยาแกปวด อาการดขนแตไมหายขาด ยงคงทางานได1 สปดาหกอนมารพ บนปวดศรษะมากขน อาเจยนบางครง ทางานไมไหว 1 สปดาหกอนมารพ. บนปวดศรษะมากขน อาเจยนบางครง ทางานไมไหว
นอนทงวน
1 วนกอนมารพ ซมลง 1 วนกอนมารพ. ซมลงPH. แขงแรงดPE T 37 C BP 150/100 H PR 80/ i RR20/ iPE. T 37 C BP 150/100 mmHg PR 80/min RR20/minSystemic exam: unremarkableNeurological exam: E V M ตอบคาถามไดแตชาNeurological exam: E3V4M5 ตอบคาถามไดแตชา
CN: normal, normal fundiMotor: grade III at leastgSensation, cerebellar : can’t evaluateReflex: 1+ all, BBK-absent, Stiffneck- positive
คาถามคาถาม
1 พยาธสภาพอยทไหน
2. พยาธสภาพนาจะเปนอะไร
3 แผนการตรวจทางหองปฎบตการคออะไร
4. เชอททาใหเกดโรคนาจะเปนอะไร
Meninges, chronic meningitis
CT scan of the brain: normal
LP: open pressure 40 closed pressure 25 mmHg
cell 200 /mm3 mono 100%cell 200 /mm mono 100%
protein 450 mg% sugar 30 mg% BS 100 mg%
India ink - positiveIndia ink - positive
Case 3 ผปวยชายอาย 40 ป อาชพกอสราง บานอยจ นครศรธรรมราช ผปวยชายอาย 40 ป อาชพกอสราง บานอยจ. นครศรธรรมราชCC. ปวดศรษะ ซมลง 2 สปดาหPI. 2 สปดาหกอนมารพ. ปวดศรษะดานขวาตอๆตลอดเวลา กนยาแกปวดดขนๆ
แตไมหายขาด อาการปวดคอยๆรนแรงมากขน มไขรวมดวย1 สปดาห กอนมารพ. แขนขาดานซายออนแรง เดนไมถนด ยงคงปวด
ศรษะบอยๆ และมไข 1 วนกอนมารพ. นอนเกอบตลอดเวลา อาเจยน และบนปวดศรษะ ซมลงPH. หนาหนวกเรอรง มหนองไหลจากหทง 2 ขางเปนๆหายๆ มา 2 เดอนPE. T 38 C BP 140/80 mmHg PR 90/min RR 22/min
Systemic exam: bilaterally chronic otitis media with discharge
Neurological exam:Neurological exam:
Neurological exam: E3V5M6
Motor: left hemiparesis grade IV
Sensation : intact
CN: left facial palsy UMN, bilateral papilledema
C ’Cerebellar: can’t evaluate
Reflex: hyper-reflexia 3+ on the left
BBK: present - left
Stiffness of the neck: negativeStiffness of the neck: negative
คาถามคาถาม
1. พยาธสภาพนาจะอยทไหน
2. พยาธสภาพนาจะเปนอะไร3 ป ไ3. แผนการตรวจทาง หองปฎบตการคออะไร
Brain, supratentorial lesion
Mass ----> infection: cerebritis or abscess
CT scan of the brain: brain abscess
Classification of CNS infection base on anatomyy
1. Meningitis
2. Parameningeal infection
2.1 Abscess
2.2 Thrombophlebitis
Str ct re adjacent to meninges2.3 Structure adjacent to meninges
3. Encephalitis
4. Cerebritis
5 Cerebellitis5. Cerebellitis
6. Myelitis
Figure 18c. Tuberculosis basilar meningitis in a 30-year-old woman with HIV infection.
Smith A B et al. Radiographics 2008;28:2033-2058
©2008 by Radiological Society of North America
Structures of brain and spinal cordStructures of brain and spinal cordMeninges
She woke up this morning complaint of severe Acute severe headacheShe woke up this morning complaint of severe headache diffuse or localize?
High grade fever 1 day priorHigh grade fever 1 day priorVery severe chills
Neck stiff sore, painful when she tilts her neck forward Stiffness of neck
B i ht li ht h t h Ph t h biBright light hurts her eyes Photophobia
No skin rash, no recent contactsNo trauma, no sinus infectionN i d fi i
No source of infectionI t t h tNo immunodeficiency
No immunosuppressive drugImmunocompetent host
Pertinent subjective data
1. Female 25 years old
2 Acute high fever with chills for 1 day2. Acute high fever with chills for 1 day
3. Severe headache, neck stiffness with pain,
photophobia
4 No source of infection from history4. No source of infection from history
Pertinent objective data
1. Vital sign SIR (systemic inflammatory response):
T39, PR115, RR24
2. Photophobia but normal fundi
3. No focal neurological deficit
4. Positive Kernig and Brudzinski signs
5. Neck – stiff and painful w flexion = stiffness of neck
6. No source of infection by physical examination
- Meningeal irritation
Stiffness of neck
g- Cervicomedulla lesion- Cervical vertebra
N k l- Neck muscle- Menigism
Duration:1 2 days
Meningeal irritation
Duration:1-2 days
Severe diffuse headacheFever
- Meningeal irritation(blood or air or pus?)- Meningismg
Photophobia Meningeal irritation= meningitis
ไข ปวดหว คอแขง Meningitis syndromeไข ปวดหว คอแขง Meningitis syndrome
Duration?
Hours to few days Weeks to months
Acute meningitis Subacute/chronici itiAcute meningitis meningitis
Pain-sensitive cranial structures1 Intracranial structure: sinus afferent v a of dura mater1. Intracranial structure: sinus, afferent v.,a. of dura mater,
circle of Willis &its branches, dura mater adjacent to large
arteriesarteries.
2. Extracranial structure: scalp, fascia, muscle, mucosa arteries.
3 CN 5 7 9 10 i l 2 33. CN 5,7,9,10, cervical nerve 2,3
Pain-insensitive cranial structures Brain parenchyma, ependyma, choroid plexus, pia, arachnoid Brain parenchyma, ependyma, choroid plexus, pia, arachnoid
membrane, dura, skull (except stretched periosteum)
Acute meningitis syndrome
ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน
Causes:1. Bacteria*** 2. Virus***3. Spirochate/ ricketsia 4. Amoeba5. Parasite: Angio, Gnatho 6. Chemical/drug induced7. Immunological 8. Miscellaneous9. Meningism
CBC: leukocytosis with neutrophilia
Urgent LP
y p
Urgent LP
Treatment
Pyogenic bacterial meningitisy g gSpecific antibiotics = urgent
Gram +: ceftriaxone (resistant strep)( p)cloxacillin (skin infection)10-14 daysy
Gram -: up to host & sourceceftazidime – melioidosis3 weeks with LP (mono <50, normal
sugar, decreased protein level, culture - )g p )Be careful complications