Acute CNS Infections

ACUTE CNS INFECTIONS
1. Bacterial
meningitis***
2.
Meningoencephalitis
3. Brain abscess
4. Subdural empyema
5. Epidural abscess
6. Septic venous sinus
thrombophlebitis
BRAIN ABSCESS
 This is a focal suppurative infection
within the brain parenchyma,
typically surrounded by a
vascularised capsule.
Predisposing factors
 otitis media, dental infection, mastoiditis,
 sinusitis, skull trauma or surgery
 cyanotic congenital heart disease
 Pyogenic infection in chest or other body
site
 Sex- more frequently in males than in
females.
 Age- occur more frequently in the first 4
decades of life
Causes
The predominant organisms include the
following:
 Staphylococcus aureus,Aerobic and
anaerobic streptococci (especially
Streptococcus intermedius)
 Bacteroides, Prevotella, and
Fusobacterium species
 Enterobacteriaceae organisms
 Pseudomonas species
 Other anaerobes
Causes ctd…
Less common causes include the
following:
 H influenzae,Streptococcus
pneumoniae
 Neisseria meningitidis,Nocardia
asteroides
 Mycobacterium
 Fungi (eg, Aspergillus, Candida,
Cryptococcus, Mucorales, Coccidioides,
Histoplasma capsulatum, Blastomyces
dermatitidis, )
 Protozoa (eg, Toxoplasma gondii,
Entamoeba histolytica, Trypanosoma
cruzi, Schistosoma, Paragonimus)
Clinical features
 headache, 70%;
 mental status changes, 65%;
 focal neurologic deficits, 65%;
 fever, 50%; seizures, 25-35%;
 nausea and vomiting, 40%;
 nuchal rigidity, 25%; and
 papilledema, 25%.
Localized neurologic signs
 Cerebellar abscess - Nystagmus,
ataxia, vomiting, and dysmetria
 Brainstem abscess - Facial weakness,
headache, fever, vomiting, dysphagia,
and hemiparesis
 Frontal abscess - Headache,
inattention, drowsiness, mental status
deterioration, motor speech disorder,
and hemiparesis with unilateral motor
signs
 Temporal lobe abscess - Headache,
ipsilateral aphasia (if in the dominant
hemisphere), and visual defects
Investigations
Lab Studies:
Routine tests
 CBC ,ESR,Serum C-reactive protein
(CRP)
 Blood cultures (at least 2; preferably
before antibiotic usage)
 Moderate leukocytosis is present, and
the erythrocyte sedimentation rate and
CRP are generally elevated. Serum
sodium levels may be lowered as a
result of inappropriate antidiuretic
hormone production.
Investigations ctd…
 Abscess aspirate by stereotactic
needle aspiration.
 Culture aspirates of abscesses for
aerobic, anaerobic, and acid-fast
organisms and fungi
 CSF –Not helpful for diagnosis or
Trt.
Ctd…
 CT scanning
 Contrast CT-show the brain
abscess as a hypodense center
with a peripheral uniform
enhancement ring.
 MRI
 Contrast enhancement with

gadolinium diethylene
triaminepentaacetic acid
BRAIN ABSCESS (CT
SCAN)
D/D
 Subdural empyema.
 Bacterial meningitis.
 Viral menigoencephalitis
 Superior sagital sinus thrombosis.
 Acute dissaminated
encephalomyelitis.
 Brain tumor
 Cerebral infarct, hematoma.
BRAIN ABSCESS
Empiric Therapy
Ceftriaxone - 2gm IV bd
OR X 6- 8 wks
Cefotaxime - 3gm IV qid
+
Metronidazole 500 mg IV q6h
 Add nafcillin 12 gm/d if staph suspected

(use vanc if MRSA a concern)
Treatment ctd…
 Aspiration and drainage under
stereotacxic guidance.
 Craniotomy or craniectomy- Multi-
loculated or unsuccess aspiration.
 Anticonvulsant
 IV dexamethasone if periabcess
edema +
CRYPTOCOCCAL MENINGITIS
Epidemiology
 Incidence of C.neoforman has
increased from 1981.
 It is the most common form of adult
meningitis in Africa
 Third most common neurologic
presentation of AIDS sub Saharan
 First AIDS defining condition in 40-
91% of patients
Clinical presentation
 Insidious onset with non specific
symptoms mean duration of 2wks
 Clinical features:
Headache 97%
Fever 61%
Altered conciousness 58%
Neck stiffness 74%
Seizures 13%,
Lab investigations
 CSF:
Elevated pressure
Abnormal
WBC,glucose,protein
(but may be normal)
Indian Ink Stain
Cryptoccocal antigen test
CSF culture
Lab investigations
 Serum cryptoccocal antigen test
 Serum & urine fungal culture
 Others:
 Neuroimaging: MRI/CT scan
INTERNATIONAL CENTRE FOR EYE HEALTH TEACHING SET NO.8 HIV/AIDS
22. HIV / AIDS: Opportunistic Infections of the Brain
•Cryptococcal
Meningitis with
papilloedema
• Cryptococcal
granuloma (before and
after treatment)
Other associated OI
 Oral candida
 Tuberculosis
 Herpes Zoster
Treatment
 AMPHOTERICIN B 0.7-1.0mg/kg/d
x2wks followed by
 Fluconazole 400mg po od 8wks or
itraconazole 400mg/day
 Maintenance
 Fluconazole 200mg od po or
 Itraconazole 200mg bd po or
 Amphotericin B 1mg/kg iv X 1-2 times/
wk
Prevention
 Primary and secondary prophylaxis
 Screening
 Monitoring
 Early diagnosis
 HAART
Course and prognosis
 Poor indicators:
altered mental status
cranial nerve involvement
high intracranial pressure
high number of organisms
Course & prognosis
 Untreated cryptococcal meningitis
is almost 100% fatal
 Median survival without treatment
in Blantyre is 4 days, Harare 14
days, Zambia 10days
 35% hospital deaths in patients
treated with fluconazole only at
Lilongwe Central Hospital
VIRAL / ASEPTIC MENINGITIS
 Aseptic meningitis is an illness

characterized by serous
inflammation of the linings of the
brain (ie, meninges), usually with
an accompanying mononuclear
pleocytosis.
VIRAL MENINGITIS/ENCEPHALITIS
Herpesviruses Enteroviruses
Herpes simplex Polioviruses
Varicella-zoster Coxsackieviruses
Epstein Barr Echoviruses
Cytomegalovirus Togaviruses
Myxo/paramyxoviruses Eastern equine
Influenza/parainfluenzae Western equine
Mumps Venezuelan equine
Measles St. Louis
Powasson
Miscellaneous
Adenoviruses California
Rabies West Nile
HIV
Differential Diagnosis
Bacteria
 Partially treated meningitis
 Parameningeal infection
 Endocarditis
 Mycoplasma pneumoniae
 M tuberculosis
 Ehrlichiosis - Monocytic, granulocytic
 Borrelia burgdorferi
 Treponema pallidum
 Brucella species
Fungi
 C neoformans
 Histoplasma capsulatum
 Coccidioides immitis
 Blastomyces dermatitides
Parasites
 Toxoplasma gondii
 Taenia solium (cysticercosis)
D/D ctd…
Noninfectious causes
Drugs
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Trimethoprim-sulfamethoxazole, amoxicillin
Azathioprine
 Intravenous immunoglobulin
 Isoniazid
 Intrathecal methotrexate
 Intrathecal cystine arabinoside
 Vaccination
 Allopurinol
D/D ctd…
Systemic diseases
 Sarcoidosis
 Leptomeningeal cancer
 Systemic lupus erythematosus
 Wegener granulomatosis
 CNS vasculitis
 Behçet disease
 Vogt-Koyanagi-Harada syndrome
CFs
 Headache, fever, stiff neck, photophobia,
drowsiness, myalgias, malaise, chills, sore
throat, abdominal pain, nausea, and vomiting
usually characterize acute viral meningitis.
Focal signs, seizures, and profound lethargy
are rarely a part of this syndrome. The
diagnosis may be suggested by associated
skin manifestations such as the rash of
varicella zoster, genital lesions for HSV-2, or a
mild maculopapular rash occurring in the
summer and fall months with
enteroviruses.Patients may exhibit altered
levels of consciousness including confusion
and visual hallucinations.
Investigations
 Presence of less than 500 mononuclear
cells/mm3 of CSF (pleocytosis) is
characteristic
 CSF pressure may be elevated,
whereas the glucose level is
characteristically normal or only
modestly decreased.
 CSF protein level usually is elevated
(50-80 mg/dL).
 Other test results include negative
bacterial antigen tests and low levels of
tumor necrosis factor (TNF) and lactate
THE PATIENT WITH SUSPECTED
CNS INFECTION
Contraindications to LP
Absolute: Skin infection over site
Papilledema, focal neuro
signs, ↓MS
Relative: Increased ICP without
papilledema
Suspicion of mass lesion
Spinal cord tumor
Spinal epidural abscess
Bleeding diathesis or ↓ plts
Lab tests
 CBC, differential, platelet count
 Sedimentation rate, antinuclear
antibody, rheumatoid factor
 Plasma glucose,BUSE
 Sjögren syndrome antigens A and B
 Serum protein electrophoresis
 Lyme titer (enzyme-linked
immunosorbent assay [ELISA])
 VDRL, fluorescent treponemal antibody
absorption test (FTA-ABS)
Imaging studies
 Chest x-ray, posteroanterior and
lateral
 MRI &CT of brain/spine
Investigation ctd…
 PCR screening of CSF has become an
important diagnostic tool and can help in
the isolation of several viruses
 Culture is the criterion standard for
diagnosis, but it may not be positive in
all patients.
 Direct viral isolation is of limited value in
making the diagnosis, since it takes
several days
 Serological test for Ab detection.
Treatment
 Acyclovir

Acute CNS Infections

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ACUTE CNS INFECTIONS

 Contrast enhancement with

 Add nafcillin 12 gm/d if staph suspected

22. HIV / AIDS: Opportunistic Infections of the Brain

 Aseptic meningitis is an illness

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