CNS Infections

J. Ned Pruitt II Associate Professor of Neurology Medical College of Georgia

Case 1

A 35 yo man is brought to the ER after 5 days of fever and chills. His wife relates that he has been very confused today and she called 911 after a seizure. PMHx is unremarkable except for a splenectomy at age 14 after a traumatic injury. Meds prn tylenol in the last week. NKDA Vaccinations are up to date.

Case 1

Exam Ill appearing man. Temp 39 C. Lethargic and can answer simple questions but can give no meaningful history. Neck is stiff to flexion and extension. A fine petechial rash is on his chest and upper arms.

Case 1 What next?

More examination or history? Labs? Radiology? Medications?

CNS Infections

Meningitis
Bacterial, viral, fungal, chemical,

carcinomatous

Encephalitis
Bacterial, viral

Meningoencephalitis Abscess
Parenchymal, subdural, epidural

CNS Infections

Signs and symptoms

Fever Headache

Altered mental status -lethargy to coma

Neck stiffness meningismus flex/ext Increased intracranial pressure papilledema,

nausea/vomiting, abducens palsies, bulging fontanelle in infants

Exam in suspected CNS Infection

Mental Status Cranial nerve and fundiscopic exam Meningeal Signs General exam rashes, lymphadenpathy Labs CBCD, BMP, PT/PTT, bHCG, blood cultures, UA C&S Radiology CT head - uncontrasted if no focal signs, contrast if mass suspected

LP
Increased intracranial pressure is expected but LP contraindicated if a mass is present or if epidural spinal abscess is suspected Left lateral decubitus position L3-L4 interspace or L4-L5 interspace Think about your studies before the LP

LP
Tube #1 glucose and protein Tube #2 cell count and differential Tube #3 gram stain and rountine culture, cyrptococcal antigen, AFB stain and culture Tube #4 VDRL, or viral studies (PCR)

CSF Characteristics
Bacterial Opening Pressure Glc Pro Rbcs Wbcs (c/mm3) Diff Elevated Low Few >200 PMNs Viral Fungal TB Slightly Normal Ususally elevated or High high Normal Low None <200 Mono None <50 Mono Low High None 20-30 Mono

Very high Normal High

Key CSF Features

CSF is not liquid gold get enough to get your answer CSF Glucose is 2/3 of serum glucose Important in diabetic patients Traumatic LPs CSF pro increases by 1 for every 1000 rbcs Tube #1 and Tube#4 for rbcs when SAH is in the differential not as a routine Very high CSF Protein levels will make CSF yellow Send a full tube of CSF for cytology not just a few ccs

Case 1

CT of head negative. LP - OP (opening pressure) 250mm, glucose 17, protein 92, Rbcs 3, Wbcs 280 with 89% pmns, 11% lymphocytes Gram stain - + for Gram neg organisms

Bacterial Meningitis

Streptococcus pneumoniae Hemophilus influenzae Listeria moncytogenes Group B streptococcus Niesseria meningitidis

Bacterial Menigitis

Age less than 3 months Group B strep L. Monocytogenes

E. coli
Strep pneumoniae

Bacterial Meningitis

3 Months to 18 years
N. meningitidis S. pneumoniae

H. influenzae

Bacterial Meningitis

Age 18 to 50 years
S. pneumoniae N. meningitidis

H. influenzae

Bacterial Meningitis

Over age 50 years

S. pnemoniae L. monocytogenes

Gram (-) bacilli

Treatment of Bacterial Meningitis

PCN G or 3rd generation cephalosporin and consult ID Steroids Dexamethasone IV q6 for 4 days

Viral Meningitis
Very common Often caused by enteroviruses

Treatment is supportive

Viral Encephalitis

Encephalitis (Meningoencephalitis)
Altered mental status and seizures Herpes Simplex virus medial temporal lobe Acyclovir Management of seizures Very high morbidity and mortality PCR diagnosis of CSF West Nile, St Lousi E, EEE, CMV

Chronic Meningitis

Immunocompromised patients
Cryptococcus neoformans HIV

M. tuberculosis
M. avium

Carcinomatous meningitis
Lung, breast

Case 1

Meningitis caused by N. Meningitidis

Treatment with 3rd generation cephalosporin for

10 days Dexamethasone Prophlaxis with Rifampin for contacts