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NERVOUS SYSTEM
RADANG I
DR. dr.Kiking Ritarwan, SpS(K), MKT
1. KAKU KUDUK
2. TANDA BRUDZINSKI I
4. TANDA BRUDZINSKI II
Absorpsi Lymphatics
/cribiform plate
Aliran Transependymal
Rute dan Absorpsi CSF
Arachnoid villi secara
mikroskopik
katup satu arah ( dimodifikasi
pia
dan arakhnoid yang penetrasi
ke
lapisan dura meningeal di
garis
sinus , karena itu vili
arakhnoid
memasuki dalam sinus
tertama
sinus sagitalis superior).
Meningitis TBC
TB meningitis (TBM)
Definition:
TBM is an infection of the meninges caused by
the acid-fast bacillus Mycobacterium
tuberculosis.
In the west country,the first make not much
difference again, but lately incident mount
drastically in all the world.
TBM happened at all of age.
Before important HIV factor in prevalens is age
+ 1,7 milyar people ( 1/3 worldwide
people) Mycobacterium tuberculosa
infected.
Reported CDC 2002 was 5,36 cases per
100.000 people, but worldwide the
infection rate is much higher.
TB in Indonesian occupy 3rd rank from 22
high burden countries.
Indonesia
22 High Burden Countries
1. India
2. China
3. Indonesia
4. Bangladesh
5. Nigeria
6. Pakistan
7. South Africa
8. Philippines
9. Russia
10. Ethiopia
11. Kenya
China 12. DR Congo
15% 13. Viet Nam
Indonesia 10%
14. UR Tanzania
Bangladesh 4%
15. Brazil
Pakistan 4% 16. Thailand
India 17. Zimbabwe
Philippines 3%
30% 18. Cambodia
Nigeria 3% 19. Myanmar
South Africa 2% 20. Uganda
Other 21. Afghanistan
Russia 1%
28% 22. Mozambique
3% of All Deaths in Developed
Countries Are Due to Tuberculosis
Tuberculosis Malaria
Diarrheal disease
Perinatal causes
2%
3% 3%
Chronic obstructive 4%
pulmonary disease 5%
Other
HIV/AIDS 5% 27%
Respiratory tract
infection 7%
Coronary heart
Injury
disease
9%
Cancer 13%
Stroke 12%
10%
(terminus/ advance)
The course of the illness depends:
- on the extend of meningeal involvement,
- the immune response of the host,
- the virulence of the organism,
- and the stage at which treatment is
administered.
Kategori diagnosis Ogawa
Definite
- bila kultur positi
- otopsi positip, atau keduanya
Probable
- likuor pleiositosis (>5/mm3), kultur bak-
teri dan jamur negatip + salah satu:
1. test tuberkulin positip
2. TB diluar SSP atau TB aktip sebelumnya
3. glukosa likuor < 40 mg/dl
4. protein likuor > 60 mg/dl
SistemSkoringKlinik
Sensitivitasuntuk
diagnosis TBM 99%
Belum diujikan terhadap
kelompok HIV+
Diagnosis Meningitis TB
Kategoridiagnostik
– Thwaites
MTB definite:
– Gejala klinis meningitis
dan
– Gambaran LCS abnormal
dan
– BTA di LCS (mikroskopi) dan/atau kultur TB positif
(PCR?)
Diagnosis Meningitis TB
Kategoridiagnostik
– Thwaites
MTB probable:
– Gejala klinis meningitis
dan
– Gambaran LCS abnormal
dan
– Didapatkan setidaknya satu dari 2 hal berikut:
Kecurigaan TB paru aktif (thorax foto)
Didapatkan BTA dari sampel lain selain LCS
Diagnosis Meningitis TB
Kategoridiagnostik
– Thwaites
MTB possible:
– Gejala klinis meningitis
dan
– Gambaran LCS abnormal
dan
– Didapatkan setidaknya 4 dari 7 hal berikut:
Riwayat menderita TB
Predominansi MN di LCS
Lama sakit > 5 hari
Rasio glukosa LCS: darah < 0.5
Penurunan kesadaran
Warna LCS kuning / xanthochrom
Didapatkan defisit neurologi fokal
Grading Meningitis TB (MIRC)
Grade I
– Sadarpenuh, tanpadefisitneurologisfokal
Grade II
– Grade 2a: GCS 15
dengandefisitneurologifokal
– Grade 2b: GCS 10 –
14denganatautanpadefisit
Grade III
– GCS < 10denganatautanpadefisitneurofokal
Complication
Arteritis thrombosis of a major artery
cerebral infarction.
Hydrocephalus
Seizures
Focal motor deficits and impaired cognitive
Hypopituitarism in childhood.
Differential DX
Viral encephalitis
Partially treated pyogenic meningitis
Fungal infection
Other inflammatory disorders
The presence of active TB elsewhere, and
the results of CSF examination are usually
sufficient to establish the dx.
Diagnostic Prosedures
1. Lumbal Puncture
CSF Parameter TB meningitis
• WBC Count < 500/ ul, MN
• Gluco moderate or marked decrease
• Protein marke increse
• Gram stain + +.-
• CSF lactic acid > 35 mg/dl.
2. Laju endap Darah
3. Radiologic
3a. Chest x ray: detect pulmonary involvement
3b. CT scan8 enhancement of the
basal cistern.
3b. MRI are more sensitive than CT
sans in detecting basal meningitis
infarction owing to arteritis hydrocephalus
and parenchymal tuberculomas often in
combination in AIDS patient.
4. Arteriografi
Images of CT Scans
file 1: Contrast-
enhanced computed
tomography (CT) scan in
a patient with
tuberculous meningitis
demonstrating marked
enhancement in the
basal cistern and
meninges, with dilatation
of the ventricles.
file 2: Petechial
hemorrhages in the
subcortical white matter of
the brain as a result of
tuberculous meningitis–
associated vasculitis.
file 3: Extensive infarcts of
the right basal ganglia and
internal capsule after the
appearance of vasculitis in
the thalamoperforating
arteries in a child treated for
tuberculous meningitis.
Treatment
1. Combination of antituberculous drug
Therapy WHO GILROY ATS
- Initial INH+R+PZA+E INH+R+PZA INH+R+PZA atau S
atau R+ PZA+S
-2MO - 2 MO - 2 MO
- Continued INH+R INH+R INH+R
-7 MO - 9 MO - 9 MO
Pyridoxine 50 mg/ hr
2. Spinal arachnoiditis and arteritis may show
improvement when terated with corticosteroid.
3. Seizure anticonvulsant
4. ventriculoperitoneal shunt.
Prognosis
Mortality 10 & 20%
The prognosis is poor in infants, the elderly,
when treatment is delayed, and in patients with
poor nutrition or debilation from HIV infection or
other chronic disease.
The outcome is clearly associated with the stage
of the disease at dx and the introduction of early
treatment. Those who are conscious and without
neurological deficits have a good prognosis;
those in coma at the beginning of treatment
have 20% mortality and only 20 oercent make
complete recovery.
Viral meningitis
Viral meningitis shares clinical features with
bacterial meningitis, but patients appear less ill
and the disease follows a more benign course.
Headache, often meningismus and photophobia,
is often the presenting symptoms.
The most pathogens include herpes simplex-1
(HSV1), mumps, enterovirus, herpes zoster,
adenoviruses and Epstein barr virus.
Dx procedure Viral meningitis
Lumbal Puncture
Cells Glucose Protein Smear CSF lactic
< 500 Normal Mild incr No org < 35 mg/dl
MN /mm3
PCR
MRI predominant temporal lobe and insular
changes in HSE-1 and basal ganglia lesion in
japanese encephalitis.
Treatment
Aciclovir 10 mg/ kg iv every 8 hours for 10-
14 days.
FUNGAL MENINGITIS
ETIOLOGY
Fungi invade of CNS producing meningitis in a small fraction of
patients with systemic fungal infection (mycoses)
Route of entry
A. Haematogenous: from the heart, lung, GIT and skin
B. Direct: from the orbit and paranasal sinuses.
Clinical Picture
Symptoms progress over days, sometimes
weeks, with headache, nausea, vomiting and
mild encephalopathy.
Neurologic examination:
1. meningeal irritation (+) 5, Visual loss
2. papilledema 6. Confusional state
3. Cranial nerve palsies 7. Focal paralysis
4. Ptosis
Investigations
Lab investigations:
1. Blood culture
2. Serum glucose
3.Arterial blood gases
4. Electrolyte
5. Liver function test
6. Urinalysis
CSF Examinations:
Imaging
Invest…..
CSF Exam:
- Pressure: Increased
- Appearance: varies with organism
- White Blood cells: 50 – 10.000 (mixed or
lymphocytic).
- Glucose :Normal
- Protein: increased
- Cryptoccal antigen is more sensitive
- Fungal culture of CSF(+)
Invest….
Chest X-ray : Hilar lymphadenopathy,
cavitation, effusion.
CT or MRI: mass lesion (Cryptococcus)
Treatment
Amphotericin B
- Protocol, starting with 1 mg/ day
- doubling the dose daily until reaching 16
mg per day, than increasing at increments
of 10 mg until reaching full therapeutic
dose of 0,5 to 1,5 mg/ kg per day IV.
Myelitis
Multiple sclerosis
Penyakit sistemik (SLE, Sjorgen disease)
Venous infarct
Malformasi vaskuler (fistula AV, AVM, angioma
kavernosa)
Fibrocartilagenous embolism
Myelopati radiasi
Treatment Viral myelitis
Antiviral treatment:
Glucocorticoid
Spasticity: baclofen (lioresal) 10 mg q6h,
benzodiazepin and tizanidine.
BRAIN ABSCESS Definition
Brain abscess is a focal intracerebral
infection that begin as a localized area of
cerebritis and develops into a collection of
pus surrounded by a weil-vascularized
capsule.
Abscess of the brain has been known for
over 200 years, and surgical treatment
started with MacEwen in 1893 [published:”
pyogenic infective disease of the Brain”].
Parenchymal brain infection can arise from
hematogenous delivery of infected material,
which often results in multiple abscess.
Especially at risk are patients with congenital
heart disease or valve infection.
Pathogenesis: abscess begin with local
cerebritis, causing necrosis and surronding
edema.
Epidemiology: 0,3 – 1,3 per 100.000 / tahun
Male to female ratio of 2:1 to 3:1
Common etiologic factors
Common etiologic factors Distingushing
characteristics
Ear inf: temporal lobe abscess, sinus inf:
Middle ear,paranasal sinus, frontal lobe abscess, mastoid inf: cerebellar
or mastoid infection abscess
A B