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Infections of CNS - Coggle Diagram

- - - - Dental infection -> Frontal lobes, Frontal or ethmoid sinuses -> Frontal Lobes, Otitis media and mastoiditis -> Inferior temporal lobe and cerebellum
    - - Chronic pyogenic Lung disease, Chronic wound/skin infections, Endocarditis or cyanotic congenital heart disease
    - - Neurosurgical Procedures
  - - - Serum antiToxoplasma IgG antibodies if indicated
    - - Variable: Often high WBC, High protein, normal or low glucsoe
    - - Blood, CSF, and aspirate
    - - CT less sensitive, but more readily available
      - MRI with contrast: Ring enhancing lesion with surrounding edema
  - - - Unknown source or hematogenous spread: Metro, ceftriaxone, vancomycin
      - Oral, otogenic, Sinus: Metronidazole, ceftriaxone
      - Neurosurgical procedure: Vancomycin, meropenem
  - - - S. Aureus, GNB most common
    - - Prodromal nonspecific fever/malaise, presents with severe back pain, rapid or indolent presentation
- - - - HSV1, VZV, CMV
    - - West Nile, St. Louis, Western equine, Eastern equine, Zika
    - - Polio, Measles, Influenza, Japanse B, Rabies
  - - - Presents with odd behaviour, rapid progression, seizures common
    - - CSF Similar to viral meningitis (Increase WBC, Increase RBC, Increase protein, normal glucose)
      - EEG (Highly abnormal, epileptiform discharges)
      - MRI: ANnterior/mesial temporal hyperintensity
    - - Acyclovir: 10mg/kg IV q8hrs
    - - Mortality, high morbidity, neuropsychiatric, cognitive changes, seizures, secondary autoimmune encephalitis
- - - - Visual symptoms classic, cognitive impairment, language troubles, hemiparesis, ataxia
    - - Lab: Serum JCV not helpful, CSF (Cell count and protein N increased, and JCV psotiive)
      - Imaging: MRI
        
        Mutlifocial lesions + Periventricular White matter
        
        Subcortical frontal and parieto-occipital common
        
        Generally non-enhancing
    - - Treat underlying immunosuppression (HIV, Medication Related)
    - - Survival common with timely immune reconstitution (Depends on underlying condition -> Worse for HIV-associated PML - risk of IRIS)
  - - - Stage 1 - Personality changes and lethargy
      - Stage 2 - Myoclonus, dementia, motor/sensory troubles
      - Stage 3: Myoclonus stops, eventual paraplegia and rigidity
      - Stage 4: Vegetative state
    - - Serum anti measles antibody (Increase)
      - CSF: +ve for anti-measles antibody
      - EEG: Abnromal slowing +/- sharp waves
      - Imaging: May be normal early in disease course, atrophy/scarring (temporoparietal lobes)
  - - - Vacuolar, neuronal loss, Gliosis, Absence of inflammation
    - - Most cases are sporadic: Unknown origin
      - Genetic CJDs: Fatal familial insomnia and Gerstmann-Straussler-Scheinker syndrom
      - Variant CJD: Ingested of infected beef
      - Iatrogenic: Corneal transplant, dural graft, human growth hormone, Surgical instruments
      - Clinical Features
        
        Startle Myoclonus
        
        Extrapyramidal Symtoms (Hypokinetic, cerebellar features)
        
        Pyramidal Signs: Spasticity, hyperreflexia, Babinski
      - Investigations
        
        CSF: 14-3-3 protein, and tau
        
        EEG: generalized slowing, periodic positive sharp wave complex
        
        MRI: "Cortical Ribboning"
        
        Biopsy: Not recommended unless diagnostic uncertainty
      - Management
        
        Symptomatic: SSRI, atypical antipsychotics, clonzepam
        
        Prognosis: Universally Fatal (Mean survival; 7 months from diagnosis)
    - - First discovered Transmissible neurogenerative disease
      - Due to ritual cannibalims
      - Symptoms
        
        Early: Tremor, ataxia, postural instability
        
        Sedentary Stage: Loss of ambulanation, mylonus
        
        Late Stage: Apathy progression to dementia
    - - Autosomal dominant PRNP Gene
      - Clinical Features
        
        Loss of circadian Rhythm/sleep
        
        Encephalopathy: Dream-like confusional state with impaired concentration
        
        Myoclonus/Ataxia
        
        Dysautonomia
- - - - Step Pneumo, Neiseirria Meningitidis, H.Influenza
      - Neonate: Group B strep
      - Elderly: Listeria
      - Immunocompromised: Listeria, TB, Cryptococcus
    - - Colonization of remote site with subsequent bacteremia, contaminated food, Direct entry into CNS
    - - Host Mucosal epithelium, Invasion bloodstream facilitated by environmental and host facts, bacteria invade subarachnoid space, aggressive inflammatory response to components of bacterial cell walls
    - - Classic Triad: Fever, headache, stiff ankle
      - Prodrome: Malaise, URTI
    - - General/Systemic: Febrile/Hypotensive, rash, other organ involvment
      - Mental Status/LOC: Confused/decreased LOC
      - Cranial Nerves: Papilledema, local CN involvment
      - Other: Kernig, brudzinki
        
        Kernig: One leg lifted, and try to straighten leg completley and you cant
        
        Brudzinski's Neck: Head is broguht up, knees will bend
    - - Infants: fever, hypothermia, lethargy, irritability, bulging fontanel, seizres, respiratory distress
      - Children: Fever, headache, nausea/vomiting,confusion, lethargy, irrgitability
      - Course: Gradually progressive febrile illness, fulminant sepsis and meningitis
    - - CBC (Increase WBC), CSF (cell count and glucose), CSF culture, CT before LP
      - Role of Cultures: Blood Cujlcutrres should be obtained prior to ABx, and CSF cultures have higher sensitiyy
        
        Do noit delay ABx for cultures
    - - Most important diagnostic test (helps with etiology and treatment)
      - Bacterial: Increase WBC, Decrease Glucose, Increase protein
      - Viral: Increase WBC, Normal Glucose, Increase protein
      - Fungal/TB: Increase lymph, decrease glucose, increase protein
      - Gram Stain
        
        Gram +ve diplococci: Pneumococcal
        
        Gram -ve diplococci: meningococcal
        
        Small Pleomorphic gram-negative coccobacilli: HiB
        
        Gram +ve rods adn coccobacilli: Listeria
    - - Indications
        
        Papilledema, Focal neurologic deficit, Abnormal LOC, new onset seizure, Immunocompromised
        
        Increased ICP -> Herniation
    - - Stabilize paitnets, ABCs, Start antibiotics ASAP
      - Antibiotics (ABx): Vancomycin, Ceftriaxone
        
        Older than 50: Ampicillin
        
        Age <1 month: Ampicillin + Cefotaxime; OR Ampicillin + aminoglycoside
        
        Immunocompromised: Vancomycin + Ampicillin + Cefepime or meropenem
        
        CNS hardware or Penetrating Trauma: Vancomycin + Meropenem or Ceftazidime or Cefepime
      - Dexamethasone
        
        Reduces CSF concentrations of cytokines, pneumococcus
        
        Recommended adjunctive therapy, lowers risk of neurological complications (increased ICP/cerebral edema, long term focal neurological deficits)
      - Duration
        
        Tailor therapy based on culture results, unknown at least 14 days empiric
      - Prevention
        
        Prophylaxis within 14 days of exposure
        
        N.meningiditis: household/day care contacts (rfampin or ciprofloxacin)
        
        H.Influenzae (type B): Household contacts of children <4 yrs who are incompletely or un-vaccinated (rifampin)
    - - Death due to
        
        Increased ICP, sepsis, Cerebral infarction, Seizure
      - Long-term neurologic complicatiosn
        
        Children: Hearing loss
        
        Adults: Chronic fatigue syndrome
  - - - Presentation
        
        Fever, headache, nausea & vomiting, photophobia, altered mental status
        
        Less rapid and severe
      - Investigations
        
        CSF: Increase WBC, increased protein, Normal Glucose
      - Enterovirus
        
        Most commonly identified pathogen
        
        Fecal-oral Transmission
        
        Presentation
        
        Preceding diarrhea, diffuse maculopapular rash, herpangina, PericardityPleurisy
        
        DIagnosis: CSF PCR
      - Other causes: HSV1 (most common), HSV2, acute, HIV, Mumps