CNS Disorders Dr Shreedhar Paudel April 2009 MENINGITIS

CNS Disorders Dr Shreedhar Paudel April, 2009

MENINGITIS Inflammation of the coverings of the brain • CAUSES – BACTERIAL – VIRAL – TOXINS – MALIGNANCIES

ACUTE BACTERIAL MENINGITIS • NEONATAL PERIOD: S. PNEUMONAE, E. COLI • 3 MTHS- 3 YEARS : H. INFLUENZAE, S. PNEUMONIA, N. MENINGITIDES • > 3 YRS : S. PNEUMONIAE, N. MENINGITIDES • IMMUNOCOMPROMISED HOST: LISTERIA, MYCOPLASMA, CRYPTOCOCCUS

ACUTE BACTERIAL MENINGITIS • PATHOGENESIS – Routes of infection • Hematogenous spread from distant focus of infection • Local spread of infection from contiguous septic foci • Exogenous infection after trauma

PATHOLOGY – Meninges are infiltrated with inflammatory cells – The cortex of brain shows edema, exudates and proliferation of microglia – Sub arachnoid space may be filled with purulent discharge – Exudates may block the foramina of Luschka and Magendie leading to hydrocephalus – Thrombophlebitis of cerebral vessels may occur leading to infarction and necrosis – Endotoxic shock and sudden death may be there if meningococcal meningitis

CLINICAL FEATURES SYMPTOMS - Acute onset - Fever/ Irritability - Projectile vomiting - Headache/ Bulging fontanel - Seizure - Altered sensorium/ photophobia - Marked neck rigidity

SIGNS • PHOTOPHOBIA , • NECK STIFFNESS, • KERNIG’S SIGN ( extension of knee is limited to less than 135 degree) • BRUDZINSKI SIGN ( the knees get flexed as neck of the child is passively flexed) • BULDGING FONTANEL, • ALTERATION OF MENTATION • PAPILLEDEMA, • NEUROLOGICAL DEFICIT • Respiration may be Cheyne-Stokes type

ACUTE BACTERIAL MENINGITIS IN NEONATES AND YOUNG INFANTS • There will be no signs of meningial irritation till 6 months of age • Meningotis should be suspected in a newborn in following conditions – Vacant stare – Alternating irritability and drowsiness – Persistent vomiting with fever – Refusal to breast feeding – Poor tone/ poor cry – Shock/ hypothermia/ fever – Seizure/ neurological deficits

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS • CNS COMPLICATIONS – SUBDURAL EFFUSION /EMPYEMA, – BRAIN ABSCESS , – HYDROCEPHALUS,

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS………. Long term neurological deficits - DEAFNESS / BLINDNESS/ APHASIA - HEMIPLAGIA - OCULAR PALSIES Systemic complications - SHOCK - MYOCARDITIS - SIADH - STATUS EPILEPTICUS

DIAGNOSIS • LUMBAR PUNCTURE • CSF FOR BIOCHEMICAL/CYTOLOGICAL EVALUATION • Turbid CSF with raised pressure, elevated protein level (>100 mg/dl), reduced sugar level (<40 mg/dl or below 50% of blood sugar level), increased cell count (>1000/μL, mostly Neutrophils)

DIAGNOSIS…. • CSF for microbilogy – Gram stain – Culture/ sensitivity • • LATEX AGGLUTINATION, ELISA, PCR CT SCAN

ACUTE BACTERIAL MENINGITIS DIFFERENTIAL DIAGNOSIS – MENINGISM ( occur in inflammatory cervical lesion, apical pneumonia, toxemia due to Hemophilus infection or typhoid fever) – PARTIALLY TREATED BACTERIAL MENINGITIS – ASEPTIC MENINGITIS – TUBERCULOUS MENINGITIS – CRYPTOCOCCAL MENINGITIS – VIRAL ENCEPHALITIS – POLIOMYELITIS – SUB ARACHNOID HEMORRHAGE – LYME DISEASE (Borrelia infection)

TREATMENT OF ACUTE BACTERIAL MENINGITIS • EMPIRICAL THERAPY – CEFTRIAXONE OR CEFATOXIME OR COMBINATION OF AMPICILLIN AND CHLORAMPHENICOL FOR 1014 DAYS • SPECIFIC ANTIMICROBIAL THERAPY – MENINGOCOCCAL MENINGITIS: PENICILLIN, CEFOTAXIME OR CEFTRIAXONE – HEMOPHILUS MENINGITIS: CEFTRIAXONE/ CEFOTAXIME

TREATMENT……. . – STAPHYLOCOCCAL MENINGITIS: CLOXACILLIN OR VANCOMYCIN, • ADDITION OF RIFAMPICIN WILL ENHANCE THE PENETRANCE OF THE CSF – LISTERIA: AMIPCILLIN AND GENTAMYCIN – PSEUDOMONAS: CEFTAZIDIME AND GENTAMYCIN, OR TICARCILLIN AND GENTAMYCIN • DURATION OF TREATMENT: 10 DAYS EXCEPT FOR STAPHYLOCOCCAL MENINGITIS

TREATMENT…. . – STERIOD THERAPY • DEXAMETHASONE 0. 15 MG/KG IV 6 HRLY FOR 5 DAYS • FIRST DOSE OF STEROID SHOULD PRECEDE 15 MIN FROM ANTIBIOTICS • DECREASES THE INCIDENCE OF RESIDUAL NEUROLOGICAL DEFICITS • ESPECIALLY USEFUL IN H. INFLUENZAE INFECTION

TREATMENT………… • SYMPTOMATIC TREATMENT – RAISED ICP: OSMOTIC DIURETICS – CONVULSION: DIAZEPAM OR PHENYTOIN – RESTRICTION OF FLUID TO 2/3 RD OF MAINTENANCE TO PREVENT SIADH – NURSING CARE • TREATMENT OF COMPLICATIONS • FOLLOW-UP AND REHABILITATION

TUBERCULOUS MENINGITIS PRIMARY SECONDARY PATHOGENESIS PATHOLOGY: TUBERCLE, BASE AND TEMPORAL LOBES • STAGES: PRODROMAL, MENINGITIS, COMA • DIAGNOSIS: LP, CT, BACTEC, PCR • •

TUBERCULOUS MENINGITIS • D/D: PURULENT MENINGITIS, PARTIALLY TREATED, ENCEPHALITIS, TYPHOID ENCEPHALOPATHY, BRAIN ABSCESS, BRAIN TUMOR, CHRONIC SUBDURAL HEMATOMA, AMEBIC MENINGOENCEPHALITIS. • TREATMENT: 12 MTHS • INITIAL 2 MTHS: HRZE • LATER 10 MTHS: HRE

TUBERCULOUS MENINGITIS • STEROIDS: DEXAMETHASONE IV- 1 -2 WEEKS • ORAL FOR 6 WEEKS AND TAPER SLOWLY • OTHER SUPPORTIVE THERAPY.

ENCEPHALITIS • DEFINE • ETIOLOGY/ PATHOLOGY : INCLUSION BODIES • VIRAL: MMR, HSV, CMV, EBV, JAPANEASE, WEST NILE, RABIES, DANGUE • OTHER: RICKETTSIA, FUNGI, TOXOPLASMA, BACTERIAL, REYES SYNDROME

ENCEPHALITIS • ONSET: SUDDEN • SIGNS AND SYMPTOMS: FEVER, HEADACHE, VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY , COMA • DECEREBRATION, DECORTICATION, PALSIES, PLAGIAS, • EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B • TEMPORAL OR FRONTAL LOBE : HSV

ENCEPHALITIS • RAISED ICT • HERNIATION • 6 TH NERVE PALSY • • DIAGNOSIS HISTORY OF EXPOSURE LP CSF, PCR

ENCEPHALITIS • MANAGEMENT • SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES • HSV: RBC IN CSF, TREATMENT : ACYCLOVIR

REYE’S SYNDROME • • GENERALISED MYOCARDIAL DYSFUNCTION LIVER, KIDNEY , CNS INHIBITION OF B-OXIDATION OF FATTY ACIDS ASPRIN OTHER SALICYLATES, VIRAL INFECTION HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA PRESENTATION: 2 MTHS – 15 YEARS RAPID PROGRESSION

REYE’S SYNDROME • • STAGES I- MILD CONFUSION II – DELIRIUM III – COMA IV – APNEA, NON REACTING PUPIL DIAGNOSIS: HYPERAMMONEMIA, DEARRANGED LFT, EEGTRIPHASIC WAVES

REYE’S SYNDROME • • • TREATMENT LOW PROTEIN DIET TREAT HEPATIC FAILURE TREAT RAISED ICT HYPOGLYCAEMIA VITAMIN K , FFP