central nervous system infection - med.mui.ac.ir filecontraindicationsforanimmediate lp...

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Suspicion to meningitis� Fever and meningeal inflammation:

� Nuchal rigidity� Decreased LOC: irritability, restlessness, confusion, lethargy,� Poor feeding� Seizures in age< �� mo� Bulging fontanel� Focal findings� Focal findings

� Fever and petechiae and purpura� Fever in < �-� mo.� Fever and recent significant head trauma� Facial cellulitis without trauma� Pre-septal cellulitis without trauma+ especially fever and

age<�� mo� Sepsis

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Lumbar puncture in FC� Should be performed :

� Meningeal signs� Other features of meningitis (nonresponsive, bulging

fontanel, altered consciousness, Petechial rash, focal seizures,recurrent seizures, not well), )

� Should be considered :� Age �-�� mon.� When the patient is on antibiotics� When FC occur after the second day of illness� Febrile status epilepticus

� May be considered:� Age of ��-�� mo and no source of fever� Complex FC

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Facial cellulitis

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False negatives of nuchal rigidity inmeningitis�Age< ��-�� mo�Coma�Focal or diffuse neurologic deficits�Focal or diffuse neurologic deficits�Early meningitis, particularly in young

children.

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Contraindications for an immediateLP� Evidence of increased ICP(except bulging fontanel)

� �rd or �th cranial nerve palsy� Depressed level of consciousness� Severe headache, Vomiting

P ill d� Papilledema� Hypertension with bradycardia or tachycardia� Pupillary changes (eg, anisocoria)� Abnormal breathing patterns (eg, Cheyne Stokes respirations)� Status seizures

� Severe cardiopulmonary compromise� Skin infection at the site of the LP� Thrombocytopenia <��,��� or coagulopathy

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Indications of CT then LP�Altered mental status (GCS <�� or drop in

GCS of ≥�)�PapilledemaPapilledema�Other symptoms of increased ICP

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Indications of CT then LP� Immune deficiency� Focal neurologic deficit� CSF shunt� Hydrocephalus� CNS trauma� History of neurosurgery or a space-occupying lesions� Right to left cardiac shunt

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Elevated ICP findings on head CT� Midline shift� Effacement of the basilar cisterns� Effacement of the sulci

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�� �� LP� An experienced assistant who can position, restrain,

and comfort the patient� Lateral decubitus or seated position with the neck and

legs flexedlegs flexed� Sick neonates in a seated position� Shoulders and hips Be straight

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Normal CSF analysis� WBC<�, all lymphocytes; in neonates< ��(��), in �-�

mo.< �� Pr: ��-�� mg/Dl in > � mo ; in neonate <��� mg/dL

Gl � % f h LP BS� Glucose : ��% of the pre-LP BS

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CSF findings in typical bacterial meningitis� WBC >���� with a predominance of PMN� Glucose <�� mg/dL� Protein between ��� and ��� mg/dL

� Early in the course, few or no WBCs and/or NL Proteinand Glucose may be present

� Pleocytosis with a lymphocyte predominance may bepresent during the early stage

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CSF findings in typical viral meningitis� WBC of <��� with a mononuclear predominance� Normal CSF glucose� CSF protein <��� mg/dL� Negative CSF Gram stain� Improvement in symptoms following LP

� Normal WBC counts can be seen in enteroviral andrarely HSV

� Neutrophilic pleocytosis may be present in early stages(�-�� hr) of the initial LP.

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CSF analysis after appropriatetherapy� Pleocytosis with a predominance of neutrophils,

elevated protein, and a reduced glucose usually persistfor several days

� No change in �� to �� hours in most cases in chemical� No change in �� to �� hours in most cases in chemicaland cellular findings

� CSF culture can be negative� After conclusion of therapy WBC and protein generally

not returned completely to normal and glucose mayremained depressed

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Traumatic LP� Gram stain, culture, and glucose not be influenced� protein is increased by approximately � mg/dL for

every �,��� red blood cells/mm�

WBC RBC / i h b f l� � WBC per ���� RBCs/mm� in the absence of clot� It is prudent to rely on the bacteriologic results rather

than interpret the CSF leukocyte and protein

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Antibiotic therapy in bacterialmeningitis� Penicillin-sensitive S. pneumoniae: third-generation

cephalosporin or penicillin for ��-�� days� Penicillin and the third-generation cephalosporin

resistant S pneumoniae: vancomycinresistant S. pneumoniae: vancomycin� N. meningitidis: penicillin for �-� days� H. influenzae type b: third-generation cephalosporin

for �-�� days� Culture negative: ceftriaxone or cefotaxime for �-��

days ??

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Response in bacterial meningitis� Neurologic signs in ��-�� hours:

� neurologic complications eg, subdural empyema,cerebral vascular thrombosis, ventricular dilation, brainabscess

� neuroimaging� Fever in � days:

� Inadequate treatment, nosocomial infection,suppurative complication (pericarditis, pneumonia,arthritis, subdural empyema), Drug fever (a diagnosis ofexclusion)

� Neuroimaging, repeat LP, …

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Meningococcal chemoprophylaxis� All household, daycare center, and nursery school

contacts, healthcare workers who have direct exposureto oral secretions (mouth-to-mouth resuscitation,suctioning intubation)suctioning, intubation)

� No Schoolroom classmates and hospital contacts� Rifampin �� mg/kg/dose every �� hr (maximum dose

of ��� mg) for � days� Ciprofloxacin ��� mg in age> �� year� Third generation cephalosporin

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International EncephalitisConsortium(���� consensus statement )

� Altered mental status or personality change ≥�� hr.ours plus

� ≥� "possible" or ≥� "probable" of the following:f �°C� fever ≥��°C

� Generalized or partial seizures� Focal neurologic findings� CSF WBC ≥� cells/microL� Suggestive neuroimaging� Abnormal EEG

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CSF analysis of encephalitis� Lymphocytic pleocytosis (��%); neutrophil

predominance in �st ��-�� hr� Mild RBCs in HSV , or other necrotizing

encephalitidesencephalitides� Moderately elevated protein ( <��� mg/dL).� Normal Glucose . Moderate reduction in HSV and

mumps

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Discontinuation of acyclovirin HSV-PCR negative patients� Low probability of HSV encephalitis(<� percent):

� Normal neuroimaging� <� cells/mm� in CSF� Normal mental status� Negative CSF HSV PCR after �� hours

� High probability of HSV encephalitis (� percent) each ofthe following:� Suggestive neuroimaging findings� CSF pleocytosis� Positive EEG findings� Seizures

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