cns infections
DESCRIPTION
CNS Infections. Keith B. Armitage, MD Vice Chair for Education, Department of Medicine University Hospitals Case Medical Center Case Western Reserve University. Case 1. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/1.jpg)
CNS Infections
Keith B. Armitage, MDVice Chair for Education, Department of Medicine
University Hospitals Case Medical CenterCase Western Reserve University
![Page 2: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/2.jpg)
Case 1
• A 54 year old woman with a history of hypertension and diabetes presents to the UH ED with fever, headache, confusion, leukocytosis and recent earache. What is your initial management approach to this patient?
![Page 3: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/3.jpg)
Acute Community-Acquired Bacterial Meningitis in Adults
• 4-6 cases per 100,000 adults per year• Streptococcus pneumonia and Neisseria
meningitides account for 80%• Listeria monocytogens 8 %; Haemophilus influenza- < 5 %
• Almost all patients present with two of the following:– Headache, fever, stiff neck, altered mental status
• For Strep pneumo- historical case fatality 20- 37 %; morbidity 30 %
• May be lower in the steroid era
![Page 4: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/4.jpg)
Mortality Rates Associated with Community-Acquired Bacterial Meningitis over the Past 90 Years
![Page 5: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/5.jpg)
van de Beek D et al. N Engl J Med 2004;351:1849-1859
Clinical Course, Outcome, and Neurologic Findings at Discharge
![Page 6: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/6.jpg)
Multivariate Analysis of Factors Associated with an Unfavourable Outcome
![Page 7: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/7.jpg)
![Page 8: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/8.jpg)
Suspected Acute Community Acquired Bacterial Meningitis:
Management issues• Timing of antibiotics and LP
– Do not delay atbx (2 hours from suspected infection to atbx); delays associated with worse outcomes
– Safety of LP- obviously avoid if increased ICP is suspected
– Criteria for LP without CT• Absence of seizures, immunosupressioin, signs of space
occupying lesions, impaired consciousness– CSF usually has > 100 wbc with neutrophilic
predominance, low glucose, high protein; but 5-10 % near normal= associated with bad outcome
• Blood cultures- “always”
![Page 9: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/9.jpg)
![Page 10: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/10.jpg)
For every patient with suspected acute community acquired bacterial
meningitis, consider five medications:• Three meds you always give• Two you consider
![Page 11: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/11.jpg)
Three meds you always give• Dexamethasone
• 10 mg 30 minutes before or after the first dose of antibiotics (for suspected or known pneumococcal meningitis)
• NEJM 2002- mortality and morbidity decreased
• Ceftriaxone 2 grams (or cefotaxime)
• Meropenam• PCN anaphylaxis-
vancomycin; plus FQ, TMP-SMX, or chloramphenicol
• Vancomycin 1 gram
![Page 12: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/12.jpg)
Two you consider
• Ampicillin• Age > 60• Risk factors- alcoholism or impaired immune status
• Acyclovir• Overlap in presentation with encephalitis
![Page 13: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/13.jpg)
Corticosteroids in meningitis
![Page 14: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/14.jpg)
Cerebrovascular Complications in Bacterial Meningitis
![Page 15: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/15.jpg)
de Gans J et al. N Engl J Med 2002;347:1549-1556
Random Assignment to Treatment, Withdrawal from Treatment, and Follow-up among 301 Adults with Bacterial Meningitis
![Page 16: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/16.jpg)
de Gans J et al. N Engl J Med 2002;347:1549-1556
Outcomes Eight Weeks after Admission, According to Culture Results
![Page 17: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/17.jpg)
de Gans J et al. N Engl J Med 2002;347:1549-1556
Unfavourable Outcome at Eight Weeks According to the Score on the Glasgow Coma Scale on Admission
![Page 18: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/18.jpg)
de Gans J et al. N Engl J Med 2002;347:1549-1556
Adverse Events
![Page 19: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/19.jpg)
Steroids: Summary• Benefit for Streptococcus pneumonia in
patients who are moderately ill• NNT 10; RR .59• Trend towards benefit for other groups
– 301 patients in the trial• New ‘standard of care’ for patients with
suspected acute community-acquired meningitis in whom Streptococcus pneumonia has not been ruled out
![Page 20: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/20.jpg)
Steroids: Summary
• For known or suspected Streptococcus pneumonia
• Given with first dose• Efficacy in developing countries not
known
![Page 21: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/21.jpg)
Other Management
• Repeat imaging and LP in cases of deterioration in the face of appropriate therapy
• MRI may be needed to detect subdural empyema
• Vaccination- Strep pneumo, NM, H flu• Neisseria meningitidis prophylaxis
![Page 22: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/22.jpg)
Nosocomial Meningitis
• Need to cover MRSE, MRSA, PSA• Vancomycin• Antipseudomonal beta-lactam
– Cefipime, ceftazidime, meropenam• NOT ceftriaxone• Aztreonam for PCN anaphylaxis• Consider IT therapy for resistant pathogens,
ventriculitis– Almost no clinical trials
![Page 23: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/23.jpg)
Case #2
• A 34 year old woman presents with a history of several days of headache, followed by a seizure, decreased level of consciousness, and focal weakness on exam. Imaging shows a ring enhancing lesion. What is your initial management?
![Page 24: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/24.jpg)
MRI Study of the Brain Showing a Heterogeneous Mass in the Right Frontal Lobe That Compresses the Right Lateral Ventricle
![Page 25: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/25.jpg)
Differential Diagnosis of Ring-Enhancing Brain Lesions
![Page 26: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/26.jpg)
Microbiologic Pathogens in Brain Abscesses, According to Major Primary Source of Infection
![Page 27: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/27.jpg)
Therapy of brain abscess
• Drainage• Vancomycin, ceftriaxone, metronidazole• Consider primary source
– Adjacent infection– Endocarditis– Atrial septal defect– Pulmonary AVMs
![Page 28: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/28.jpg)
Differential diagnosis of brain abscess
– Epidural and subdural empyema– Septic dural sinus thrombosis– Mycotic cerebral aneurysms– Septic cerebral emboli with associated
infarction– Acute focal necrotizing encephalitis (most
commonly due to herpes simplex virus)– Metastatic or primary brain tumors– Pyogenic meningitis
![Page 29: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/29.jpg)
Case 3
• A 76 year old woman presents with subacute onset of fever and change in mental status, which has worsened significantly over the past 24 hours. She is found to have pyuria and bacteuria. What is your initial management?
![Page 30: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/30.jpg)
Case #3
• Initial evaluation shows normal labs, including white blood cell count, and an unremarkable head CT. An LP is preformed and reveals a modest CSF pleocytosis with lymphocytic predominance and near normal glucose and protein. Additional management?
![Page 31: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/31.jpg)
Encephalitis Rule #1
• In any patient with suspected encephalitis- administer acyclovir
![Page 32: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/32.jpg)
Encephalitis Rule #2
• There is no rule 2…………….
![Page 33: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/33.jpg)
Encephalitis
• Role of HSV PCR• Other diagnostic tests
– West Nile, Arbovirus panel, Enterovirus– ? EBV, [CMV], other Herpesvirus
![Page 34: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/34.jpg)
Treatable Diseases Mimicking Herpes Simplex Encephalitis in a Study of 432 Patients
![Page 35: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/35.jpg)
West Nile Virus• Cuyahoga County- summer 2002
– 221 cases of WNV illness, including 11 fatalities and 155 cases of West Nile-associated neurologic disease
• Most per capita cases in the US• Encephalitis, meningitis, “polio-like” transverse myelitis
– Adverse outcomes associated with advanced age– No established therapy
• Planned clinical trial of WNV immunoglobulin at UH CMC…but
![Page 36: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/36.jpg)
Approximate Global Distribution of Medically Important Members of the Japanese Encephalitis Serogroup of Flaviviruses
![Page 37: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/37.jpg)
Hirsch M and Werner B. N Engl J Med 2003;348:2239-2247
Transmission Cycle of West Nile Virus
![Page 38: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/38.jpg)
Case #4
• 69 year old man presents with headache and nausea. He takes weekly methotrexate for RA. He has subjective chills but no documented fever. CNS imaging is negative. A temporal artery biopsy is done and corticosteroids are initiated.
![Page 39: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/39.jpg)
Case #4
• Patient presents five days later with worsening symptoms. On this admission, LP is completed revealing lymphocytic pleocytosis with low glucose and elevated protein. Your diagnosis?
![Page 40: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/40.jpg)
Cryptococcal meningitis
• Don’t forget Cryptococcal meningitis• Presentation of infection due to Cryptococcus
neoformans can be subtle in patients with mild immunosupression
• CSF CRAG, Serum CRAG, India Ink• AmphotericinB; later fluconazole
• Other fungal infections- Histoplasmosis, sporothrix
![Page 41: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/41.jpg)
Case #5
• A 22 year old woman presents with low grade fever, headache and mild photophobia. Her temp is 100.8; other vitals stable. CSF shows a normal glucose, moderate protein elevation and 90 wbc, 80 % lymphocytes. What is your diagnosis.
![Page 42: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/42.jpg)
Viral Meningitis• Enterovirus!
• Young adults• Summer months• Fecal oral transmission• benign
• HSV• Recurrent• Not encephalitis…..
• HIV seroconversion• Aseptic meningitis syndrome
• Drugs, partially treated, malignancy, etc.
![Page 43: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/43.jpg)
![Page 44: CNS Infections](https://reader035.vdocument.in/reader035/viewer/2022062323/5681678c550346895ddcab12/html5/thumbnails/44.jpg)
• Friedlander R et al. N Engl J Med 2003;348:2125-2132
van de Beek D et al. N Engl J Med 2006;354:44-53
Solomon T. N Engl J Med 2004;351:370-378
• Crumpacker C et al. N Engl J Med 2003;349:789-796