infectious and inflammatory disorders - ucsdspinwarp.ucsd.edu/neuroweb/ppt/infection-45.pdf ·...
TRANSCRIPT
Department of Radiology
University of California
San Diego
John R. Hesselink, M.D.
Infectious and
Inflammatory Disorders
Intracranial Infection
and Inflammation
Cerebral abscess
Meningitis
Ependymitis
Encephalitis
Cranial neuritis
Cerebral Abscess
URI - Septicemia - Endocarditis
Sinus & mastoid infections
Immune-compromised patient
Diabetic patient
Congenital heart disease
Trauma, Surgery
Sources/Predisposing Factors
Brain Abscess
Staph & strep most common
Tuberculosis
Fungal infection
Parasitic infection
Opportunistic organisms if
immune-compromised
Infectious Agents
History: 45 y/o man with new seizure
453
Dx: Toxo cerebritis
{Page 2}
History: 16 y/o male
with new onset of seizures
350
{Page 2} Diffusion
Dx: Brain abscess -
Streptococcus milleri
{Page 3}
Pyogenic
Brain Abscess
Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece
Acetate
Alanine
Lactate
Amino
Acids
History: 87 y/o woman on treatment
for abdominal lymphoma
780 - 14316798
Dx: Abscess (Nocardia & Gram + rods)
{Page 2}
Acetate Alanine
Lactate Succinate
History: 41 y/o man with headache,
lethargy & inappropriate behavior
606
{Page 2}
Dx: Streptococcal abscess &
diabetic ketoacidosis
(venous pH = 7.28)
{Page 3}
2
1 3
1
3
2
Ketones (2.2 ppm)
Ketones
History: 5 y/o girl with seizures
361
{Page 2}
Diffusion image
Dx: Amoebic abscesses
{Page 3}
History: 34 y/o male with
headache & a lung mass
435
{Page 2}
Dx: Aspergillus abscess
{Page 3}
Differential Diagnosis
Clinical presentation
Capsule features
Multiple lesions
Time course
Diffusion Properties
MR Spectroscopy
Abscess & Tumor
760
History: 27 y/o female
with seizures
{Page 2}
Dx: Cysticercosis – colloidal phase
{Page 3}
2 months s/p Rx with
Albendazole & Dexamethasone
Neurocysticercosis
Larval stage of the pork
tapeworm (Taenia Solium)
History: 54 y/o woman with chronic seizures
610
Dx: Calcified diffuse cysticercosis
{Page 2}
History: 22 y/o man with severe headaches
555
{Page 2}
Dx: Intraventricular cysticercosis
{Page 3}
History: 32 y.o. woman with headaches
History: Headaches
{Page 2}
Dx: Racemose cysticercosis
{Page 3}
History: 42 y/o female with chronic headaches
549
Dx: TB meningitis - HIV+
{Page 2}
History: 54 y.o. man with headaches for 2
months & decreased mental status
132
Dx: Cocci meningitis
Decreased mental
status {Page 2}
Meningitis
Organisms Bacteria
Virus (meningoencephalitis)
Tuberculosis
Fungus
Enhancement of basal cisterns
Differential diagnosis
Leptomeningeal seeding of tumor
Encephalitis
Cerebral Tuberculomas
D 13-17
{Page 2}
Complications of Meningitis
Communicating hydrocephalus
Loculated CSF collections
Subdural effusion / empyema
Cerebral infarction
Cerebral abscess
Dural sinus thrombophlebitis
History: 39 woman with SLE
on chronic immunosuppression
with steroids & methotrexate
701
{Page 2}
Dx: TB meningitis
{Page 3}
History: 38 y/o man with fever & headaches
254
Dx: Tuberculous meningitis with vermian
& left temporal lobe abscesses
Fever & headaches {Page 2}
Leptomeningeal Disease
Meningitis
Fungal, TB, Bacterial, Neurosyphilis
Sarcoidosis
Cysticercosis (Racemose form}
Metastatic disease
Arachnoiditis
Differential Diagnosis
History: 37 y/o man with nausea & vomiting,
low testosterone, and diabetes insipidus.
362
{Page 2}
{Page 3}
Diabetes insipidus
Dx: Neurosarcoidosis
{Page 4}
History: 42 y.o. man with chronic
head and neck pain
66
Head & neck pain {Page 2}
Dx: Chronic pachymeningeal
inflammation - 2o V/P shunt
{Page 3}
Encephalitis
A diffuse parenchymal
inflammation of the brain
Encephalitis
Herpes simplex
Arboviruses
Enteroviruses
Lyme disease
Congenital TORCH agents
Organisms
History: 27 y.o. man with
increasing confusion & lethargy
5
Dx: Herpes simplex
encephalitis
Confusion & lethargy
{Page 2}
Herpes Simplex Encephalitis
Rapid course
Temporal lobes, inferior
frontal & insular cortex
Cortical edema & mass effect
Gyral enhancement
Early therapy critical
History: 50 y/o female with acute
onset of headache & confusion
540
Dx: Herpes simplex encephalitis
{Page 2}
Non-Herpetic
Meningoencephalitis
More benign
Generalized cortical pattern
Better prognosis
History: A 40 year old man with 2
days of headaches and right facial
weakness and numbness
SC - JZ
Dx: Lyme meningitis
{Page 2}
Lyme Disease
A tick-borne illness
Caused by bacterium: Borrelia burgdorferi
Flu-like symptoms
Bull’s eye rash
CNS: facial palsy, meningitis, encephalitis,
polyradiculopathy
Treatment: antibiotics during early stages
C-53-56
History: 8 year old boy with 1-2 week history of
left eye ptosis, limited EOMs, and ataxia.
Dx: ADEM
{Page 2}
Acute Disseminated
Encephalomyelitis (ADEM)
A post-infectious encephalitis
Immune-mediated reaction
Viral agents: measles, chickenpox or
vaccination for rabies or smallpox
Acute demyelinating disease
Mostly a monophasic illness
History: 61 y/o woman with diabetes &
hypertension presented with aphasia
255
Aphasia {Page 2}
Dx: Post-Infectious encephalitis
(Acute disseminated encephalomyelitis)
{Page 3}
Neonatal Infections
Toxoplasmosis
Other (Treponema, Listeria)
Rubella (measles)
Cytomegalovirus
Herpes simplex
HIV
TORCH
Congenital Toxoplasmosis
Osborn & Byrd, NCNA 1:105, 1991
History: Newborn baby
girl (38 wk) with microcephaly
658
Dx: Congenital CMV with
microcephaly
{Page 2}
Dx: Congenital CMV
History: 34 week
Premature girl
477
Congenital Herpes Type 2
Osborn & Byrd, NCNA 1:105, 1991
HIV Infection
RNA retrovirus
Deficient cell-mediated immunity
Infects monocytes & macrophages
of CNS - microglial nodules
Neurological symptoms in 39%
At autopsy, 75-80% of brains involved
AIDS Brain Pathology
Human immunodeficiency virus (HIV)
Toxoplasmosis
Cryptococcosis
Progressive multifocal leuko-
encephalopathy (PML)
Cytomegalovirus (CMV)
Lymphoma
History: 38 HIV+ male with headache
328
Headaches
{Page 2 }
Dx: Toxoplasmosis with good
response to anti-toxo medication
Two weeks
following treatment
{Page 3}
Toxoplasmosis
A protozoan
50% of brain lesions in AIDS
Ring-enhancing masses on CT and MR
History: 38 y/o HIV+ male
with headache & weakness
505
{Page 2}
Dx: Toxoplasmosis
{Page 4}
1 2
2
1
History: 38 y/o female with
progressive left sided weakness
602
Dx: HIV & Lymphoma
{Page 2}
History: 41 y/o man with a right hemiparesis
& speech difficulty
621
{Page 2}
Dx: Primary CNS Lymphoma
{Page 3}
CBV
History: 45 male with AIDS,
headaches & generalized wasting
730
Dx: Cryptococcal menigitis
{Page 2}
Cryptococcosis
Most common fungal infection
in AIDS patients
Produces meningitis primarily
Access to brain via VR spaces
Imaging studies negative in 80%
Hydrocephalus, Brain atrophy
History: 49 y/o man with AIDS
& a right hemiparesis
381
Dx: Cryptococcosis
Hemiparesis
{Page 2}
History: 31 y/o male with
multiple neurological deficits
407
{Page 2}
Dx: AIDS - PML
{Page 3}
Clinical Features of PML
Reactivation of latent DNA papovavirus
Immunocompromised host
Defective oligodendrocytes &
myelin maintenance
Progressive neurologic deterioration
No effective therapy - poor prognosis
History: 48 y/o HIV+ man
with fever, mutism,
ataxia & dysphagia
288
Dx: PML - Progressive
multifocal leukoencephalopathy
Ataxia & dysphagia
{Page 2}
Gd+
History: 40 y/o male with headache and fever
233
16 months later {Page 2}
Now with lethargy & confusion
Dx: AIDS - HIV encephalitis & brain atrophy
{Page 3}
History: 35 y/o male with fever & ataxia
511
Dx: HIV encephalitis
{Page 2}
Cytomegalovirus
Retinitis
Encephalitis
Ependymitis / Ventriculitis
Neuritis of cranial nerves
Peripheral polyneuropathy
History: 43 y/o man
with visual deficits
428
Dx: CMV retinitis with optic
pathway involvement
{Page 2}
History: 45 y.o. man with
multiple cranial nerve palsies
63
Dx: AIDS - CMV cranial
nerve neuropathy
{Page 2}
History: 42 y.o. man with fever and confusion
41
Fever & confusion {Page 2}
{Page 3}
Dx: HIV encephalitis +
Tuberculomas (Ca++
)
Creutzfeldt-Jakob Disease
Caused by a prion – a small non-viral, infectious,
protein particle
Neuronal loss, reactive astrocytosis and formation
of cytoplasmic vacuoles
Rapid cognitive decline, often with psychosis and
delirium, leading to death within 1 year
MRI: symmetrical increased T2 signal in basal
ganglia with restricted diffusion
History: Elderly patient with
progressive mental decline
Courtesy Ajax George, NYU
new variant CJD
The
Pulvinar
Sign
Collie, et al. AJNR (2003); 24:1560-1569
Zeidler, et al, Lancet,2000
Bovine spongiform Encephalopathy
Mad Cow Disease