pedia - cns infection, seizures, nmd [agrava]

8/11/2019 Pedia - CNS Infection, Seizures, NMD [Agrava]

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Highlight = Memorize per Dr. Agrava

Table of ContentsInfections of the CNS ................................... 2

DefinitionsBacterial Meningitis

EtiologyNewborn period2 months 12 years

Neisseria meningitidesHaemophilus influenza type bRisk FactorsPathophysiology of Bacterial Meningitis .................... 3Clinical ManifestationsLumbar PunctureContraindications for LP

5 Absolute, 1 relative CINormal CSFTypical CSF Findings in Meningi tis ............................ .......... 4T602-1(partial) CSF Findings in Meningitis

Techniques in DiagnosisNeurodiagnostic Procedures

Treatment ................................................................. 5Recommendations for Empiric antibiotic Therapy in Bacterial

MeningitisPathogen-specific therapy for Meningitis

Complications of Bacterial MeningitisPrognosis

Poor PrognosisPrevention ................................................................ 6

N. meningitidesH. Influenzae Type BS. Pneumoniae

Tuberculous MeningitisPathophysiologyClinical Features of TB MeningitisRadio diagnostic criter ia ............. .............. ............... .. 7Diagnosis

ClinicalCT ScanLumbar puncture

InvestigationOther Forms of CNS TBManagement ............................................................. 8Treatment

Viral Meningoencephalitis ................................... 9VE Etiology

Enteroviruses

Mumps virusArbovirusesHerpes Family

Pathology and pathogenesisTissue sectionsPredilection

Clinical manifestationDiagnosis

Tb Diagnostic proceduresLaboratory findings ............................................................ 10

TreatmentPrognosis

Possible ComplicationsEosinophilic meningitis

EtiologyOthersNoninfectious causes include

Clinical ManifestationsDiagnosisTreatmentPrognosis

Brain Abscess .................................................. 11CausesPathology

Location and sourceClinical manifestationDiagnosis

CT with contrast and MRITreatment

Surgery is indicatedPrognosis

Seizures in Chi ldhood ................................ 12EpidemiologyEvaluation of the First Seizures

HistorySeizure typeExamination

Febrile seizures ................................................ 13FS Recurrent Seizures

Factors assoc with !recurrence risk!Risk of developing epilepsy

FS Treatment

Unprovoked SeizuresUS First seizure

Recurrent SeizuresRS Etiology

Diagnostic Evaluation of First SeizuresFebrileUnprovokedRecurrent

Intl Classification of Epileptic Seizures .................. 14Epileptic syndromesPartial seizures

SIMPLE partial seizuresCOMPLEX partial seizures

AutomatismComplex partial seizures with 2generalizationDiagnosis

Benign Partial Epilepsy w/Centrotemporal Spikes(BPEC)

Clinical FeaturesDiagnosisTreatment

Rasmussen EncephalitisGeneralized Seizures ......................................... 15

Absence seizuresAbsence TypicalAbsence Atypical

Generalized Tonic-clonic SeizuresGeneralized Seizures Precipitating factors

Myoclonic Epilepsies of ChildhoodBenign myoclonus in infancyTypical myoclonic epilepsy of early childhoodComplex Myoclonic Epilepsies of ChildhoodJuvenile Myoclonic Epilepsy (Janz syndrome)Progressive Myoclonic Epilepsies

Infantile spasms ...................................................... 16CryptogenicSymptomaticTheories

Landau-Kleffner Syndrome (LKS)LKS DxLKS Tx

Mechanism of SeizuresTwo hypotheses

Use of EEG in diagnosing EpilepsyProlonged EEG monitoring with simultaneous closed-circuit video recording

Treatment of Epil epsy ........................ ................ 17Pharmacologic

Indications for anticonvulsant drug monitoringProminent risk factorsNon pharmacologic

Ketogenic dietSurgery for epilepsyVagal nerve stimulation

Neonatal Seizures ............................................. 18Focal seizuresMultifocal clonicTonic seizuresMyoclonic seizuresSubtle seizures

NS EEG ClassificationClinical sz w/ consistent EEG eventClinical sz w/ inconsistent EEG eventElectrical sz w/ absent clinicalseizures

NS Etiologic DiagnosisDiagnostic ExamsF593-3 An approach to the child with a suspected convulsive

dsoCauses by AgeInborn errors of metabolism ................................................19Unintentional injection of local anestheticBenign familial neonatal seizuresFifth-day fitsPyridoxine dependency

Drug withdrawal seizuresStatus epilepticusSE Major subtypes

Febrile seizureIdiopathic status epilepticusSymptomatic status epilepticus

SE PathophysiologyGeneral Principles in the Management of StatusEpilepticusSE Treatment

First line drugSecond line Drugs

Conditions that MimicSeizures ............................ 20Benign paroxysmal vertigoNight terrorsBreath holding spells

Cyanotic spellsPallid spells

Paroxysmal kinesigenic choeoathetosisShuddering attacks

Benign paroxysmal torticollis of infancyHereditary chin tremblingNarcolepsy & CataplexyRage attacks or episodic dyscontrol syndromeMasturbationPseudoseizuresSyncope .................................................................. 2

Simple syncopeCough syncopeProlonged QT syndrome

Neuromuscular Diseases.............................. 22Evaluation and Investigation

Components of the motor unitsInnervation

Nervous systemClinical Manifestations

Neuropathic or MyopathicLaboratory Findings

Serum Creatinine kinase (CK) levelsOtherDistinguishing Features of Dsos of Motor System ............... 23

Patterns of Weakness and Localization in Floppy InfantsDevelopmental Dso of Muscle ............................. 24

DiseasesDisease

Transmission LocusMuscular Dystrophies

Duchenne & Beckers Muscular Dystrophy .............. 25Duchenne muscular dystrophyBecker muscular dystrophyD&B Clinical M anifestationLab Findings ...................................................................... 26

DiagnosisGenetic Etiology and PathogenesisTreatmentNutritional State

Emery-Dreifuss Muscular DystrophyClinical ManifestationsDiagnosisTreatment

Myotonic Muscular Dystrophy (Steinert dse)MMD TypesClinical Manifestations

Periodic Paralyses (Potassium-Related) .................... 27PP Treatment

Congenital Myotonic DystrophyLab FindingsDiagnosis ........................................................................... 2

Treatment

Myotonic chondrodystrophy (Schwartz-Jampel dse)Myotonia congenital (Thomsen disease)Paramyotonia

Guillain-Barr SyndromeClinical Manifestations

Bulbar Involvement 50%GBS vs. Polio

GBS VariantsMiller-Fisher SyndromeChronic Relapsing/Unremitting Polyradiculoneuropathy .... 29

Congenital Guillain-Barr syndromeLab Findings and Diagnosis

CSF studiesOther

TreatmentPrognosis

Endocrine and Toxic MyopathiesThyroid Myopathies

HyperthyroidismHypothyroidismTreatment

HyperparathyroidismSteroid-Induced MyopathyHyperaldosteronism (Conn syndrome)

Chronic Growth Hormone ExcessToxic Myopathies .................................... ......... 3

Malignant HyperthermiaDSO of NM Transmission & of Motor Neurons

NMJ dso: Myasthenia GravisJuvenile MGTransient MGCongenital MGDiagnosis

Anterior Horn Cell: Spinal Muscular Atrophy (SMA)Perinatal SMA (Type 0)Infantile SMA (Type1, Werdnig-Hoffman Dse)Juvenile SMA (Type 2)Adult SMA (Type 3, Kugelberg-Welander Dse)DiagnosisTreatment

Course: Pediatrics

Week: 7

Lecturer: Dr. Agrava

Topic: CNS Infections

Seizures and Neuromuscular

Diseases

Source: Lecture


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Infections of the CNS

DEFINITIONS

BACTERIAL MENINGITIS

Etiology

o

Newborn period

2 months 12 years

!

o

o

! o o

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Neisseria meningitides

o

o

o o

Haemophilus influenza type b

o

!

Risk Factors

o o

Risk Factors for Common Orgs

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Pathophysiology of Bacterial Meningitis

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Clinical Manifestations

Neonates Infants Older Children and Adults

Very non-specific

Fever or hypothermia

Seizures

Lethargy or irritability

Vomiting, poor feeding or feeding intolerance

Respiratory distress, apnea

Diarrhea

Fever - 50%

Seizures - 40%

Poor feeding

Abdominal distention

Respiratory distress

Bulging anterior fontanelle - 30%

Altered sensorium

Classic Triad:

Fever

Headache

Nuchal rigidity

Lumbar Puncture

Contraindications for LP

5 Absolute, 1 relative CI !

Normal CSFPRETERM TERM INFANTS/CHILD

WBC (cell/mm3)Mean

-2SD%PMN

9.0

0-25.457.2%

8.2

0-22.461.3%

0

0-70

Glucose (mg/dl)

MeanRange

5024.63

5232-119

>4040-90

CSF glucose/Blood glucose

MeanRange

7455-105

8144-248

5040-60

Protein (mg.dl)

MeanRange

11565-150

9020-170


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Typical CSF Findings in Meningitis

o

Bacterial Viral Fungal Tuberculous

Opening pressure Normal or High Normal Normal or High Usu High

WBC count (cells/mm3) 1,000 10,000 80


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Subdural effusion !focal seizures; note thickened sulci = pus

Meningitis; thickened; whitish material is exudate

TreatmentRecommendations for Empiric antibiotic Therapy in Bacterial Meningitis

Pathogen-specific therapy for Meningitis

Complications of Bacterial Meningitis

Prognosis !"

Poor Prognosis #

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Sensorineural hearing loss

o o

o


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PreventionN. meningitides H. Influenzae Type B S. Pneumoniae

o

o

TUBERCULOUS MENINGITIS

Pathophysiology #

! $

Rupture of these encapsulated foci results in spread of infection intothe subarachnoid space

Clinical Features of TB Meningitis

Inferior brain surface showing exudate in basal cisterns

Stage

INon-specificsymptoms -fever, lethargy

Stage

2Confusion,cranial nerveparesis,`meningism!arteritic

Complications:hemiparesis,ataxia,dysarthria

Stage

3Coma localising,flexing orextending topain,opisthotonos


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Radio diagnostic criteria

!

Normal vs Tuberculous Meningitis

Enhancement in basal exudates of Tb meningitis as shown in CT Scan

DiagnosisClinicalCT Scan

Lumbar puncture

o

" o

Investigation

o "

Other Forms of CNS TB

o

4yo/F, prolonged fever, ataxia, vomiting, headache; thought it was atumor in the cerebellum but it was actually caseation necrosis


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VIRAL MENINGOENCEPHALITIS

o

o

VE Etiology

Enteroviruses

Mumps virus

Arboviruses

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Pathology and pathogenesis

Tissue sections

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Predilection $ $

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Clinical manifestation

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Diagnosis

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Laboratory findings>6R

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Treatment

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Prognosis

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Possible Complications

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EOSINOPHILIC MENINGITIS

Etiology

Others

Noninfectious causes include:

Clinical Manifestations !

o

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Diagnosis

o

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Treatment

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Prognosis


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BRAIN ABSCESS

Causes

Pathology

o

Location and source

Clinical manifestation

o

o o

o

Diagnosis

o $

o o

o

CT with contrast and MRI

o

o

Large multiloculated frontal lobeabscess showing ring enhancement andmidline shift as seen on CT scan

Hypoechoic 6.7 x 5.2 cm.Oval ParietoTemporal Lesion

Treatment

!

!

! !

Surgery is indicated

o !

Prognosis

o o o

o o o o o


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BacterialMeningitis

Tuberculous Meningitis Viral Encepahlitis

S/sx


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FEBRILE SEIZURES

o o

FS Recurrent Seizures

Factors assoc with !recurrence risk

!Risk of developing epilepsy

FS Treatment

o

o o o

o

UNPROVOKED SEIZURES

o

US First seizure

RECURRENT SEIZURES

RS Etiology !

!

o

!o o o o

o

DIAGNOSTIC EVALUATION OF FIRST SEIZURES

Febrile Unprovoked Recurrent

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