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SPAZIO EPI-DURALE ASCESSO EPIDURALE
DURA MADRE
PIA MADRE
ENCEFALITI
ENCEFALO ASCESSI CEREBRALI
Meningite
BATTERI
- Leptospira
- Brucella
VIRUS
- Borrelia burgdorferi - Enterovirus
- T. pallidum - Adenovirus
- Rickettsiosi - Coxsackie
- Virus della parotite
- Mycoplasma P. - HIV
-Mycobacterium T - Virus influenzali
- Virus parainfluenzali
- Virus della coriomengite linfocitaria
- Virus del morbillo
- Rotavirus
- WNF virus
- TOSV
CNS infections
Incidence Morbidity Mortality
Bacterial 0.6-4 cases per 30-50% 3-37%
meningitis 100,000 permanent
adults/year neurological
sequelae
Encephalitis “Rare” If due to HSV 0-70%
HSV: 0.2-0.4 >50% ~ 10%
cases per neurological
100,000 sequelae
adults/year
Cerebral Rare 20-70% 8-25%
abscess
Bacterial meningitis in United States,
1998-2007 Thigpen MC NEJM 2011; 21: 2016-25
587pts
1083 pts
Listeria 11 7 0 1 19 (2%)
monocytogenes
Streptococcus 28 8 0 3 39 (4%)
pneumoniae
Conclusions
diffusione ematogena
replicazione batterica esponenziale
danno neuronale
rilascio di citochine pro-infiammatorie
MENINGITI
INFETTIVE
patogenesi
Does this patient have an acute CNS infection?
Case 1 Case 2
-A previously healthy 70-year-old -A 30 year old man presents to the
woman presents to the emergency emergency department with a few
department with a 3-day history of days history of “bad flu” with fever
fever, confusion, and lethargy. and headache.
-She is unable to cooperate with a -On clinical examination, he is febrile
full physical examination, but she has and quite confused. He can fully flex
neck stiffness upon neck flexion. his neck Kerning and Brudzinski
-The findings from a chest singns are absent
radiograph and urinanalysis are
normal
MENINGITI INFETTIVE - MANIFESTAZIONI
CLINICHE
Stato FEBBRE
settico
CEFALEA
Ipert. endocranica ALTERAZIONI SENSORIO
S. pneumoniae,
H. influenzae
N. meningitidis
0 24 2 3 4 5 6
ORE GIORNI
Sepsi da Meningococco
Sepsi da Meningococco
MENINGITI INFETTIVE
PECULIARITA’ DELLE MANIFESTAZIONI CLINICHE IN ETA’
PEDIATRICA
NEONATO
- MAI RIGOR
- AGITAZIONE / SONNOLENZA
- SUZIONE RIDOTTA
- CONVULSIONI MOLTO FREQUENTI
LATTANTE
- NUCA CIONDOLANTE
- TENSIONE delle FONTANELLE
ESCMID guideline: diagnosis and treatment of
acute bacterial meningitis
Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62
ESCMID guideline: diagnosis and treatment of
acute bacterial meningitis
Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62
Does this patient have an acute CNS infection?
Metanalysis of 845 patient-episodes, in adult patients with meningitis confrmed
by LP or autopsy Attia J et al. JAMA 1999;281:175-181
Sens Spec PPV NPV
Fever, neck stiffness and
Jolt accentuation 97% 60% NA NA
altered mental status: of headache
sens 46%, spec 100% Fever 85% 45% NA NA
Altered mental 67% More common in
The absence of all 3 signs status bacterial than viral
meningitis
of the classic triad
Neck stiffness 30-70% 71% 41% 61%
reduces the probability of
Kernig’s sign 11% 95% 60% 60%
meningitis
Brudzinski’s 9% 95% 50% 62%
Focal neurologic 23% Not useful in ruling out
95% of pts with ABM findings meningitis
have ≥ 2: F, NS, AMS and Rash 22% More common in
headache meningococcemia
Van de Beek D et al. NEJM 2004;351:1849-59
Brouwer MC Lancet 2012;380:1684-1692
Diagnosi
Esame del liquor microscopico e
colturale
La diagnosi precoce ed il trattamento
precoce della meningite batterica sono
imperativi per ridurre la mortalità e la
morbilità.
I medici devono praticare la puntura
lombare ad ogni paziente in cui sospettino
tale diagnosi a meno che non vi siano
specifiche controindicazioni a questa
procedura.
Le infezioni del SNC causano
alterazioni liquorali
• Both in adults and children that characteristics are present in 90% of patients. A completely normal
CSF occurs but is very rare.
•In neonatal meningitis, CSF leukocyte count, glucose and total protein levels are frequently
within normal range or only slightly elevated.
The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and
meningococcal sepsis in immunocompetent adults
McGill et al. J.Infect 2016
Guidelines on routine cerebrospinal fluid
CSF glucose concentration, CSF/serum analysis. Report from an EFNS task
Force
glucose ratio Deisenhammer et al. Eur J Neurology 2006;13:913
• Glucose is actively transported across the blood–brain barrier the CSF glucose levels
are directly proportional to the plasma levels and therefore simultaneous measurement in
CSF and blood is required.
• CSF glucose takes several hours to equilibrate with plasma glucose; therefore, in unusual
circumstances levels of CSF glucose can actually be higher than plasma levels for several
hours.
CSF Gram
CSF culture
Algoritmo gestionale
ED Medical Ward
mean time to mean time to p
Timing ATB antibiotics antibiotics
1: 08 h + 13’ 6+9h
.03
(8 min to 6) (1 -48 h)
Therapy in ED Therapy in MW
Mortality
7.9% 29% .003
Delays in the administration of antibiotics are associated with
mortality from adult acute bacterial meningitis. Proulx N et al QJM 2005
Inpatient
Median Length Readmission
Etiology (No.) No. (%) Mortality, No.
of Stay (d) (IQR) Rate, No. (%)
(%)
Overall sample 26429 (100) 4 (5) 776 (2.9) 845 (3.2)
Enterovirus 13463 (51.6) 3 (2) 65 (0.5) 164 (1.2)
Unknown etiology 4944 (21.4) 5 (7) 247 (5.1) 253 (5.1)
Bacterial
3692 (14.1) 7 (8) 302 (8.2) 245 (6.7)
meningitis
Herpes viruses 2184 (8.3) 5 (5) 45 (2.1) 79 (3.6)
AUCCSF/AUCS ratio
Barrier integrity
7,00
6,00
5,00 Control
4,00 LFX
3,00 CTX
2,00 CTX+LFX
1,00
0,00
Initial titer log Killing rate over 8
CFU/mL) h (logCFU/mL)
AUCCSF/AUCs RATIOS IN HUMANS
Nau R et al. Antimicrob Agents Chemother 1996; 42: 2012-6
Lutsar I & Friedland IR, Clin Pharmacokinet 2000; 39: 335-43
Pea F. et al. Antimicrob Agents Chemother 2003;47:3104-8
Nau R. et al. Clin Microbiol Rev 2010; 23:858-877
4. C’è indicazione all’uso di steroide in acuto ?
P = .04
Follow 15 15
up
at 8 w 7
placebo DXMT
4. C’è indicazione all’uso di steroide in acuto ?
Dexamethasone for the Treatment of Tuberculous
Meningitis in Adolescents and Adults Thwaites GE et
al, N Engl J Med 2004
545 patients randomly assigned to either dexamethasone (274) or placebo
(271)
P =
41,3 .001 HIV
%
31,8
placebo
DXMT
DEATHS at 9 m follow up
Our approach to the management of CNS
infection
Implementation of a meningitis care bundle in the
emergency room reduces mortality associated with acute
bacterial meningitis Viale P et al. Ann of Pharmacother 2015
Implementation of a meningitis care bundle in the
emergency room reduces mortality associated with acute
bacterial meningitis Viale P et al. Ann of Pharmacother 2015
Esami ematochimici urgenti (emocromo, glicemia, creatininemia, Na, K, Cl, FBG, D-dimero, PCR)
Valutazione parametri vitali Valutazione status neurologico
desametasone 10 mg
SOSPETTA INFEZIONE ACUTA SNC
Esami ematochimici urgenti (emocromo, glicemia, creatininemia, Na, K, Cl, FBG, D-dimero, PCR)
Valutazione parametri vitali Valutazione status neurologico
desametasone 10 mg
SOSPETTA INFEZIONE ACUTA SNC
Esami ematochimici urgenti (emocromo, glicemia, creatininemia, Na, K, Cl, FBG, D-dimero, PCR)
Valutazione parametri vitali Valutazione status neurologico
desametasone 10 mg
VALUTAZIONE SI NO
INTENSIVISTICA Paziente critico Emocolture (2 set)
Complicanze sistemiche TER. ANTIBIOTICA EMPIRICA
Emocolture (2 set) Complicanze neurologiche cefotaxime 4 g
TER. ANTIBIOTICA EMPIRICA CONS. INFETTIVOLOGICA
cefotaxime 4 g
CONS. NEUROLOGICA
CONS. INFETTIVOLOGICA TC ENCEFALO urgente
CONS. NEUROLOGICA
TC ENCEFALO urgente Ipertensione endocranica
TORBIDO LIMPIDO
Algoritmo gestionale
Alcune domande ricorrenti:
1. Quanto precoce deve essere la terapia antibiotica ? IL PIU’
POSSIBILE
2. CT scan encefalo pre- puntura lombare ? SI
3. Quali farmaci di prima linea ? CEF 3^gen ANTI-PNEUMO +
CHINO
4. C’è indicazione all’uso di steroide in acuto ? SI
5. Quanto deve durare la terapia ? Fino a remissione clinica
completa
6. C’è indicazione a PL di controllo a fine terapia ? NO
ESCMID guideline: diagnosis and treatment of
acute bacterial meningitis Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62
Case definitions, diagnostic algorithms, and priorities
in encephalitis: consensus statement of the
international encephalitis consortium
Venkatesan A et al. Clin Infect Dis 2013 Oct;57(8):1114-28
Diagnostic Criteria for Encephalitis and Encephalopathy of Presumed Infectious or
Autoimmune Etiology
Major Criterion (required)
Patients presenting to medical attention with altered mental status (defined as decreased or
altered level of consciousness, lethargy or personality change) lasting ≥24 h with no
alternative cause identified
Minor Criteria (2 required for possible encephalitis; ≥3 required for probable or
confirmed encephalitis)
Documented fever ≥38° C within the 72 h before or after presentation
Generalized or partial seizures not fully attributable to a preexisting seizure disorder
New onset of focal neurologic findings
CSF WBC count ≥5/cubic mm
Abnormality of brain parenchyma on neuroimaging suggestive of encephalitis
Abnormality on EEG that is consistent with encephalitis and not attributable to another
cause
Case Definitions, Diagnostic Algorithms, and Priorities in Encephalitis:
Consensus Statement of the International Encephalitis Consortium
Venkatesan et al, CID 2013;57:1114-28
The requirement for objective documentation of fever within a restricted time frame of ≤72
h after hospitalization was chosen to exclude secondary health-care associated infections. It is
recognized that fevers can occur as a result of a number of infections outside of the central
nervous system that can cause encephalopathy, as well as with noninfectious entities that mimic
encephalitis.
It is also recognized that fever may fluctuate and, as such, objective fever may be lacking in
patients with infectious encephalitis at the time of clinical assessment.
Seizures associated with encephalitis may be generalized, suggestive of global CNS dysfunction,
or focal, indicating a localized process.
Subclinical seizures may also occur and can be a cause of altered sensorium.
Seizures associated with high temperatures are relatively common in young children and, if
occurring in isolation, do not mandate evaluation for encephalitis.
The major requirement for at least 24 h of altered mentation was selected to exclude the
postictal state seen in patients with febrile seizures.
CSF pleocytosis is suggestive of an inflammatory process of the brain parenchyma, meninges,
or both (meningoencephalitis).
The absence of CSF pleocytosis, however, does not exclude encephalitis. In particular, it is
recognized that the CSF may be devoid of cells in immunocompromised patients
The CSF profile with inflammation limited to the meninges may be indistinguishable from that
in patients with encephalitis. In the majority of cases of encephalitis, however, the absolute
number of leukocytes is <1000/mm3 and lymphocytes typically predominate.
Magnetic resonance imaging (MRI) is the radiologic modality of choice for evaluation of
patients with suspected encephalitis.
MRI or CT may not be available in resource-limited settings, in which case the diagnosis of
encephalitis will need to rely on clinical and laboratory criteria.
EEG abnormalities reported in cases of encephalitis range from nonspecific generalized
slowing to distinctive patterns suggestive of specific entities:
Repetitive sharp wave complexes over the temporal lobes or periodic lateralizing epileptiform
discharges in HSV-1. [Lai and Gragasin J Clin Neurophysiol 1988 5:87– 103]
Bilateral synchronous periodic sharp and slow waves associated with subacute sclerosing
panencephalitis. [Gutierrez et al. Dev Med Child Neurol 2010 52:901–7]
Mostly asymptomatic
About one in
five infected
develop fever
About one in
150 infected
develop SNC
disease
In New York, Romania, and Israel, the risk for neurologic disease increased
with age, which may explain, in part, the different epidemiologic patterns
seen in parts of Africa.
In Egypt and South Africa neurologic disease is rare.
Although immunosenescence affecting innate and/or adaptive immune
responses is a likely scenario, other observations indicate roles for functional
or structural CNS changes that facilitate neuroinvasion.
WNV- Clinical manifestation
42 decessi
Verosimili cause:
-Primavera calda e piovosa
-Maggiore quantità di zanzara Culex
-Proporzione maggiore di zanzare infette per WNV
-Proporzione maggiore di uccelli morti positivi per
WNV
Toscana Virus
Famiglia: Bunyavirus > 350 specie
virali
85-120 nm
Toscana Virus in Europa
Arthropode- borne virus
Trasmesso da pappataci
Meningite
Tropismo: SNC
Encefalite
Disribuzione geografica
E’ collegata alla circolazione del vettore
BOLOGNA
Mediterraneo
ITALIA: casi di
encefalite
rilevati nel periodo
tra maggio-ottobre
Con un picco elevato
in agosto
TOSV: aspetti clinici
TOSV nell’uomo:
The incidence of brain abscesses has been estimated at 0.3 to 1.3 per
100,000 people per year but can be considerably higher in certain risk groups,
for example, patients with HIV/AIDS.
Over the last 30 years, new diagnostic procedures, such as brain imaging
techniques (MRI and CT) and stereotactic biopsy, and the introduction of new
antibiotics have considerably changed the management of patients with brain
abscess, at least in high-income countries
PATOGENESI
CEREBRITE TARDIVA
4-9 gg
CAPSULA PRECOCE
10-13 gg
PMN
infiltrato infiamm. acuto
CAPSULA TARDIVA
14 gg
necrosi parte centrale della lesione
PMN
infiltrato infiamm. acuto
CEFALEA 70%
ALTERAZIONI FUNZIONI SUPERIORI 70%
SEGNI NEUROLOGICI FOCALI 60%
FEBBRE 40-50%
FEBBRE + CEFALEA + SEGNI FOCALI < 50%
CONVULSIONI 25-45%
VOMITO 25-50%
RIGIDITA’ NUCALE 25%
EDEMA della PAPILLA 25%
Indagini per
DIAGNOSI di MALATTIA
Indagini per
RICERCA FATTORI PREDISPONENTI
Indagini per
DIAGNOSI ETIOLOGICA
DIAGNOSI
Indagini per
DIAGNOSI di MALATTIA
• TAC
• RMN
Indagini per
RICERCA FATTORI PREDISPONENTI
• Anamnesi
• TC rocche e seni paranasali,
• Rx ortopantomografia Indagini per
• Rx torace, DIAGNOSI ETIOLOGICA
• ecocardiogramma,
• sierologia x HIV • esame colturale
• sierologia x Toxoplasma gondii del materiale drenato (se disponibile)
• sierologia x Toxocara canis • esame colturale
• Mantoux del materiale da biopsia
• Ag Aspergillus (in pz. con condizioni • emocolture
predisponenti)
• criteri “ex juvantibus”
TERAPIA
DRENAGGIO CHIRURGICO