Sekar Satiti

Infections of Central Nervous System

Meningitis refers to an inflammatory process of
the leptomeninges and CSF within the
subarachnoid space.
Meningoencephalitis refers to inflammation of
the meninges and brain parenchyma.
Encephalitis refers to inflammation of the brain
parenchyma.

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Pathogenesis
 Extension from cranial structures
 Hematogenous spread (bacteremia or viremia)
(emboli of bacteria)
 Neuronal: HSV, rabies
 Iatrogenic infections
• Shunt infection
• Pasca LP
• Pasca craniotomy
• Intracranial pressure monitor placement (ICP)
Direct Spread
(extension from cranial structure)

Cranial injuries
Ears (Otitis media)
Osteomyelitis
Paranasal Sinusitis

Mastoiditis purulenta

Pus:  erosion the bone and

invasion the dura, arachnoid, pia, and the brain
Indirect
(hematogenous spread)

ginggiva
heart
pharynx
lung
bowel
septicemia
systemic infection
Bacterial invasion
Transmission bacteria
Colonization
& Invasion of the nasopharyngeal epithelium

Survival in the bloodstream

Bacteremia

Infected thrombi
 spread along the vessels to dural sinuses
along meningeal veins into the brain
Viral invasion
Viral infection
(arthropod borne virus, enterovirus, arbovirus)

Primary Replication:
skin, muscle, respiratory tract & gastrointestinal tract

Viremia
Secondary Replication:
In the vascular endothelial, RE system, muscle

Persistent viremia

Throw the BBB via

Plexus choroideus leucocyte/vasc. endothelial
Causa
• DNA virus
– Herpes simplex type 1, 2
– Cytomegalovirus
– Ebstein-Barr
– Varicella Zoster
• RNA VIRUS
– Japanese encephalitis
– Poliovirus
– Measles virus
– Mumps virus
– Influenza virus
– Rabies virus
– Human
immunodeficiency virus
type 1

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Bakteri
• Gram negatif • Gram positif
– Neisseria meningitidis – Streptococcus
– Escherichia coli – Staphylococcus
– Salmonella typhosa – Clostridium tetani
– Haemophilus influenzae
– Rickettsia

• Mycobacterium TB
• Non MTB
– Mycobact avium complex
– Mycobact kansasii
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Parasit
• Treponema pallidum /spirocheta
• Toxoplasma gondii
• Malaria
• Leptospira
• Taenia solium

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Fungi
• Cryptococcus neoformans
• Coccidioides
• Candida
• Aspergillus

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Gejala klinis
 Trias klasik meningitis : demam, kaku kuduk, nyeri
kepala
 Trias klasis encephalitis : demam, kejang, penurunan
kesadaran
 Meningeal signs +
 Defisit neurologis +
Meningeal signs
 Kaku kuduk
 Brudzinski 1, 2, 3, 4
 Kernig sign
 Edelmann
 Guillain
Defisit neurologis
 Gangguan kesadaran,
 Delirium, somnolent, coma
 Paresis saraf kranialis, misalnya
 Disartria/pelo: paresis n. hipoglosus
 Deafness: paresis n. acusticus
 Diplopia/pandangan dobel: paresis saraf
penggerak bola mata
 Mulut perot: paresis n. fasialis
 Gangguan bicara, misal:
 Afasia:
 Gangguan tingkah laku, misal
 Halusinasi
 Bicara sendiri
 Gangguan visus, contoh
 Kabur
 Pandangan gelap sebelah

 Gangguan sensorik, contoh

 Hemihipestesi
 Hipestesi wajah unilateral
 Hemiparesis
 (kelumpuhan separo badan)

 Gerakan involunter, contoh

 Ataxia, chorea

 Keseimbangan, contoh
 Dizzines
 vertigo
Gold standard
 Analisis liquor cerebrospinalis
 Kultur
 Sitologi
 Kimiawi
Lumbal Pungsi
Pendukung
 Head ct scan dengan menggunakan kontras
 MRI cerebral
 Meningitis Purulent Exudates
Terapi
 Perawatan umum = 5 B
 Brain: status kesadaran/GCS
 Blood: tekanan darah, nadi, Hb, AL, dll
 Breath: frekuensi, pola nafas
 Bladder: balance cairan
 Bowel: diet, defekasi
 Perawatan khusus
 Antibiotika
 Antiedema serebri
 Antiviral
 Antiparasitic
 Antifungi
 Anticonvulsion
 Pengendalian faktor primer
 Mengatasi infeksi primer-nya, misal: toxoplasmosis, Otitis
media dll.
 Rehabilitasi
 Exercise, terapi kerja, ADL (activity daily living)
Prognosis
 Viral: baik
 Kecuali: HIV
 Bakterial: jelek
 Parasit: dubia
 Jamur: jelek
Thank You
Vaccination
 Hib vaccine.
 Has had major impact in incidence of pediatric Hib meningitis
 Pneumococcal vaccine.
 For chronically ill and elderly, & now universal use in children.
 PCV-7. Use of PCV-7 for children has been an effective means of
preventing disease in older adults (JAMA. Vol. 294 No. 16, October
26, 2005 )
 Meningococcal vaccine
 Effective vs serotype A, C, Y, W135
 Major reduction of disease in military recruits
 Recommended for travelers to endemic areas.
 Offered to college students, specially those residing in dormitory
 A new quadrivalent vaccine (Menactra) was recently approved.
Who Should Be Vaccinated with the NEW
MENINGOCOCCAL VACCINE
(Menactra)

•Children aged 11-12 years

•Previously unvaccinated adolescents before entering high school or at

age 15 (whichever comes first)

•All first-year college students living in dormitories

•Other high-risk groups, such as those with underlying medical conditions

or travelers to areas with high rates of meningococcal disease, such as
Africa and India.

•Other adolescents who choose to get the vaccine to reduce their risk

"As the vaccine supply increases, CDC hopes, within three years, to recommend routine
vaccination [for] all adolescents beginning at 11 years of age," per CDC's news release
 FDA and CDC Issue Alert on Menactra Meningococcal Vaccine
and Guillain Barre Syndrome

• FDA and CDC alerted consumers and health care providers to five reports of
Guillain Barre Syndrome (GBS) following administration of Meningococcal
Conjugate Vaccine (trade name Menactra).

• It is not known yet whether these cases were caused by the vaccine or are
coincidental.

• Prelicensure studies conducted by Sanofi Pasteur of more than 7000 recipients

of Menactra showed no GBS cases.

• CDC conducted a rapid study using available health care organization

databases and found that no cases of GBS have been reported to date among
110,000 Menactra recipients.

September 30, 2005

 CRITERIA FOR OUTPATIENT ANTIMICROBIAL THERAPY IN
PATIENTS WITH BACTERIAL MENINGITIS

• Inpatient antimicrobial therapy for > 6 days

• Absence of fever for at least 24- 48 h prior to initiation of outpatient therapy
• No significant neurologic dysfunction, focal findings, or seizure activity
• Clinical stability or improving condition
• Ability to take fluids by mouth
• Access to home health nursing for antimicrobial administration
• Reliable intravenous line and infusion device (if needed)
• Daily availability of a physician

• Established plan for physician visits, nurse visits, laboratory monitoring, and
emergencies
• Patient and/or family compliance with the program
• Safe environment with access to a telephone, utilities, food, and refrigerator

CID 2004;39:1267-1284