CNS infection

R3江宜蓁
Definition ~
*Meningitis ~ inflammatory process involving the
subarachnoid space, pia and arachnoid matter
(leptomeninges)
 fever, headache, meningeal sign
 change in mental status
* Encephalitis ~ inflammation of the cerebral
parenchyma
 fever, consciousness disturbance, seizure, focal
neurological signs
* Focal infection ~ brain abscess, subdural empyema...
Cardinal manifestations of CNS infection
• Fever
• Headache
• Seizure
• Meningeal signs (neck stiffness, Brudzinski/Kernig’s sign)
(B – brain, K – knee)
• May absent in infant < 6m/o and in elderly
• IICP signs ~ headache, projectile vomiting, papilledema
Cushing triad:
hypertension, bradycardia, irregular respiration pattern
• Focal signs or mental status change
• Course:
• Acute: viral or bacterial
• Subacute: TB or Cryptococcal
Pathogenesis
 Hematogenous
 From septicemia, infection of lung, heart
(endocartditis), or other viscera
 Direct extension
 From skull, spine, sinusitis, otitis, osteomyelitis,
and brain abscess
 Risk factors
 DM, alcoholism, liver cirrhosis, head trauma or
operation (otological or neurosurgical )
Diagnosis - CSF and Lumbar Puncture
• CSF
• Production : 60% from choroid plexus
• Total volume: 140ml in adult
• Production rate in adult: 500-600ml/day
• Function
• Normal composition ~
-- Cells: mononuclear cells < 5/ul (lymphocyte predominant)
-- RBCs: indicate SAH
-- Glucose: 50-75 mg/dl (1/2 ~ 2/3 of blood glucose)
-- Total protein: 15-50 mg/dl
-- Pressure: 80-180mmCSF
Contraindication of lumbar puncture

 Spinal cord or intracranial mass lesion

 Risk of herniation
 Local infection
 Epidural abscess, cellulitis…
 Coagulopathy
 Thrombocytopenia, prolonged PT, aPTT…
How to Interpretate CSF Data ~
* Point: Pressure
Cell ( WBC/RBC)
Protein
Sugar
N/L ratio
 CSF in meningitis (1)
Meningitis Pressure WBC Protein Glucose

Acute
bacterial ↑ > 100 WBC, PMN
predominant
60-1000 5-40, in most
case (absence of
hyperglycemia ),
or <20%,
elevated lactate

50 – 500, lymphocyte
Tuberculous
↑ predominant except in
Nearly
always
Usually reduced,
<45 in 75% of
early stages when PMN elevated, cases (<50%)
may >80% usually 60-
700

Cryptococcal
↑ 30-300, average 50,
lymphocyte predominant
Usually
100-700
Reduced in most
cases, average
average 30 (<50%)
100
 CSF in meningitis (2)
Meningitis Pressure WBC Protein Glucose

Viral Normal to 10 -350, lymphocyte Frequently Normal (reduced

moderately predominant, except in early normal or in 25% of
elevated stage PMN maybe >80% slightly mumps and
elevated,40- HSV)
100
Syphilitic ↑ 5- 500, usually lymphocyte Average 100 Normal ,
predominant

Cysticercosis ↑ Increased mononuclear and Usually 50- Reduced in 20%

PMN with 2-7% eosinophilia 200 cases (<1/2)
in about 50% case
Sarcoid Normal to 0 to <100 mononuclear cells Slight to Reduced in 50%
considerabl moderate cases
ely elevation
increased
Tumor Normal or 0 -500 mononuclear Elevated, Normal or
elevated leukocyte and malignant often to high greatly reduced
cells levels (low in 75%
cases)
*Bacterial meningitis
* Etiology: Newborns: Gr B streptococci, E.Coli
Infant, child: H. influenza
Young adult: N. meningitis > S.p
Old adult: S.pneumonia, N.meningitis ,
H.influenza, Listeria
Taiwan: G(-)/K.p, Streptococcus, Staphylococcus
* Tx: Newborn~ Ampicillin + cefotaxime
ICU~ cefotaxime+ aminoglycoside
+ penicillin or vancomycin
Infant ~ Ampicillin+ cefotoxime
Child ~ Cefotaxime or ceftriaxone
Adult ~ Vancomycin +Rocephin
Trauma/OP~ Vancomycin + ceftazidime
(with/without aminoglycoside)
-- Virus: aseptic meningitis
• Dx: CSF, culture or PCR, immune reaction
• Tx : self-limited within 3-7 days
-- TB
• Dx: CSF, TB-PCR, AFB (20-30% => 75% ), TB culture
(4-6 wks)
• Course: Stage I: no neurological sign
• Stage II: Lethargy or alteration in behavior
meningeal irritation
minor neurological deficit
Stage III: Abnormal movement/Convulsions
Stupor/coma/severe neurological deficit
(CN palsy, turbeculoma, obstructive hydro, vasculitis
 infarction, seizure)
• Tx: as pulmonary TB, but duration for 18-24 months
-- Cryptococcosis ~
Diagnosed by pathogen and polysacharide Ag in
CSF treated with Amphotericin B/ Flucytosine/
Fluconazole
– Viral encephalitis:
the treatable one is HSV encephalitis  diagnosed
by EEG, MRI  treated with Acyclovir
(30mg/kg/day) x 10-14 days
-- Abscess :
diagnosis by Image/aspiration  treated with
antimicrobials and drainage
Syphilis
 Syphilis (Chronic systemic infection)
 Primary:
 chancre (firm, painless, genital ulcer)
 Secondary
 bacteremic stage:2-12 weeks later:
generalized mucocutaneous lesion
(palmar/plantar rash) + lymphadenopathy,
CNS seeding
 Tertiary syphilis: gummas, aortistis,
chorioretinitis, CNS involvement
Tertiary Neurosyphilis
 General Paresis
 chronic, diffuse encephalitis, dementia,
 Tabes Dorsalis
 Chronic spinal polyradiculitis (dorsal
root/column degeneration)
 S/S: neuropathic shooting pain, loss of
posterior column sensation, areflexia
 Argyll Robertson pupil
 Small irregular pupil, react to accomodation
but not to light (chronic optic neuritis)
Prion Disease
 Cretzfelt-Jakob disease, subacute
spongiform Encephalopathy
 Prion Protein
 S/S:
 rapid/progressive dementia
 diffuse myoclonic (startle response)
 cerebellar signs and ataxia
 changes in behavior and emotional
response
 Abnormality of Vision (distortion of shapes)
CJD
 EEG: PLED (67-100% of CJD
patients), for self-limited period -
>biPLED, positive sharp waves 
diffuse suppression
 Fatal, rapid progressive course
 CSF: 14-3-3 protein
 Pathology: cerebral and cerebellar
cortices, diffuse
 Treatment: non, supportive
Lyme Disease
 Neuroborrelis
 Borrelia burgdorferi (tick)
 Erythmatous target lesion (erythema
chronicum migrans)
 Acute/chronic relapsing dermatologic,
immunologic, rhematologic, cardiac,CNS or
PNS involvement
 +IgM to Borrelia (serum or CSF)
 CSF: Lymphocytic pleocytosis
 Treatment: Ceftriaxone or Penicillin G for 2-4
weeks
 Conclusion
 Infection of CNS can be life-threatening
 Prompt diagnosis and treatment to
prevent death or permanent neurologic
disability
 Fever+Headache+neurologic signs
CNS infection until proven otherwise