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Central Nervous
System Infection
(Infeksi
Susunan Saraf Pusat)
2
FOREWORD
• Central Nervous System Infections is a
serious Illness
• Late diagnosis and proper
Management leads to death or serious
disabilities
• Early diagnosis and treatment is
important
3
Route Infection :
• Open Wound around cephalic
• Direct contiguous infection from otitis media,
sinus-sinus paranasal, skin infection around
cephalic and face.
• Septisemia/ bakteriemia
• Abses cerebri.
• Retrograde infection along nerve.
• Direct infection to CSF by non steril
lumbal punction.
6
• Course :
• Acute :
• Purulent meningitis
Subacute :
• CNS listeriosis •Cerebral abcess
•Focal encephalitis
• Herpes simplex encephalitis
•Neuroborreliosis
•Neurosyphillis
•Tuberculous meningitis
•Actinomycosis
Chronic
•Nocardiosis
•Tuberculous meningitis
•Ricketsiosis
•Neuroborreliosis
•Neurobrucellosis
•Neurosyphillis
•Whipple encephalitis
•Creutzfeldt-Jacob disease
7
DIAGNOSIS OF
MENINGO-ENCEPHALITIS
1. Presence of symptoms of an infection / fever
2. Presence of signs and symptoms of Central Nervous
System abnormalities:
• Lowering of consciousness
• Confusion
• Convulsions
• Neurological deficits
8
GENERAL LABORATORY
EXAMINATION
• Blood Leukocyte and differential
count
• Blood test for micro-organism :
• culture / staining
• serological
• staining
• PCR
9
2. Neuro-Imaging :
• CT-Scan
• MRI
10
CSF EXAMINATION
In Viral infections:
• Cell count, Protein and Glucose content are not so
prominently altered.
CSF ABNORMALITIES
Bacterial Serous Viral Meningitis/
Meningitis Meningitis Encephalitis
Protein
Glucose -0 N
12
14
POLYMERASE CHAIN
REACTION
Advantage:
Rapid diagnosis for certain diseases:
• Tb Meningitis
• Herpes Simplex encephalitis
Disadvantage:
• Not readily available.
• For certain specimen, contamination
is high
LUMBAR PUNCTURE
• Contraindications
• Infection in overlying skin
• Signs of intracranial mass lesion/ papil edema
• If an intracranial mass/hydrocephalus is suspected.
• NEURO IMAGING is indicated, before CSF examination
• Relative
• Coagulopathy
• Thrombocytopenia
• If delay is anticipated obtain blood cultures and GIVE
antibiotics
• You have 2 hours after ATB given before sensitivity is
effected
17
PLAIN X-RAY
• Indirectly to look for focus of Infections
• Chest x-ray is a must : present of pulmonary
infections
• Skull x-ray to look for focal infarction:
Mastioditis , Para nasal sinus infections ,
periodontal infection.
• In suspected Cysticercosis , calcified cyst in
the muscle.
18
NEURO -IMAGING
CT-Scan should be done with contrast
• In Brain Abscess - hyperintense ring
enhancement
• Intracranial mass lesions due to
Toxoplasmosis, Fungal infections,
cysticercosis
• In Tuberculous meningitis, hyperintense
visualization of the subarachnoidal
space will be seen
19
OTHER LESIONS
MAGNETIC RESONANCE
IMAGING
Advantage:
• More sensitive for certain lesions
• Can detect abnormalities in more earlier stage
than CT-Scan
Disadvantage:
• Good apparatus are more expensive
• Takes more time for examinations, difficult in
delirious patients
22
ETIOLOGY OF CNS
INFECTIONS
• In case of suspected CNS Infections, we
have to differentiate between:
• Bacterial : Specific /non-specific
• Parasites : Malaria / Toxoplasma
• Fungal : Cryptococcus/Aspergillus's
• Viral : Japanese Encephalitis HIV, Herpes
• Prion Disease : TSE , CJD
• Look for the possibility of MIXED infections
23
CLINICAL PRESENTATION
• Acute Meningo-Encephalitis
• Intracranial tumor Like : Brain abscess,
tuberculoma,Toxoplasma etc.
• First sign as Epilepsy : Cystecercosis
• Degenerative disease Like : SSPE,TSE
26
CLINICAL PRESENTATION
OF INFECTIVE AGENTS
• Meningitis: Bacterial / viral / fungal
• Encephalitis: Viral
• Brain abscess: Bacterial, fungal, parasitic
• Sinus thrombosis: Bacterial
27
HISTORY TAKING
• When does signs and symptoms begins
• History of past illnesses ( HIV , Tuberculosis )
• Economic status and occupation
• Habit : i.v. drug use ?
• Coming /traveling from Endemic areas ?
• Any recent outbreak of human or animal desease? (
West Nile , Nipah )
28
PHYSICAL EXAMINATION,
NEUROLOGICAL
• Any sign of Infections ? Fever ,with headache, muscle
pain ?
• Lowering of Consciousness
• Alteration of Consciousness
• Cranial nerve palsies
• Neck stiffness/ meningeal signs
• Limb paralysis / hemiplegia
29
PHYSICAL EXAMINATION,
INTERNAL
• Skin abnormalities , exanthema , bleedings.
• Body temperature ? Fever ?
• Vital signs ; Blood pressure ,pulse, respiration,
• Respiratory abnormalities : Dyspnoeic ?
• Abdomen : tenderness , stiffness . Liver /spleen
palpable ?
VIRAL MENINGITIS
31
INFEKSI VIRAL
• Tergantung pada :
• Jumlah virus & virulensinya
• Daya tahan tubuh yang rendah seperti :
• Penyakit kronik
• Gangguan imunologik
• Reaksi alergi
• Demam, obat-obatan
• Radioterapi
• Adanya kerusakan ginjal, paru, hepar, jantung &
susunan eritropoetik
VIRAL MENIGITIS
• 85% secondary to
• Echo-
• Coxsackie
• Entero-
• Also consider HSV, and EBV
• Neutrophils may predominate in the CSF in the first 24
hours
• Consider starting ATB’s until cultures come back (-)
INFEKSI VIRAL
33
MENINGITIS VIRAL
Bersifat benigne , gejalanya kadang sangat ringan
Pada keadaan berat memberikan gejala:
• Sakit kepala
• Kaku kuduk
• LP : Pleiositosis limfositer . liquor jernih
• Penyebab : paling sering dari kelompok enterovirus :
• V. poliomyelitis
• V. coxsakie
• V. ECHO (Entero Cytophatic Human Orphan)
• Penetrasi melalui lintasan oral fecal / droplet spray
MENINGITIS
VIRAL 34
V. Coxsakie dikenal :
• Kelompok A :
• Menyebabkan meningitis
• Eksantema bersifat rubeliform dengan herpangina di
tangan, kaki, mulut
• Kelompok B
• Menyebabkan meningitis disertai keletihan otot hingga
paralysis.
• Rhinitis, laryngitis, bronchitis.
• Eksantema tidak dijumpai.
MENINGITIS
VIRAL 35
V. ECHO :
• Tersebar diseluruh dunia
• Lebih sering pada anak
• Anak sering rewel/ cengeng
• Sering timbul gejala eksantema yang lebih
menonjol
• Sakit kepala
• Muntah, nyeri otot anggota gerak
• ± 24 jam timbul bercak bercak merah mulai
dari muka hingga ke badan.
• Kaku kuduk & nyeri
EMPERIC ANTIVIRALS
• Concern of herpes
• Acyclovir 10mg/kg IV Q 8 hours
VIRAL
ENCEPHALITIS
VIRAL ENCEPHALITIS
Cytology (-) _ _ + +
59
TREATMENT
• First priority
• Antibiotics
• Second priority in some cases
• Anti-inflammatories
• Third priority
• Counter the adverse effects of increased ICP &
vasculopathy
EMPERIC ANTIBIOTICS
Age/Special Gram Stain Drug
18-50y/o Negative Ceftriaxone 2g IV +
vanco 1g IV or rifampin
63
MENINGITIS TUBERKULOSA
Pemeriksaan Fisik:
– Tanda-tanda rangsangan meningeal berupa kaku
kuduk, tanda Laseque dan Kernig
– Kelumpuhan saraf otak sering dijumpai
Pemeriksaan Penunjang :
– LCS :
• Pelikel (+)/Cobweb Appearance (+)
• Peliositosis 50 – 500/mm3, dominan sel mononuklear,
protein meningkat 100-200 mg%, glukosa menurun < 50-
60%, bakteriologis Ziehl Nielsen (+), kultur BTA (+)
– IgG anti TB atau PCR
– Thorax foto
– CT Scan Kepala atau MRI
64
MENINGITIS TUBERKULOSA
Diagnosa Banding
– Meningoencephalitis karena Virus
– Meningitis bakterial yang pengobatannya tidak
sempurna.
– Meningitis oleh karena infeksi jamur/parasit
(Cryptococcus neoformans atau toxoplasma
gondii), sarcoid meningitis
– Tekanan selaput yang difus oleh sel ganas,
termasuk karsinoma, limfoma, leukemia, glioma,
melanoma dan medulablastoma.
65
MENINGITIS TUBERKULOSA
Tatalaksana :
– Umum
– Terapi kausal : kombinasi obat anti
tuberkulosa (OAT)
• INH
• Pyrazinamida
• Rifampisin
• etambutol
66
MENINGITIS TUBERKULOSA
Komplikasi :
– Hidrosefalus
– Kelumpuhan saraf kranial
– Iskemi dan infark pada otak dan mielum
– Epilepsi
– SIADH
– Retardasi mental
– Atrofi nervus optikus
Prognosis
– Sembuh lambat dan umumnya
meninggalkan sekuele neurologis
67
Brain Abscess
Brain Abscess
Focal pyogenic infection
Pus-filled cavity ringed by
granulation tissue & outer fibrous
capsule surrounded by edematous
brain tissue
Epidemiology
Paranasal sinus focus
– 10-30 y/o
Otic
– Bimodal: <20 y/o & >40 y/o
Pathophysiology
Hematogenous spread
– 1/3 of cases
Contiguous (middle ear, sinus,
teeth)
– 1/3 of cases
– Otogenic (Bacteroides)temporal
lobe/cerebellum
– Sinogenic & odontogenic(anaerobic &
microaerophilic streptococci)frontal
lobe
Clinical Features
Classic triad
– Headache, fever, focal deficit <1/3 of
cases
– Toxic appearance is rare
– Seizures, vomiting, confusion,
obtundation possible
– Frontal lobe-hemiparesis
– Temporal lobe- homonymous superior
quadrant visual field deficit or aphasia
– Cerebellum-limb incoordination or
nystagmus
73
Diagnosis
CT with contrast
LP contraindicated
Biopsy or aspiration for
confirmation
Treatment
Presumed Primary Empiric Alternative Tx
Source Tx
Otogenic Cefotaxime 2g IV q8h Bactrim 5mg/kg IV q6h
+
Flagyl 1giv then 500mg
q6 or chloramphenicol
INFEKSI SPIROKHETAL
INFEKSI SPIROKHETAL
LEPTOSPIROSIS
• Penularan leptospirosis melalui air minum
yang terkontaminasi dengan kencing host
leptospira seperti tikus , kelinci, marmot.
INFEKSI SPIROKHETAL
LEPTOSPIROSIS
• Kuman masuk kedalam traktus digestivus
menyebar melalui pembuluh darah ke
organ organ tubuh terutama ke hati dan
ginjal kemudian menimbulkan reaksi
peradangan, oedema akhirnya terjadi
hepatic failure dengan ikterus obstruktif,
renal failure.
79
INFEKSI SPIROKHETAL
LEPTOSPIROSIS
• Gejala lain yang menyertainya : myalgia,
konjunctivitis perikorneal, uveitis,
hemorhagi, meningitis leptospirosis (paling
sering ± 50%), hemorhagi serebri.
INFEKSI SPIROKHETAL
SIFILIS
• Disebabkan oleh kuman Treponema
pallidum.
• Kuman ini tidak tahan terhadap panas,
mudah terbunuh oleh sabun, antiseptika,
pengeringan. Hanya bisa bertahan hidup
pada keadaan dingin.
INFEKSI SPIROKHETAL
SIFILIS
Gambaran penyakit :
• Menyerupai organic brain syndrome.
• Gejala prodromal berupa sakit kepala,
insomnia, cepat lupa, daya konsentrasi
menurun, badan letih. Pada tahap lanjut
timbul dementia dan perubahan watak
yang menyerupai psikosis.
82
INFEKSI FUNGAL
• Sering disebabkan oleh kriptokokus,
nokardia, mukomikosis, koksidiomikosis,
aktinomikosis, aspergillus.
• Penyebaran secara hematogen sering
berasal dari paru – paru.
• Meningitis oleh infeksi fungal ini menyerupai
meningitis serosa.
83
INFEKSI PROTOZOAL
Disebabkan oleh :
• Tripanosomiasis (tripanozoma gambiense)
• Malaria (Plasmodium Falciparum)
• Toksoplasmosis & amubiasis
INFEKSI PROTOZOAL
84
TOXOPLASMOSIS
Gejala Klinis :
• 80 – 90 % pasien tidak menimbulkan
gejala
• jika ada tersering limpadenopati
• Hidrosephalus
• Kalsifikasi serebral
• Khorioretinitis
Liquor : TOXOPLASMOSIS
• kronik N
• Akut protein & limphosit meningkat
• EEG gelombang delta diselingi spike.
Pada keadaan kronis EEG normal
CT Scan :
• lesi multiple yang menyerap kontras
• bentruk bisa cincin atau noduler
• tumor di white matter
• dgn edema otak diffus
86
INFEKSI METAZOAL
• Disebabkan oleh :
• Nematoda : trikinela spiralis
• Trematoda : Skistosoma & paragonimus
• Sestoda :
• Tenia solium sistiserkosis
• Ekinokokus granularis
hidatidosis
• Mutiseps-mutiseps
INFEKSI METAZOAL
87
SCHISTOSOMIASIS
• Terbanyak di Cina, Philipina, Indonesia, Laos,
Thailand
• CT Scan : seperti granuloma lainnya
• EEG : gelombang lambat abnormal, fokal epilepsy
• LP : sel meningkat lymphositosis, bebrapa
eosinofil. Protein meningkat
• Gejala klinik : kejang umum & epilepsy Jakson.
INFEKSI METAZOAL
88
CEREBRAL
PARAGONIMIASIS
• Biasanya di lobus oksipitalis & parietal
• Bisa kena n II
• LP : protein meningkat, pleiocytosis
(eosinofil (+))
• CT Scan :
• biasanya selain ada kalsifikasi terdapat
banyak vascularisasi
INFEKSI METAZOAL
89
CYSTICERCOSIS
• Sering kena otak, mata (visual field terganggu) , otot
(pseudohipertropi)
• Kejang , hidrosephalus
• Gejala klinik : SOP
• CT Scan : single/multiple area hipodens didalam
jaringan otak
• Tidak dikelilingi cincin dan edema
• LP : tekanan meningkat, pleiositosis, Ig G meningkat,
glukosa menurun
90
MIELITIS TRANSVERSA
Yaitu radang medulla spinalis yang mengenai segmen
medulla spinalis (substansia alba & grisea).
Etiologi :
• Pasca infeksi atau parainfeksi : infeksi virus, rubeola,
varisella, variola, jarang pada rubella, mumps,
influenza.
• Pasca vaksinasi : anti rabies, varisella, pertusis, polio,
tetanus.
• Nekrotik atau degeneratif
• AIDS (Aquired Immuno Deficiency Syndrom)
• Dasar terjadinya mielitis oleh karena reaksi alergi
91
MIELITIS TRANSVERSA
GAMBARAN KLINIS :
• Pasca infeksi / pasca vaksinasi mulai timbul
deficit neurology setelah 5 – 10 hari
• Perjalanan penyakit akut
• ± 50% timbul dalam waktu 12 jam
• ± 75% timbul dalam waktu 24 jam
• Mula mula berupa demam, malaise, mialgia.
• Deficit neurologik berupa
• Kelemahan ekstremitas
• Gangguan sensibilitas
• Gangguan genitourinaria & defekasi
• Segmen medulla spinalis yang sering terkena
antara segmen thoracal 2 – thorakal 6.
92
MIELITIS TRANSVERSA
GEJALA NEUROLOGIK
AWAL :
• Parestesia anggota gerak bawah dan tubuh dengan
pola segmental
• Kadang nyeri punggung yang menjalar sepanjang
batas atas lesi medulla spinalis.
• Pada keadaan akut timbul fase syok spinal dengan
gejala paralysis flaksid ke 2 tungkai, retensio urine &
alvi, setelah 3 – 6 mg baru muncul paralysis spastic.
• Neuritis optika Devic disease.
93
MIELITIS TRANSVERSA
LABORATORIUM :
Liquor :
• Hambatan aliran liquor
• Pleiositosis moderat 20 – 200 sel/mm3 . limfosit lebih
banyak.
• Protein sedikit meningkat 50 – 120 mg/dl.
• Kadar glukosa normal.
94
TERIMA
KASIH