Intracranial infection

Objectives To know about clinical presentation of meningitis and Encephalitis To know about the common infective organisms responsible meningitis and encephalitis. To know about the pathophysiology of meningitis and Encephalitis To know how to investigate a patient suspected of intracranial infection To know the main differential diagnosis of meningitis and of encephalitis To know about empirical treatment of meningitis and encephalitis To know about complications of meningitis and Encephalitis

Sites Meningitis Encephalitis Parameningeal: sinusitis, mastoiditis, otitis media, brain abscess, spinal epidural abscess.

Presentation Fever Headache Vomiting. Neck pain and signs of meningeal irritation. +? Disturbed consciousness Seizures Focal neurological manifestations +? Manifestations of the causative agent.

Pathophysiology Inflammation -> fibrinous exudate -> fibrosis Subpial Encephalopathy Increase intracranial pressure Brain Oedema -> herniation Vasculitis -> infarcts Venous sinus thrombosis Hydrocephalus Encephalitis -> Direct dysfunction of areas of brain

Ventriculitis

Cortical Infarcts

Inflammation around vessels

Subpial Encephalopathy

Inflammation of Cranials

Atiology Infective - Bacterial -> Acute : Pneumo, Meningo, H.Inf, List.mono Subacute: TB, Ricketseal, Brucellosis -Viral: H.simplex, V.Z, E.Bar, JC, etc.. -Fungal Non infective -> Connective Tissue Malig: fixed, Leuk, Lymph Radiation, Chemeical

Aetiology According to Age:

CSF changes

CSF appearance

Analysis

Other CSF parameters Manometry Gram stain Sereological Procalcitonin PCR

Cases 10 years old boy presented with fever headache, photophobia and vomiting of 3 days duration, was very toxic, history of similar condition in his brother was noted, which lead to death. O/E Neck stiffness and Kernig’s sign were positive. CSF: protein 120 mg/dl, sugar 39 mg/dl (blood 99 mg/dl), cells: 600 WBC, 90% Neutrophils. Gram stain shown below, also picture of his brother’s condition is shown below: What is the most likely pathogen?

Cases 5 years old boy presented with fever headache and vomiting of 3 days duration, O/E Neck stiffness and Kernig’s sign were positive. CSF: protein 120 mg/dl, sugar 39 mg/dl (blood 99 mg/dl), cells: 600 WBC, 90% Neutrophils. Gram stain shown below: What is the most likely pathogen?

Cases 35 years old man known thalasemic presented with fever headache and vomiting of 3 days duration, O/E Neck stiffness and Kernig’s sign were positive. CSF: protein 200 mg/dl, sugar 39 mg/dl (blood 99 mg/dl), cells: 2600 WBC, 90% Neutrophils. Had a history of splenctomy 1 year ago. Gram stain shown below: What is the most likely pathogen?

Cases 30 years old pregnant lady with fever headache and vomiting of 5 days duration, with acute onset deterioration in level of consciousnss following a complaint of double vision. O/E Neck stiffness and Kernig’s sign were positive. Bilateral VI, and spastic quadriparesis. CSF: protein 200 mg/dl, sugar 39 mg/dl (blood 99 mg/dl), cells: 300 WBC, 90% Neutrophils. What is the most likely pathogen?

Cases 17 years old girl brought to A&E with severe agitation and speaking non sense, sustained three fits each preceded by abnormal sense of smell for few seconds. O/E there was mild neck stiffness, Kernig sign was negative. However she was Dilerious. CSF showed protein 67 mg/dl, sugar normal, cells 10 WBC, all lymphocytes. Gram stain negative.EEG reveals bilateral temporal spikes and MRI picture shown below. What is the diagnosis:

Differential Diagnosis Meningitis: -Subarachoid Hemorrhage -Venous Sinus Thrombosis -Encephalitis Encephalitis -Venous Infarction -Hemorrhagive Leucoencphalitis -Meningitis

Investigations CBC & ESR, U&E, LFT, Nasopharyngeal swab, Blood cultures CXR CT scan & MRI brain, also for sinuses, otitis media, and other parameningeal source. EEG MRV & MRI Tuberculin test HIV screen

Management

Steroids Pyogenic Meningitis: Dexamethason: 4mg q6h iv x 4d Herpes Simplex encephalitis: Dexamethason 8mg q12h x 4d TB: 8mg iv q12h x 20 days

Antimicrobial therapy

Specific

Of meningococcal M. Prophylaxis Households, close contact (children) Rifampicine: po q12h x2d 5mg/kg/dose >1 year -> 10mg/kg/dose Adult: 600mg/dose OR Single dose Ciprofloxacin 500mg

Complications Hydrocephalus Cranial nn palsies Stroke Dementia Amnesia Aphasias Venous sinus thrombosis Death