CNS Disorders Dr Shreedhar Paudel April, 2009

MENINGITIS Inflammation of the coverings of the brain CAUSES – BACTERIAL – VIRAL – TOXINS – MALIGNANCIES

ACUTE BACTERIAL MENINGITIS NEONATAL PERIOD: S. PNEUMONAE, E.COLI 3 MTHS- 3 YEARS : H. INFLUENZAE, S.PNEUMONIA, N. MENINGITIDES > 3 YRS : S. PNEUMONIAE, N. MENINGITIDES IMMUNOCOMPROMISED HOST: LISTERIA, MYCOPLASMA, CRYPTOCOCCUS

ACUTE BACTERIAL MENINGITIS PATHOGENESIS – Routes of infection Hematogenous spread from distant focus of infection Local spread of infection from contiguous septic foci Exogenous infection after trauma

PATHOLOGY – Meninges are infiltrated with inflammatory cells – The cortex of brain shows edema, exudates and proliferation of microglia – Sub arachnoid space may be filled with purulent discharge – Exudates may block the foramina of Luschka and Magendie leading to hydrocephalus – Thrombophlebitis of cerebral vessels may occur leading to infarction and necrosis – Endotoxic shock and sudden death may be there if meningococcal meningitis

CLINICAL FEATURES SYMPTOMS - Acute onset - Fever/ Irritability - Projectile vomiting - Headache/ Bulging fontanel - Seizure - Altered sensorium/ photophobia - Marked neck rigidity

SIGNS PHOTOPHOBIA, NECK STIFFNESS, KERNIG’S SIGN ( extension of knee is limited to less than 135 degree) BRUDZINSKI SIGN ( the knees get flexed as neck of the child is passively flexed) BULDGING FONTANEL, ALTERATION OF MENTATION PAPILLEDEMA, NEUROLOGICAL DEFICIT Respiration may be Cheyne-Stokes type

ACUTE BACTERIAL MENINGITIS IN NEONATES AND YOUNG INFANTS There will be no signs of meningial irritation till 6 months of age Meningotis should be suspected in a newborn in following conditions – Vacant stare – Alternating irritability and drowsiness – Persistent vomiting with fever – Refusal to breast feeding – Poor tone/ poor cry – Shock/ hypothermia/ fever – Seizure/ neurological deficits

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS CNS COMPLICATIONS – SUBDURAL EFFUSION /EMPYEMA, – BRAIN ABSCESS, – HYDROCEPHALUS,

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS………. Long term neurological deficits - DEAFNESS / BLINDNESS/ APHASIA - HEMIPLAGIA - OCULAR PALSIES Systemic complications - SHOCK - MYOCARDITIS - SIADH - STATUS EPILEPTICUS

DIAGNOSIS LUMBAR PUNCTURE CSF FOR BIOCHEMICAL/CYTOLOGICAL EVALUATION Turbid CSF with raised pressure, elevated protein level (>100mg/dl), reduced sugar level ( 1000/μL, mostly Neutrophils)

DIAGNOSIS…. CSF for microbilogy – Gram stain – Culture/ sensitivity LATEX AGGLUTINATION, ELISA, PCR CT SCAN

ACUTE BACTERIAL MENINGITIS DIFFERENTIAL DIAGNOSIS – MENINGISM ( occur in inflammatory cervical lesion, apical pneumonia, toxemia due to Hemophilus infection or typhoid fever) – PARTIALLY TREATED BACTERIAL MENINGITIS – ASEPTIC MENINGITIS – TUBERCULOUS MENINGITIS – CRYPTOCOCCAL MENINGITIS – VIRAL ENCEPHALITIS – POLIOMYELITIS – SUB ARACHNOID HEMORRHAGE – LYME DISEASE (Borrelia infection)

TREATMENT OF ACUTE BACTERIAL MENINGITIS EMPIRICAL THERAPY – CEFTRIAXONE OR CEFATOXIME OR COMBINATION OF AMPICILLIN AND CHLORAMPHENICOL FOR DAYS SPECIFIC ANTIMICROBIAL THERAPY – MENINGOCOCCAL MENINGITIS: PENICILLIN, CEFOTAXIME OR CEFTRIAXONE – HEMOPHILUS MENINGITIS: CEFTRIAXONE/ CEFOTAXIME

TREATMENT…….. – STAPHYLOCOCCAL MENINGITIS: CLOXACILLIN OR VANCOMYCIN, ADDITION OF RIFAMPICIN WILL ENHANCE THE PENETRANCE OF THE CSF – LISTERIA: AMIPCILLIN AND GENTAMYCIN – PSEUDOMONAS: CEFTAZIDIME AND GENTAMYCIN, OR TICARCILLIN AND GENTAMYCIN DURATION OF TREATMENT: 10 DAYS EXCEPT FOR STAPHYLOCOCCAL MENINGITIS

TREATMENT….. – STERIOD THERAPY DEXAMETHASONE 0.15 MG/KG IV 6 HRLY FOR 5 DAYS FIRST DOSE OF STEROID SHOULD PRECEDE 15 MIN FROM ANTIBIOTICS DECREASES THE INCIDENCE OF RESIDUAL NEUROLOGICAL DEFICITS ESPECIALLY USEFUL IN H. INFLUENZAE INFECTION

TREATMENT………… SYMPTOMATIC TREATMENT – RAISED ICP: OSMOTIC DIURETICS – CONVULSION: DIAZEPAM OR PHENYTOIN – RESTRICTION OF FLUID TO 2/3 RD OF MAINTENANCE TO PREVENT SIADH – NURSING CARE TREATMENT OF COMPLICATIONS FOLLOW-UP AND REHABILITATION

TUBERCULOUS MENINGITIS PRIMARY SECONDARY PATHOGENESIS PATHOLOGY: TUBERCLE, BASE AND TEMPORAL LOBES STAGES: PRODROMAL, MENINGITIS, COMA DIAGNOSIS: LP, CT, BACTEC, PCR

TUBERCULOUS MENINGITIS D/D: PURULENT MENINGITIS, PARTIALLY TREATED,ENCEPHALITIS, TYPHOID ENCEPHALOPATHY, BRAIN ABSCESS, BRAIN TUMOR, CHRONIC SUBDURAL HEMATOMA, AMEBIC MENINGOENCEPHALITIS. TREATMENT: 12MTHS INITIAL 2 MTHS: HRZE LATER 10 MTHS: HRE

TUBERCULOUS MENINGITIS STEROIDS: DEXAMETHASONE IV- 1-2 WEEKS ORAL FOR 6 WEEKS AND TAPER SLOWLY OTHER SUPPORTIVE THERAPY.

ENCEPHALITIS DEFINE ETIOLOGY/ PATHOLOGY : INCLUSION BODIES VIRAL: MMR,HSV, CMV, EBV, JAPANEASE, WEST NILE, RABIES, DANGUE OTHER: RICKETTSIA, FUNGI, TOXOPLASMA, BACTERIAL, REYES SYNDROME

ENCEPHALITIS ONSET: SUDDEN SIGNS AND SYMPTOMS: FEVER, HEADACHE, VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY, COMA DECEREBRATION, DECORTICATION, PALSIES, PLAGIAS, EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B TEMPORAL OR FRONTAL LOBE : HSV

ENCEPHALITIS RAISED ICT HERNIATION 6 TH NERVE PALSY DIAGNOSIS HISTORY OF EXPOSURE LP CSF, PCR

ENCEPHALITIS MANAGEMENT SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES HSV: RBC IN CSF, TREATMENT : ACYCLOVIR

REYE’S SYNDROME GENERALISED MYOCARDIAL DYSFUNCTION LIVER, KIDNEY, CNS INHIBITION OF B-OXIDATION OF FATTY ACIDS ASPRIN OTHER SALICYLATES, VIRAL INFECTION HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA PRESENTATION: 2MTHS – 15 YEARS RAPID PROGRESSION

REYE’S SYNDROME STAGES I- MILD CONFUSION II – DELIRIUM III – COMA IV – APNEA, NON REACTING PUPIL DIAGNOSIS: HYPERAMMONEMIA, DEARRANGED LFT, EEG- TRIPHASIC WAVES

REYE’S SYNDROME TREATMENT LOW PROTEIN DIET TREAT HEPATIC FAILURE TREAT RAISED ICT HYPOGLYCAEMIA VITAMIN K, FFP