1. Inflammations & infections of CNS and Cerebrospinal fluid Dr Aarathi Rau

2. Infections of the CNS Meninges,brain,both  Meningitis-  Pachymeningitis:Epidural and subdural infections  Leptomeningitis-Subarachnoid  Brain-  Cerebral abscess-focal inflammation  Encephalitis-diffuse inflammation

4. Formation,circulation,function of CSF  Formation-500 ml/day  Ultrafilteration & secretion –choroid plexus, ependymal lining of ventricles  Circulation: ventricular system-foramina- subarachnoid space

5. Function of CSF  Protects, lubricates the brain  Provides nutrients, removes waste 90-150 ml adult 90-150 ml adult 10-60 ml in newborn 10-60 ml in newborn Blood brain barrier – homeostasis;electrolytes Urea,glucose,protein,creatinine passively along concentration gradient

6. Normal CSF  Thin, colourless, clear fluid  Pressure 90-180mm WATER (10-100 neonates)  0-5 WBC’s /mm 3 (neonates 0-30/ mm 3 )  Lymphocytes & monocytes  Occasional ependymal or choroid plexus cells  Protein 15-45mg/dl  Glucose 50-80mg/dl  Chloride 113-130 mEq/L  Sterile

7. Meningitis Def: inflammatory process of the leptomeninges & CSF within the subarachnoid space  Meningoencephalitis =+inflammation of brain parenchyma  Classification  Acute  Aseptic  Chronic

8. Pyogenic meningitis pathogenesis  Blood borne  Direct-sinuses,mastoid,middle ear,dural venous sinuses,direct trauma,fracture skull  Neonates:E Coli,Strep pneumoniae, Adolescents: N Meningitides, H influenzae Adolescents: N Meningitides, H influenzae  Adults: N Meningitides, Strep pneumoniae type 3  Elderly :Listeria monocytogenes,strep pneumoniae type 3

9. Clinical features  General  Headache,altered consciousness,vomiting  Neck stiffness

10. Gross  Pus in the subarachnoid space  Meningeal vessels engorged  Location-Pneumococcal-convexities  Tracks along vessels, ventriculitis  Microscopy  PMN in SA space,> meningial vessels  Thrombosis of superficial vessels &  Cerebral ischemic damage

12. CSF in Pyogenic Meningitis  Increased pressure  Purulent/cloudy  ↑protein  ↓ glucose  Leucocytosis  Neutrophils ++  Gram stain  Culture

13. Sequele  Resolution  Cerebritis,hemorrhagic infarction of brain  Fibrosing meningitis  Hydrocephalus  Chronic adhesive arachnoiditis

14. (Aseptic)Lymphocytic meningitis  Viral usually (Coxsackie, EBV, ECHO) Less fulminant than bacterial Less fulminant than bacterial  Usually recover  Few specimens  Mild lymphocytic infiltrate of the meninges

15. CSF in Viral meningitis Clear appearance Mild pleocytosis Lymphocytes + Protein↑ Glucose –WNL Culture sterile Virological exam-Coxsackie, EBV, ECHO

16. Tubercular meningitis  Hematogenic spread  Gross:Thickening & opacity of leptomeniges  Basal meningitis, encasing cranial N’s  Discrete white granules on the meninges +/-  Microscopy-granulomas, lympho- plasmacytic infiltrate  Obliterative endarteritis

17. Tubercular meningitis  Sequele-adhesive, fibrous, arachnoiditis,  Hydrocephalus  Infarction following endarteritis  Tuberculoma-intraparenchymal

18. CSF in Tubercular meningitis  Moderate pleocytosis  Lymphocytosis (early –neutrophilia)  Glucose ↓ (< pyogenic )  Protein +++  Cobweb appearance /clot  AFB, culture, PCR.  Atypical mycobacteria

19. Syphilis Meningovascular neurosyphilis:Chronic meningitis Base of brain Cerebral convexities+/-, Spinal leptomeninges Cerebral Gumma Microscopy-endarteritis obliterans (Heubner arteritis) with plasma cell cuffing

21. Cerebral abscess  Def: Focal inflammation of the parenchyma of the brain  Routes of infection  Secondary to meningitis  Local spread (middle ear,mastoid)  Hematogenous-BE,cyanotic heart disease,bronchiectasis  Trauma

22. GROSS MORPHOLOGY GROSS MORPHOLOGY  Ill defined local swelling  preferred sites frontal lobe,parietal lobe cerebellum depending on aetiology depending on aetiology  C/S fibrous capsule soft central liquefactive necrosis surrounding oedema surrounding oedema

23. Morphology  Microscopy  Abscess containing necrosis surrounded by granulation tissue,fibrosis & gliosis  Microbiology:mixed bacteria + anaerobes

24. Encephalitis  Diffuse brain inflammation  Causative org: viral,rickettsia,bacteria (listeria)  Death of neurons

25. HIV associated Neurologic disorders  Primary:  CNS  Primary HIV encephalopathies  Giant cell encephalitis, leucoencepalopathy, gray matter disease  Myelopathy  Lymphocytic Meningitis-seroconversion  PNS  Skeletal muscle myositis

26. HIV associated Neurologic disorders  Associated with immune supressed condition  Opportunistic infections  Lymphoma

27. CSF in AIDS  Aseptic HIV meningitis-lymphocytic meningitis  Infections  M. tuberculosis less reactive  Mycobacterium avium intracellulare  Cryptococci  Neurosyphilis  Malignancies

29. OTHER INFECTIONS  Prion disease (CJD)  Fungal infections  Parasitic infections malaria, toxoplasmosis,Echinococcus,cysticercosis

33. Intracranial hemorrhage  Intracerebral hematoma-associated with hypertension,(AV malformations,tumour ) hypertension,(AV malformations,tumour )  Subarachnoid hemorrhage  Any age group  Associated with rupture of Berry aneurysm

36. Hemorrhagic tap  Traumatic  Clear supernatant  Clearing from tube 1 to 3  Fresh RBC’s  Subarachnoid hemorrhage  Xanthochromia>4 hrs upto 2-4 weeks  Same appearance in 1,2 & 3  Crenated RBC’s

38. Lumbar puncture  Diagnostic  Meningitis;bacterial,TB,fungal, viral *,syphilis  encephalitis  Guillain Barre Syndrome  Matastasis lymphoma,leukaemia,breast,lung Haemorrhage Haemorrhage  Any disorder affecting the nervous system!  Therapeutic  Administer dye for imaging studies  Administer medications eg CT,anaesthesia

41. Processing  Method of collection  3 sterile bottles  Biochemistry & immunology-blood glucose  Microbiology  Cell count,cytology  Send QUICKLY