Meningitis

• Definition

• Headache —> ... —> {fever, altered mental status, meningismus}

• Meningitis <—> encephalitis (cause and vice versa often)

• Viral : lymphocytic pleocytosis on CSF

• Enteroviruses (picornavirus family)

• Late summer, early fall

• Children

• Anorexia, vomiting, rash, diarrhea

• Adult
• Myalgia, anorexia, vomiting, sore throat, malaise, fever

• Acutely

• SEVERE headache (frontal)

• Photophobia

• Nuchal rigidity

• Chronic?

• X-linked agammaglobulinemia —> Rituximab tx

• Arboviruses : same causes as encephalitis

• Herpesviruses

• HSV-2 during primary genital infection

• Recurrent benign lymphocytic meningitis (Mollaret’s meningitis)

• Urinary symptoms + genital ulcerations

• HSV-1 —> more common encephalitis

• VZV —> acute meningitis during/after shingles

• CMV/EBV —> meningoencephalitis

• Pharyngitis, lymphadenopathy, splenomegaly —> EBV

• HHV-6 —> possible meningitis with roseola infantum

• Mumps

• Parotid enlargement in 50%

• Lymphocytic Choriomeningitis Virus (LCM)

• Rodent excreta (usually urine)

• Non-specific illness

• Human immunodeficiency virus

• 5-10% during primary infection

• Bacteria :

• CSF PMN predominance, low glucose, profoundly ill appearance

• Often delirious, most have nuchal rigidity

• Brudzkinski’s sign : neck flexion —> hip/knee flexion

• Kerning’s sign : hip flexion, knee extension —> back/neck pain

• CN involvement/seizures in 1/3 pt

• Haemophilius influenza

• Type B : not as common in children now (vaccination)

 • Non-typeable capsular : adults >65

• Neisseria meningitidis (A, B, C, Y, X, W135)

• Rapidly fatal in hours

• Meningococcemia

• Young adults

• Look for characteristic rash

• Non-blanching purpuric (and purple) rash

• Recurrent meningitis —> terminal complement component deficiencies

• Streptococcus pneumoniae

• Most common cause of. bacterial meningitis in USA

• More common in adults, associated with...

• Sinusitis

• Otitis media

• Mastoiditis

• Pneumonia

• Predisposing factors

• HIV

• Hypogammaglobulinemia (multiple myeloma)

• Alcoholism

• Liver/renal disease

• DM

• Malignancy

• Recurrent meningitis —> chronic CSF leak from basal skull fracture

• Listeria monocytogenes

• Common in...

• neonates

• immunocompromised (cell-mediated immunity)

• Also corticosteroid use

• elderly

• pregnancy/post-partum

• Alcoholism

• Malignancy

• TNF-alpha inhibitors
• Transplantation

• Often exposure to contaminated food (cold-cuts, soft cheeses)

• May be genital tract commensal in females

• May be associated BS involvement —> rhomboencephalitis

• Staphylococcus aureus + coagulase negative staphylococci

• After...

• Head trauma

• Neurosurgical procedures

• CSF shunts (staphylococcus epidermidis)

 • Complicates...

• Bacteremia

• Endocarditis

• Glucocorticoid use

• Hemodialysis

• IVDU

• Gram negatives : E. Coli, Klebsiella, Salmonella, Pseudomonas, Enterobacter

• Post-neurosurgical

• Immunocompromised

• Unlikely in healthy adults

• Nocardia - recurrent neutrophilic meningitis

• Immunocompromised (cell mediated)

• particularly corticosteroid use

• Suspect in setting of pneumonia + CNS symptoms

• Fungi : lymphocytic pleocytosis on CSF (subacute to chronic presentation)

• Cryptococcus neoformans and gatti

• Bird droppings

• Immunocompromised (cell mediated)

• HIV

• Corticosteroid use

• Coccidiodes immitis

• Sonoran life zone

• Common to disseminate from lungs to meninges

• Immunocompromised (cell mediated)

• Can occur in normal hosts...

• Tuberculosis (mistaken for aseptic, bacterial, or fungal)

• Classic subacute

• Early on : neutrophilic predominance in CSF

• Later on : shift to lymphocytes in cSF

• High protein, low glucose

• Altered sensorium —> obtundation

• CSF block? —> hydrocephalus

• CNS involvement more common in HIV-1 pt

• Do not need prior hx of TB

• Spirochetes

• Treponema pallidum

• Syphilitic meningitis (early, uncommon neurosyphilis)

• Early after primary or usually secondary stages

• Mostly seen in HIV infection

• Late forms of neurosyphilis (years,decades)

• Meningo-vascular syphilis

• Parenchymatous neurosyphilis

• Tabes

 • Borrelia burgdorferi (Lyme disease)

• CSF lymphocytes predominate

• Serology is +

• Cranial nerve palsy common (particularly 7th)

• Rickettsia + related

• Rocky Mountain spotted fever

• Q fever

• Ehrlichia

• Protozoa and helminths

• Naegleria fowleri (waterborne + fatal)

• Amebic meningoencephalitis

• Balamuthia

• Angiostrongylus cantonensis (nematode —> roundworm)

• Most common cause of eosinophilic meningitis

• Primarily in Pacific (Hawaii, southeast Asia, now in Caribbean)

• Spread by rats

• Ingesting intermediate host —> mollusks, shrimp, slugs

Encephalitis
Probable encephalitis? —> TREAT FOR HERPES (VZV also responds to Tx)

• Definition : inflammation of brain —> change in sensorium (Inability to think clearly or

concentrate)

• Seizures MORE LIKELY than in meningitis

• Obtundation usually earlier in illness

• Tx available only for herpresviruses

• Common etiologies

• Worldwide

• Japanese B encephalitis virus

• US

• HSV-1

• West nile

• St. Louis encephalitis virus

• California encephalitis group

• Others...

• HIV

• Varicella-zoster

• CMV, EBV, HHV6

• Rabies

• Toxoplasmosis

• Bartonella henselae (cat scratch disease)

• More viruses...

• Arboviruses

• Eastern equine encephalitis virus

• Western equine encephalitis virus

• Venezuelan equine encephalitis virus

• Other alphaviruses, bunyaviruses, togaviruses

• West Nile Virus

• Most infections are asymptomatic

• Most symptomatic occur in elderly

• Sxs —> Flaccid paralysis (suggesting poliomyelitis)

• Herpes encephalitis (usually HSV-1)

• Present with altered mentation, some focal findings, often speech difficulties
• Almost always FEVER and some personality change
• ~60% have seizures at some point

• Progression : day to week (RARELY LONGER)

• Can lead to death/neurologic deficits

• Tx? —> WORSENS

• DDx

• Hydrocephalus

 • Stroke

• Infection

• Subdural hematoma

• Tumor

• Rarely an associated oral lesion

• MRI —> unilat or bilat temporal lobe involvement

• VZV encephalitis

• CBL involvement (ataxia)

• Occur after rash resolved

• Present : granulomatous vasculitis —> hemiplegia (stroke)

• Immunocompromised pt

• Acute chickenpox or H. Zoster (CN V distribution)

• Rare complications in healthy pt...

• CMV encephalitis

• Immunocompromised pt

• AIDS, transplant

• Periventricular inflammation on imaging

• Neutrophilic pleocytosis on CSF

Brain Abscess
Host characteristics
• HIV/AIDS —> toxoplasmosis until otherwise proven
• Immunocompromised —> Nocardia + fungal
• High endemicity —> Neurocysticercosis

• Definition

• Intracerebral collection of pus

• “Classic Triad”
• Fever (32-79%)
• Headache (most common)a
• Focal neurologic signs (50%)
• Clinical presentation

• Non-specific to organism

• Depending on size/location

• Headache —> mental status change, nausea, vomiting

• Seizures less frequent

• Some have nuchal rigidity

• 25% with papilledema

• Fungal

• Vascular occlusion —> stroke-like picture

• Mucormycosis

• Sinus involvement

• Retro-orbital involvement (proptosis, diplopia) + facial swelling

• Etiologies

• Direct extension from sinus, mastoid/middle ear infections

• Sinusitis and Otitis

• Organisms of mouth/sinuses origin —> Streptococcus milleri + other streptococci

• Hematogenous spread

• Brain injury

• Bacteria

• Streptococcus milleri

• Mouth/gut commensals

• Staphylococcus aureus

• Commonly seen in bacteremia + after injury/surgery

• E. Coli, Klebsiella, Pseudomonas

• Less frequent (up to 20%)

• Anaerobes (30% of cases)

• Can occur even when there is a predominate aerobe —> always considered in tx
decisions, even when not isolated

• Nocardia asteroides

• Immunocompromised

 • Can occur in normal hosts...

• Fungi

• Immunocompromised

• Transplant

• DM

• Corticosteroid

• HIV

• Renal/liver

• Candida, Aspergillus, Zygomycetes, Scedosporium

• (Route 1) Hematogenous dissemination

• (Route 2) direct extension from infected sinuses

• (Route 3) open-head trauma

• Scedosporium in non-immunocompromised + association with near-drowning

• Fungi associated with fungal meningitis causing abscesses...

• Dematiaceous (pigmented) fungi

• Cladiophialophora bantiana

• Bipolaris spp.

• Exophiala dermatitidis

• Curvularia pallescens

• Others causing infection in normal host

• Protozoa and Helminth

• Neurocysticercosis : larval form of Taenia solium

• Ingest EGGS

• Major cause

• Entamoeba histolytica

• Schistosoma spp.

• Paragonimus spp.

• Trypanosoma cruzi