Infectious Disease [BRAIN INFLAMMATION]

Presentation and Differential Bacterial

Any brain inflammation will present with a backbone of fever + Crypto
Meningitis TB
a headache. This is nonspecific for a particular diagnosis, but
Lyme
antennae should go up for “problem in the brain.” Other signs and Rocky Mountain
symptoms that help (photophobia, N/V, and seizures) may be + Stiff Neck Syphilis
present but are likewise nonspecific. There are 3 categories of Listeria
disease - each with their own unique findings. 1Meningitis will
Fever + + FND
have a stiff neck (Kernig and Brudzinski’s Signs), 2Abscesses Abscess or Cancer
Headache
will present with Focal Neurological Deficits, and 3Encephalitis
will present with encephalopathy (aka confusion).
+Confusion Eastern Equine
Western Equine
Encephalitis St Louis
HSV
West Nile
(flaccid paralysis)

Encephalitis
Encephalitis is the inflammation of the brain parenchyma itself.
It should present with the fever + headache AND confusion.
Altered mental status is part of the FAILS mnemonic, and so a
CT is performed before the LP. The CT should be normal (the
test may say something about temporal lobe or anosmia,
implying that the question is about HSV). The LP should reveal a
bloody tap (while only 30% are bloody, it’s still a classic
teaching). What separates it from a subarachnoid hemorrhage is
the presence of white cells. Definitive diagnosis is made with
HSV PCR. Treat empirically with Acyclovir while awaiting the
results of the PCR.

The other association to know is that west nile virus presents with
flaccid paralysis.

Abscess vs Cancer (Mass Lesions)

Since mass lesions present as a fever and a headache with Focal
Neurological Deficits, this will also require a CT scan before the
LP - usually with a dose of ceftriaxone. The CT will come back
for a ring enhancing lesion; it’ll be contraindicating the
lumbar puncture. Instead, additional investigation of the mass
must take place (i.e. a Biopsy). This will tell us if there’s an
abscess requiring drainage and investigation of a primary source,
( organisms) or if it’s a cancer requiring radiation and chemo.
That’s useful since antibiotics won’t work for a cancer, nor will
chemo/radiation work for an abscess.

There’s one exception to jumping to a biopsy - an HIV/AIDS

patient. In a patient with a CD4 count < 200 AND a Toxo
Antibody positive at any time in life, the mass is Toxoplasmosis
90% of the time. For this patient treat empirically with
pyrimethamine and sulfadiazine for 6 weeks. If there’s
improvement keep it going. If not, go to biopsy. If “treat
empirically” isn’t an option, look for Toxoplasmosis-Ab.

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 Infectious Disease [BRAIN INFLAMMATION]

Meningitis Lumbar Puncture Findings
Meningitis is inflammation of the meninges caused by any # of Bug Cell Count Glucose Protein WBC Tx
etiologies. The challenge is to identify which organism is most Bacterial ↑↑↑ ↓↓ ↑ PMNs Ceftriaxone
likely, confirm it, then treat it. The definitive test is the Lumbar Viral ↑ - ↑ Lymph
Fungal ↑ ↓ ↑ Lymph
Puncture. It gives a wealth of information (glucose, protein,
TB ↑ ↓ ↑ Lymph RIPE
cells) of the CSF as well as a body fluid for Gram Stain and
Culture. But sometimes you can’t just jump straight to an LP. A
CT must be done first if they have any of the FAILS mnemonic.
Hence, two treatment pathways:

1. The LP is UNsafe. This treatment plan uses the blood

culture as a chance at getting a diagnosis. Antibiotics are
given prior to the CT scan and the LP. Cultures are sterilized
after 2-4 hours. Then the CT scan is done; if it’s normal the
LP follows.
2. The LP is Safe. This strategy uses the CSF culture as the
chance to get a diagnosis (aka the next step is LP).
Antibiotics are given immediately after the LP is performed.

The LP gives a wealth of information, but most of it is useless.

The only thing you care about is the number of cells and what
type they are (lymphocytes or neutrophils). Ignore pH / glucose
/ protein for most questions.

If there are mega (100s to thousands) neutrophils you can be

assured that it’s a bacterial meningitis. Its treatment revolves
around Vancomycin, High-Dose Ceftriaxone, and Steroids. In
the immunocompromised, include ampicillin to cover for listeria.

If the LP comes back “no bacterial” then we have a dilemma. It’s

“easy” to find what you’re looking for when you know what
you’re seeking, but hard to find something if you don’t know what
it could be. Repeated from the first Page

Cryptococcal meningitis is found in patients with AIDS and a

CD4 count < 200. There may be seizures. Opening pressure is Bug Suspicious Hx Test Tx
often quite elevated and serial taps may be required to keep the RMSF Rash on hands, Spread Proximal Antibody Ceftriaxone
Lyme Targetoid Rash, Hiker, Ticks Antibody Ceftriaxone
pressure down. Diagnose with a cryptococcal antigen (do NOT
Crypto HIV/AIDS Antigen Amphotericin
use India Ink). Treatment is with induction for 2 weeks with IV TB Pulmonary TB AFB RIPE
Liposomal Amphotericin B and IV Flucytosine, followed by Syphilis STD, Palmar Rash, DCMLS RPR Penicillin
consolidation with PO Fluconazole. Listeria Elderly Neonate on Steroids - Ampicillin
Viral Diagnosis of Exclusion - -
Lyme disease can be suspected if there’s a targetoid lesion and
travel to endemic areas such as New England. There’s often NO
tick noticed because they’re so small. Use ceftriaxone for Lyme
meningitis (not doxycycline as you do for non-invasive disease).
Borrelia burgdorferi is the bacteria. Ixodes is the Tick.

RMSF is seen in campers who develop a peripheral rash that

moves towards the trunk. Obtain the antibody on the CSF. If
positive, treat it with ceftriaxone.

TB meningitis is simply extrapulmonary TB. Consider this in

someone who has Pulmonary TB risk factors. Treat with RIPE.

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