LIST OF INFECTIONS OF CNS

5/26/2021
 There are four main causes of infections of
CNS

Dr. Vidhi Garala (MPT Neurology)

 Bacterial
 Viral
 Fungal
 Protozoal
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 Fungal infections
 Cryptococcal meningitis

Dr. Vidhi Garala (MPT Neurology)

 Brain abscess
 Spinal epidural infection
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 Protozoal infections
 Toxoplasmosis

Dr. Vidhi Garala (MPT Neurology)

 Malaria
 Primary amoebic meningoencephalitis
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 Bacterial infections
 Tuberculosis

Dr. Vidhi Garala (MPT Neurology)

 Leprosy
 Neurosyphilis
 Bacterial meningitis
 Brain abscess
 Neuroborreliosis
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 Viral infections  Slow virus infections, which
 Viral meningitis include:
 Eastern equine encephalitis  Subacute sclerosing
panencephalitis

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 St Louis encephalitis
 Japanese encephalitis  Progressive multifocal
leukoencephalopathy
 West nile encephalitis
 AIDS
 Herpes simplex encephalitis
 Rabies
 California encephalitis virus
 Varicella-zoster encephalitis
 La crosse encephalitis
 Measles encephalitis
 Poliomyelitis
MENINGITIS
INTRODUCTION

5/26/2021
 It is an acute inflammation of meninges of brain
& spinal cord characterized by combination of
pyrexia, headache & meningium (confusion or

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altered consciousness)
 Inflammation may be caused by infection with
 viruses, bacteria, or other microorganisms,
 less commonly by certain drugs
 It can be life-threatening because of
inflammation's proximity to brain & spinal cord;
hence condition is classified as a medical
emergency
 CLINICAL FEATURES
Acute onset of illness

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

 High grade of fever

 Severe headache

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 Nuchal rigidity & pain

 Irritability & drowsiness

 Photophobia & phonophobia

 Features of rapid raised ICP (normally 6-18cm water)

 Projectile vomiting, blurring of vision, altered sensorium &
convulsions, loss of pupillary light reflex, & abnormal
posturing
 In infants up to 6 months of age, bulging of fontanelle
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 Septic shock & septicimia
 Cranial nerve damage

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 Acute renal failure

 Meningitis caused by meningococcal bacteria may

be accompanied by a characteristic rash
 consists of numerous small, irregular purple or red
spots ("petechiae") on trunk, LE, mucous membranes,
conjuctiva, & (occasionally) palms or soles
COMPLICATIONS

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 Meningitis can lead to serious long-term consequences
 deafness

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 epilepsy
 hydrocephalus
 cognitive deficits
 if not treated quickly
TYPES

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 Pyogenic / bacterial meningitis
 Tubercular meningitis

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 Viral meningitis
5/26/2021 Dr. Vidhi Garala (MPT Neurology)
P YOGENIC BACTERIAL MENINGITIS
PYOGENIC BACTERIAL MENINGITIS

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 Causative organism
 Neonates – E-coli, proteus

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 Children – Haemophillus influenza type B, Neisseria
meningitides (Meningococcus)
 Adolescent - N meningitides
 Adult – streptococcus pneumoniae
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 Route of entry
 Direct contact of the CSF by Contaminated lumbar

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puncture, Sinusitis, Trauma
 Otitis media
 Through the blood stream
 Incubation period
 4- 24 hours
 PATHOGENESIS

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 The large-scale inflammation that occurs during
meningitis is largely attributed by response of
immune system

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 Immune cells of brain (astrocytes and microglia),
respond by releasing large amounts of cytokines,
hormone-like mediators that recruit other cells &
stimulate other tissues to participate in an immune
response.
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 Blood-brain barrier becomes more permeable,
leading to "vasogenic" cerebral edema (swelling

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due to fluid leakage from blood vessels)
 Large numbers of WBC enter CSF, causing
inflammation of meninges, & leading to
"interstitial" edema (swelling due to fluid
between cells).
 In addition, walls of blood vessels become
inflamed (cerebral vasculitis), which leads to a
decreased blood flow causing "cytotoxic" edema
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 The three forms of cerebral edema all lead to an
increased ICP together with low BP often

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encountered in acute infection,
 Brain cells are deprived of oxygen & undergo
apoptosis (automated cell death)
SIGNS

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 Positive Kernig’s sign & Positive Brudjinski’s
 Kernig's sign is assessed with patient lying supine, with hip
& knee flexed to 90 degrees.

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 Positive Kernig's sign - pain limits passive extension of knee
 Brudzinski's sign – if positive, flexion of neck causes
involuntary flexion of knee & hip.
 Jolt accentuation maneuver helps determine whether
meningitis is present in patients reporting fever &
headache
 The patient is asked to rapidly rotate his head
horizontally; if this does not make the headache worse,
meningitis is unlikely
 Papillary oedema
INVESTIGATIONS

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 Blood analysis
 TC is increased
 DC- neutrophillia

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 ESR- normal
 Hb- normal
 CSF analysis
 Glucose decreased
 Protiens increased (100-200mg/dl)
 Cells – neutophillia (>90%)
 CT or MRI scan is recommended prior to lumbar
puncture in suspects of risk
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 Gram stain to identify the organism
 Culture & sensitivity test

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PREVENTION

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 For some causes of meningitis, prophylaxis can be
provided in long term with vaccine
against Haemophilus influenzae type B

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
 Meningococcus vaccines
 against Streptococcus pneumoniae with pneumococcal
conjugate vaccine (PCV)
 Childhood vaccination with Bacillus Calmette-Guérin (BCG)
 Short-term antibiotic prophylaxis is also a method of
prevention, particularly of meningococcal meningitis
 rifampicin, ciprofloxacin or ceftriaxone can reduce their
risk of infection , but does not protect against future
infections
MANAGEMENT

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 High dose intravenous antibiotic
 Penicillin, Cephalosporin

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 Rifampicin, norfloxacin, erythromycin
 Mannitol to decrease the raised ICP
 Corticosteroids can also be used to prevent
complications from overactive inflammation
 IV fluids should be administered if hypotension
or shock are present
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 Mechanical ventilation may be needed if level of
consciousness is low, or if evidence of

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respiratory failure
 Seizures are treated with anticonvulsants

 Hydrocephalus may require insertion of a

temporary or long-term drainage device
(cerebral shunt)
TUBERCULAR MENINGITIS

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 It can be seen as a part of primary TB in
children & a part of secondary TB in adults

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 The primary focus being in the lung
PATHOGENESIS

5/26/2021
 TB bacilli reached all parts of body & remains
dormant in meninges

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 When immunity is less the foci or bacilli will
rupture in CSF
 Produce TB meningitis & lots of exudates

 Obstruction of CSF circulation

 Damage to lower cranial nerves

CLINICAL FEATURES

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 Gradually progressive disease
 Gradual onset of fever associated with

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headache, general weight loss & weakness
 Loss of appetite

 Raised ICP

 Feature of lower cranial nerve paralysis (IX, X,

XI, XII)
 Difficulty in speaking, swallowing etc
INVESTIGATIONS
 Blood analysis

5/26/2021
 TC nearly normal
 DC – lymphocytosis
ESR elevated

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

 CSF analysis
 Turbid & cloudy
 High protien (500mg/ dl)
 Boderline increase in glucose
 Cell are increased (lymphocytosis)
 Gram stain: gram positive
 CT scan with contrast: exudates can be seen
TREATMENT

5/26/2021
 Anti – tubercular drugs
 Corticosteroids

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 Mannitol
VIRAL MENINGITIS

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 It is also known as aseptic meningitis
 Clinical presentation is similar to that of acute

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pyogenic meningitis
INVESTIGATION

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 Microbiological findings shows no microorganisms
 CSF glucose is normal

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 Boderline se in CSF cells (lymphocytes) & protiens
 Gram stain is of no importance
 Polymerase chain reaction amplify small traces of
DNA & detect presence of bacterial or viral DNA in
CSF
 Assist in distinguishing various causes of viral meningitis
(enterovirus, herpes simplex 2 and mumps in those not
vaccinated for this)
 Serology (identification of antibodies to viruses) may
be useful in viral meningitis
TREATMENT

5/26/2021
 Viral meningitis typically requires supportive
therapy only

Dr. Vidhi Garala (MPT Neurology)

 Most viruses responsible for causing meningitis
are not amenable to specific treatment
 Herpes simplex virus & varicella zoster virus may
respond to treatment with antiviral drugs such
as aciclovir
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 Mild cases of viral meningitis can be treated at
home with conservative measures such as fluid,

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bed-rest, & analgesics.
 Prognosis is good

 Gradually recovers without any treatment

PT ASSESSMENT
History of presenting illness:

5/26/2021

 acute onset of illness, high grade fever
 Past history

Dr. Vidhi Garala (MPT Neurology)

 Infectious history, trauma, spinal anaesthesia, lumbar
puncture, sinusitis, ottitis media
 Vital signs:
 temperature: high grade fever,
 BP: low
 HR: tachycardia
 RR: increased
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 Observation:
 abnormal posturing may be seen

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 Abnormal respiration
 Topical changes: pressure sores may be present if
bed ridden
 Examination
 Level of consciousness, orientation, memory, speech
may be altered
 Cranial nerve examination: signs of damage of cranial
nerves (altered vision, hearing, dysphagia &
dysarthria)
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 Sensory screening: sensations may be intact
 Motor assessment

Dr. Vidhi Garala (MPT Neurology)

 ROM: may be decreased due to abnormal posturing
 Tone: increased
 Reflexes: exaggerated
 Muscle power: reduced
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 Chest examination: important in TB meningitis
 May have an underlying pulmonary TB

Dr. Vidhi Garala (MPT Neurology)

 Respiratory assessment
 Abnormal respiratory pattern (rapid shallow
breaths)
 Gustatory examination: difficulty in swallowing
 Bladder & bowel involvement: may be affected if
there is altered consciousness
 Functional capacity: reduced
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 Special test: kernig, Brudjinski
 Investigations: blood & CSF examination, CT or

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MRI, gram stain, serology
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 Problem list
 Altered sensorium

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 Muscular weakness
 Abnormal posturing
 Nuchal rigidity and pain
 Chest complications
 Reduced functional capacity
PT MANAGEMENT (GOALS)

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 Psychological support
 Positioning strategies & prevent bed sores

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 Prevent chest complications

 Promote vital function

 Prevent DVT

 Promote integration of sensory input

 Postural correction

 General fitness exercise

PSYCHOLOGICAL SUPPORT

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 Maintain a non threatening positive attitude
 Good support

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 Gain confidence of the patient

 Counseling of family members & patient

 Give information as necessary only

POSITIONING STRATEGIES & PREVENT BED SORES

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 Proper positioning with pads & cushions
 Use of water bed or foam mattress

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 Regular inspection of the skin

 Use cotton clothing to absorb sweat

 Avoid dragging during transfer

 Regular turning & changing position

PREVENT CHEST COMPLICATIONS

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 Breathing exercise, postural drainage &
suctioning as required

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 Cervical & thoraxic mobility exercise

 Thoraxic expansion exercise

 Strengthening of respiratory muscles

 PROMOTE VITAL FUNCTION

5/26/2021
 Improve respiratory capacity with positioning &
tech s/a glossopharyngeal breathing exercise in

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respiratory paralysis
 Keeping the neck in slight flexion improves
respiratory capacity
 Specific positioning increase air entry in targeted
lobes
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 Massage & mechanical pressure provides reflex
stimulus to improve peristalsis (kneading/

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stroking)
 Facilitate swallowing with positioning, right
selection of food texture, oromotor stimulation
 Maintaining cardio respiratory endurance with
active exercise of possible muscle work
PREVENT DVT

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 Active & passive ankle & toe exercise
 Active limb exercise

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 Limb elevation

 Early mobilization as soon as possible

 Propped up position in bed & bed mobility

exercise
PROMOTE INTEGRATION OF SENSORY INPUT

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 Stimulation by combined proprioceptive, visual &
auditory input

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 Cues & commands
 Demonstration of activity
 Sensory re education if necessary
 Training in different environment
POSTURAL CORRECTION

5/26/2021
 Proper positioning in the lying, sitting & all
functional position

Dr. Vidhi Garala (MPT Neurology)

 Use of braces, sitting & standing frames can be
helpful in children
 Stretching & strengthening of key postural
muscles
 Endurance training
GENERAL FITNESS EXERCISE

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 Early mobilization & early propped up position
 Moving around the bed

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 Regular exercise with bouts of 15-20 min session
for 3-4 times a day
 Then progress to 30-45 min of exercise

 Maintenance can be done by 45- 60 min session

of exercise 3-5 times/wk