LIST OF INFECTIONS

OF CNS

Bacterial
Viral
Fungal

Protozoal

Dr. L. Surbala (MPT Neurology)

There are four main causes of infections of

CNS

Fungal infections

meningitis
Brain abscess
Spinal epidural infection

Dr. L. Surbala (MPT Neurology)

Cryptococcal

Protozoal infections
Malaria
Primary

amoebic meningoencephalitis

Dr. L. Surbala (MPT Neurology)

Toxoplasmosis

Bacterial infections
Leprosy
Neurosyphilis
Bacterial

meningitis
Brain abscess
Neuroborreliosis

Dr. L. Surbala (MPT Neurology)

Tuberculosis

Viral infections

Viral meningitis
Eastern equine encephalitis
St Louis encephalitis
Japanese encephalitis
West nile encephalitis
Herpes simplex encephalitis
Rabies
California encephalitis virus
Varicella-zoster encephalitis
La crosse encephalitis
Measles encephalitis
Poliomyelitis

Slow virus infections, which include:

Subacute

sclerosing
panencephalitis
Progressive multifocal
leukoencephalopathy
AIDS

Dr. L. Surbala (MPT Neurology)

MENINGITIS

INTRODUCTION
It is an acute inflammation of meninges of brain &
spinal cord present with characteristic combination
of pyrexia, headache & meningium (confusion or
altered consciousness)
The inflammation may be caused by infection with
viruses, bacteria, or other microorganisms, and 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

Dr. L. Surbala (MPT Neurology)

CLINICAL FEATURES
Acute onset of illness
High grade of fever
Severe headache
Nuchal rigidity & pain
Irritability & drowsiness
Photophobia & phonophobia

Dr. L. Surbala (MPT Neurology)

Features of rapid ICP (normally between 6and 18cm water)

Projectile vomiting, blurring of vision, altered sensorium &
convulsions, loss of pupillary light reflex, & abnormal posturing
In infants up to 6months of age, bulging of fontanelle

consists of numerous small, irregular purple or red spots

("petechiae") on trunk, LE, mucous membranes, conjuctiva, &
(occasionally) palms or soles

Dr. L. Surbala (MPT Neurology)

Septic shock & septicimia

Cranial nerve damage
Acute renal failure
Meningitis caused by meningococcal bacteria may be
accompanied by a characteristic rash

COMPLICATIONS

deafness
epilepsy

hydrocephalus
cognitive

deficits

if not treated quickly

Dr. L. Surbala (MPT Neurology)

Meningitis can lead to serious long-term

consequences

TYPES
Pyogenic / bacterial miningitis
Tubercular miningitis
Viral meningitis

Dr. L. Surbala (MPT Neurology)

Dr. L. Surbala (MPT Neurology)

PYOGENIC BACTERIAL
MENINGITIS

PYOGENIC BACTERIAL MENINGITIS

Causative organism

E-coli, proteus
Children Haemiphillus influenzae type B, Neisseria
meningitidis (Meningococcus)
Adolescent - N meningitidis
Adult streptococcus pneumoniae

Dr. L. Surbala (MPT Neurology)

Neonates

Route of entry

contact of the CSF by Contaminated lumbar

puncture, Sinusitis, Trauma
Ottitis media
Through the blood stream

Incubation period
4-

24 hours

Dr. L. Surbala (MPT Neurology)

Direct

PATHOGENESIS
The large-scale inflammation that during meningitis
largely be attributed to response of immune system
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.

Dr. L. Surbala (MPT Neurology)

The blood-brain barrier becomes more permeable,

leading to "vasogenic" cerebral edema (swelling of
brain 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 and a third type of edema, "cytotoxic"
edema

Dr. L. Surbala (MPT Neurology)

The three forms of cerebral edema all lead to an

increased ICP together with low BP often
encountered in acute infection,
Brain cells are deprived of oxygen & undergo
apoptosis (automated cell death)

Dr. L. Surbala (MPT Neurology)

SIGNS

Positive kernigs sign & Positive brudjinskis

sign is assessed with patient lying supine, with hip &

knee flexed to 90 degrees.

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

Dr. L. Surbala (MPT Neurology)

Kernig's

INVESTIGATIONS

Blood analysis
TC

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

Dr. L. Surbala (MPT Neurology)

is increased
DC- neutrophillia
ESR- normal
Hb- normal

Gram stain to identify the organism

Culture & sensitivity test
Postmortem

findings are widespread inflammation of pia

mater and arachnoid layers
Cranial nerves & spinal cord, may be surrounded with
pus

Dr. L. Surbala (MPT Neurology)

The

PREVENTION

Haemophilus influenzae type B

Meningococcus vaccines
against Streptococcus pneumoniae with pneumococcal
conjugate vaccine (PCV)
Childhood vaccination with Bacillus Calmette-Gurin (BCG)
against

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

Dr. L. Surbala (MPT Neurology)

For some causes of meningitis, prophylaxis can be

provided in long term with vaccine

MANAGEMENT

High dose intravenous antibiotic

Cephalosporin
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
Mechanical ventilation may be needed if level of
consciousness is low, or if evidence of respiratory
failure

Dr. L. Surbala (MPT Neurology)

Penicillin,

Seizures are treated with anticonvulsants

Hydrocephalus may require insertion of a
temporary or long-term drainage device
(cerebral shunt)

Dr. L. Surbala (MPT Neurology)

TUBERCULAR MENINGITIS

The

primary focus being in the lung

Dr. L. Surbala (MPT Neurology)

It can be seen as a part of primary TB in

children & a part of secondary TB in adults

PATHOGENESIS
TB bacilli reached all parts of body & remains
dormant in meninges
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

Dr. L. Surbala (MPT Neurology)

CLINICAL FEATURES
Gradually progressive disease
Gradual onset of fever associated with
headache, general weight loss & weakness
Loss of appetite
Raised ICP
Feature of lower cranial nerve paralysis (IX, X,
XI, XII)

in speaking, swallowing etc

Dr. L. Surbala (MPT Neurology)

Difficulty

INVESTIGATIONS

Blood analysis
TC

CSF analysis
Turbid

& cloudy
High protien (500mg/ dl)
Boderline increase in glucose
Cell are increased (lymphocytosis)

Gram stain: gram positive

ZN stain: AF bacilli
CT scan with contrast: exudates can be seen

Dr. L. Surbala (MPT Neurology)

nearly normal
DC lymphocytosis
ESR elevated

TREATMENT
Anti tubercular drugs
Corticosteroids
Mannitol

Dr. L. Surbala (MPT Neurology)

VIRAL MENINGITIS
It is also known as aseptic meningitis
Clinical presentation is similar to that of acute
pyogenic meningitis

Dr. L. Surbala (MPT Neurology)

INVESTIGATION
Microbiological findings shows no microorganisms
CSF glucose is normal
Boderline increase in CSF cells (lymphocytes) & protiens
Gram stain is of no importance
Polymerase chain reaction (PCR) amplify small traces of
DNA & detect presence of bacterial or viral DNA in CSF

in distinguishing various causes of viral meningitis

(enterovirus, herpes simplex virus 2 and mumps in those not
vaccinated for this)

Serology (identification of antibodies to viruses) may be

useful in viral meningitis

Dr. L. Surbala (MPT Neurology)

Assist

TREATMENT
Viral meningitis typically requires supportive
therapy only
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

Dr. L. Surbala (MPT Neurology)

Mild cases of viral meningitis can be treated at

home with conservative measures such as fluid,
bed-rest, & analgesics.
Prognosis is good
Gradually recovers without any treatment

Dr. L. Surbala (MPT Neurology)

PT ASSESSMENT
History of presenting illness: acute or gradual onset of
illness, high grade fever
Past history

history, trauma, spinal anaesthesia, lumbar puncture,

sinusitis, ottitis media

Vital signs: temperature, BP, HR, RR

Observation:

abnormal

posturing may be seen

Abnormal respiration
Attitude of limb

Examination
Level

of conciousness, orientation, memory, speech

Cranial nerve examination: signs of damage of lower cranial nerves

Dr. L. Surbala (MPT Neurology)

Infectious

Sensory screening: sensations may be intact

Motor assessment

tonicity, reflexes, muscle power

Chest examination: important in TB meningitis

Respiratory assessment
Gustatory examination: swallowing
Bladder & bowel involvement
Functional assessment
Special test: kernig, brudjinski
Investigations: blood & CSF examination, CT or MRI,
gram stain, serology

Dr. L. Surbala (MPT Neurology)

ROM,

Problem list

Dr. L. Surbala (MPT Neurology)

PT MANAGEMENT (GOALS)
Psychological support
Positioning strategies & prevent bed sores
Prevent chest complications
Promote vital function
Prevent DVT
Promote integration of sensory input
Postural correction
General fitness exercise

Dr. L. Surbala (MPT Neurology)

PSYCHOLOGICAL SUPPORT
Maintain a non threatening positive attitude
Good support
Gain confidence of the patient
Counseling of family members & patient
Give information as necessary only

Dr. L. Surbala (MPT Neurology)

POSITIONING STRATEGIES & PREVENT

BED SORES
Proper positioning with pads & cushions
Use of water bed or foam mattress
Regular inspection of the skin
Use cotton clothing to absorb sweat
Avoid dragging during transfer
Regular turning & changing position

Dr. L. Surbala (MPT Neurology)

PREVENT CHEST COMPLICATIONS

Breathing exercise, postural drainage &
suctioning as required
Cervical & thoraxic mobility exercise
Thoraxic expansion exercise
Strengthening of respiratory muscles

Dr. L. Surbala (MPT Neurology)

PROMOTE VITAL FUNCTION

Improve respiratory capacity with positioning &
tech s/a glossopharyngeal breathing exercise in
respiratory paralysis
Keeping the neck in slight flexion improves
respiratory capacity
Specific positioning increase air entry in targeted
lobes

Dr. L. Surbala (MPT Neurology)

Massage & mechanical pressure provides reflex

stimulus to improve peristalsis (kneading/
stroking)
Facilitate swallowing with positioning, right
selection of food texture, oromotor stimulation
Maintaining cardio respiratory endurance with
active exercise of possible muscle work

Dr. L. Surbala (MPT Neurology)

PREVENT DVT
Active & passive ankle & toe exercise
Active limb exercise
Limb elevation
Early mobilization as soon as possible
Propped up position in bed & bed mobility
exercise

Dr. L. Surbala (MPT Neurology)

PROMOTE INTEGRATION OF SENSORY

INPUT

Cues & commands

Demonstration of activity
Sensory re education if necessary
Training in different environment

Dr. L. Surbala (MPT Neurology)

Stimulation by combined proprioceptive, visual &

auditory input

POSTURAL CORRECTION
Proper positioning in the lying, sitting & all
functional position
Use of braces, sitting & standing frames can be
helpful in children
Stretching & strengthening of key postural
muscles
Endurance training

Dr. L. Surbala (MPT Neurology)

GENERAL FITNESS EXERCISE

Early mobilization & early propped up position
Moving around the bed
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

Dr. L. Surbala (MPT Neurology)