CNS Infections

Mohammad Assaf , A1 group

Main types:
▪ Meningitis
▪ Encephalitis
▪ Brain abscess
▪ Myelitis
▪ Rhombencephalitis
Route of infection
• CNS infections generally result from blood-borne spread of the
respective microorganisms.
• Bacteremia or viremia can result from infection at sites adjacent or
contiguous to the CNS, such as the mastoid, sinuses, or middle ear,
or from primary infections at more remote anatomic sites (e.g.,
lungs, heart, skin, gastrointestinal tract, or kidney).
• In children the most common predisposing conditions are sinus or
middle ear infection, which lead to transient bacteremia and
hematogenous seeding of the CNS
Meningitis
▪ The meninges are 3 layers covering the brain : Dura – Arachnoid – Pia
▪ Can be bacterial, viral, fungal, mycobacterial ( tuberculosis ) and from parasites.
▪
Clinical information on bacterial meningitis
▪ The most common clinical features include a severe headache (84 percent),
fever greater than 38°C (74 percent), stiff neck (74 percent), a Glasgow Coma
scale <14 (71 percent), and nausea (62 percent)
▪ In addition to the classic findings, less common manifestations are seizures (23
percent), aphasia or hemi- or monoparesis (22 percent), coma (13 percent),
cranial nerve palsy (9 percent), rash (8 percent), and papilledema (4 percent).
▪ The classic Brudzinski sign refers to spontaneous flexion of the hips during
attempted passive flexion of the neck.
▪ The Kernig sign refers to the inability or reluctance to allow full extension of the
knee when the hip is flexed 90 degrees. The Kernig test is usually performed in
the supine position, but it can be tested in the seated patient.
▪ Jolt accentuation of headache may be a more sensitive maneuver for the
diagnosis of meningitis. A positive test consists of accentuation of headache by
horizontal rotation of the head at a frequency of two to three times per second.
▪ Lumbar puncture
+ Dexamethasone
Other causes
Encephalitis
▪ The presence or absence of normal brain function is the important distinguishing
feature between encephalitis and meningitis.
▪ Patients with meningitis may be uncomfortable, lethargic, or distracted by
headache, but their cerebral function remains normal.
▪ In encephalitis, however, abnormalities in brain function are a differentiating
feature, including altered mental status, motor or sensory deficits, altered
behavior and personality changes, and speech or movement disorders.
▪ Seizures and postictal states can be seen with meningitis alone and should not
be construed as definitive evidence of encephalitis. Other neurologic
manifestations of encephalitis may include hemiparesis, flaccid paralysis, and
paresthesias.
Signs and symptoms
▪ Patients with encephalitis have an altered mental status ranging from subtle
deficits to complete unresponsiveness.
▪ Symptoms and signs of meningeal irritation (photophobia and nuchal rigidity) are
usually absent with a pure encephalitis, but often accompany a
meningoencephalitis. Seizures are common with encephalitis, and focal
neurologic abnormalities can occur, including hemiparesis, cranial nerve palsies,
and exaggerated deep tendon and/or pathologic reflexes. Patients may appear
confused, agitated, or obtunded.
Physical examination
▪ Parotitis strongly suggests the diagnosis of mumps encephalitis in an
unvaccinated patient with mental status changes.
▪ Grouped vesicles in a dermatomal pattern may suggest varicella zoster virus
(VZV), which can occasionally cause encephalitis; however, the absence of rash
does not eliminate VZV from consideration 
▪ Findings of hydrophobia, aerophobia, pharyngeal spasms, and hyperactivity
suggest encephalitic rabies. Atypical presentations of rabies include seizures,
cranial nerve palsies, and myoclonus.
Treatment
▪ Empiric treatment for herpes simplex virus (HSV)-1 infection with acyclovir (10
mg/kg intravenously every eight hours) should always be initiated as soon as
possible if the patient has encephalitis without apparent explanation. Early
therapy is vital because it is associated with a significant decrease in mortality
and morbidity
Infectious Myelitis
▪ Epidural abscess: Spinal epidural abscess is a rare disease, occurring in only 1
patient per 10,000 admitted to the hospital. The infection can originate via
contiguous spread from infections of skin and soft tissues or as a complication of
spinal surgery and other invasive procedures, including indwelling epidural
catheters. Other cases of epidural abscess arise from a remote site via the
bloodstream. Diabetes, alcoholism, and human immunodeficiency virus (HIV)
infection are risk factors.
▪ The most common pathogen is Staphylococcus aureus, which accounts for
approximately two-thirds of cases 
▪ Bacterial meningitis may be complicated by a myelopathy due to formation of an
epidural abscess, myelitis, or vasculitis infarction.
▪ Parasite infection: The parasites Schistosoma mansoni and Schistosoma
haematobium typically infect the spinal cord, producing rapidly progressing symptoms of
TM, including lower limb pain, weakness, and bowel and bladder dysfunction. CSF
evaluation reveals pleocytosis and elevated protein; eosinophilia occurs in almost half of
patients. Most patients are treated with glucocorticoids and praziquantel and achieve at
least partial recovery.
▪ Syphilis:  Tabes dorsalis is a form of tertiary neurosyphilis in which the dorsal or
posterior columns of the spinal cord are primarily affected. Patients present with a
sensory ataxia and lancinating pains reflecting dorsal column and dorsal nerve root
involvement. Treatment is with antibiotics ( penicillin )
▪ Acute viral myelitis: 2 forms : one has clinical and diagnostic test features that are
similar to transverse myelitis. Associated viruses include cytomegalovirus, varicella
zoster, herpes simplex virus, hepatitis C, and Epstein Barr virus .
one that affects gray matter of the spinal cord, producing acute lower motor neuron
disease , related viruses are Enteroviruses and Flaviviruses
▪ AIDS myelopathy 
Rhombencephalitis 
▪ Rhombencephalitis (inflammation of hindbrain which includes the brainstem and
cerebellum) is characterized by myoclonic jerks, tremor, ataxia, cranial nerve
involvement, respiratory abnormalities, shock, and coma.
▪ Infection with bacteria of the genus Listeria is the most common cause of
rhombencephalitis. Primary rhombencephalitis caused by infection
with Listeria spp. occurs in healthy young adults. It usually has a biphasic time
course with a flu-like syndrome, followed by brainstem dysfunction; 75% of
patients have cerebrospinal fluid pleocytosis, and nearly 100% have an abnormal
brain magnetic resonance imaging scan. 
Brain abscess
▪ Brain abscess is a focal collection within the brain parenchyma, which can arise
as a complication of a variety of infections, trauma, or surgery. The diagnosis of
brain abscess requires a high index of suspicion since it can have a subtle
presentation. Successful treatment requires a combination of surgical drainage
and antimicrobial therapy.
▪ Most patients with brain abscess require surgical drainage, in addition to
antibiotics, for both diagnostic and therapeutic purposes.
▪  A neurosurgeon should be contacted at the time of initial diagnosis of brain
abscess in all patients. In most settings, needle aspiration or surgical excision
should be performed to identify the causative pathogen prior to the initiation of
antibiotic therapy and to reduce the size of the collection.
▪ Once an organism is identified, the regimen can be further tailored. Therapy is
usually administered for four to eight weeks.
▪ Metronidazole readily penetrates brain abscesses. This drug has excellent
bactericidal activity against many anaerobes.
▪  Ceftriaxone covers most aerobic and microaerophilic streptococci (and can be
used in place of penicillin) but also covers many Enterobacteriaceae as well,
which can cause brain abscess, particularly in association with chronic ear or
sinus infections or following penetrating trauma. Cefotaxime provides similar
coverage.
▪  Vancomycin should be included until culture and susceptibility results are
available when brain abscess follows penetrating head trauma or craniotomy or
when S. aureus bacteremia is documented.
Thank you!