CNS

INFECTIONs
Bernamieh Calam-Pastor, MD
CUMC LEVEL II- IM Resident
● MENINGITIS
● ENCEPHALITIS
● FOCAL INFECTIONS (e.g Brain
Abscess, Subdural Empyema)
Key goals

● Emergently distinguish
● Identify responsible pathogen
● Initiate appropriate antimicrobial therapy
Meningitis
ACUTE
- duration of < 5 days
- 75% of all community acquired meningitis cases

SUBACUTE
- 5 days or more
- comorbidities, immunosuppressed

CHRONIC
- >4 weeks duration
- broad differential diagnosis
Bacterial Meningitis
• Most common form of suppurative CNS infection

10%

15%

50%

H. Influenzae type b - <10%

25%
N. Meningitidis – recurring epidemics every 8-12yrs

S. pneumoniae N. meningitides
group B streptococci L. monocytogenes
Inflammatory reaction induced by the invading bacteria
NUCHAL
FEVER HEADACHE
RIGIDITY
BRUDZINSKI SIGN KERNIG SIGN
LUMBAR PUNCTURE
GOAL:
Begin antibiotic
within 60 min from
arrival in ER
Dexamethasone
- Giving 20min before antibiotic therapy
-> inhibits the production of TNF-α by macrophages and microglia
-decrease meningeal inflammation and neurologic sequelae
PROGNOSIS:

Increase Risk of death:

1) decreased level of consciousness on admission

2) onset of seizures within 24 h of admission
3) signs of increased ICP
4) young age (infancy) and age >50
5) the presence of comorbid conditions including shock and/or the need for
mechanical ventilation
6) delay in the initiation of treatment
Viral Meningitis
Aseptic Meningitis Syndrome
Immunocompetent patient

Immunocompromised patients
PROGNOSIS
In adults, the prognosis for full recovery
from viral meningitis is excellent.
TB Meningitis

-miliary tubercles form in

the parenchyma of the
brain
 Normal TB Meningitis

Opening pressure 5-20 cmH2o elevated

WBC <5 PMN/mm3 Lymphocytic

Differentials pleocytosis
10-500 cells/uL
Protein 0.18-0.45 g/dL 1-5g/L

Glucose 2.5-3.5 mmol/L 1.1-2.2 mmol/L (20-

40mg/dL)
CSF Lymphocytic pleocytosis
Mildly decreased glucose
Initial therapy:
Isoniazid (300 mg/d)
Rifampin (10 mg/kg per day)
Pyrazinamide (30 mg/kg per day in divided doses)
Ethambutol (15–25 mg/kg per day in divided doses)
Pyridoxine (50 mg/d)

Antimicrobial sensitivity is known

Ethambutol can be discontinued

Clinical response is good

-pyrazinamide can be discontinued after 8 weeks
-isoniazid and rifampin continued alone for the next 6–12 months

A 6-month course of therapy is acceptable, but therapy should be prolonged for 9–12
months in patients who have an inadequate resolution of symptoms of meningitis or
who have positive mycobacterial cultures of CSF during the course of therapy
Encephalitis
ENCEPHALATIS
Inflammation of the brain
Encephalopathy
● diffuse cerebral dysfunction without associated inflammation of
brain tissue
● Most common causes: toxins and metabolic dysfunction
Clinical Manifestation

Focal neurologic disturbance

Aphasia
Ataxia
Upper and Lower Motor weakness
Involuntary movements
Cranial nerve deficits
 Diagnostic goals:

-obtain CSF studies

-neuroimaging (MRI)

Empiric Treatment:
Acyclovir 10mg/kg three times daily IV
Diagnostics
Neuroimaging
-assist in differentiation between a focal and diffuse encephalitic process
-MRI is more sensitive

CSF studies
-characteristics profile is indistinguishable from viral meningitis
-consists:
lymphocytic pleocytosis
mildly elevated protein concentration
normal glucose concentration

CSF PCR
- primary diagnostic test: HSV, CMV, EBV, HHV-6 and enteroviruses

Brain biopsy
Management

Specific antiviral therapy should be initiated when appropriate.

Vital functions should be monitored continuously and supported as required.

Basic management and supportive therapy

Seizures precautions
Prognosis

Most frequent sequelae:

• difficulties in concentration
• behavioral and speech disorders
• memory loss

Incidence and severity

Age
Level of consciousness
Take Home ..

● Vigilance and high index of suspicion

● History and PE must be viewed as a whole

● Time is of the essence..

● Aggressive course of action is always prudent

REFERENCES

● Harrison’s Principles of Internal Medicine 21st Edition.

● Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases 9 th
Edition