CNS INFECTIONS

Meningitis
Encephalitis
Brain Abscess

Dr. Saurabh Sharma

AP Gen. Surgery
 COMMON CNS INFECTIONS
 BACTERIAL INFECTIONS  VIRAL
INFECTIONS
 Bacterial meningitis  Viral meningitis
 Tuberculosis  Herpes simplex encephalitis
 Brain abscess  Rabies
 Lysteriosis
 Neurosyphilis

 FUNGAL INFECTIONS  PARASITIC INFECTIOS

 Cryptococcal meningitis  Neurocysticercosis
 Toxoplasmosis
NORMAL ANATOMY OF MENINGIES
 MENINGITIS
 INTRODUCTION

 Meningitis is an acute inflammation

of the protective membranes
( collectively known as meninges)
covering the brain and spinalcord.

 Meningitis can be life threatening

condition because of the inflammation
proximity to the brain and spinal cord,
therefore the condition is termed as
MEDICAL EMERGENCY.
 TYPES OF MENINGITIS

 Bacterial meningitis
 Tuberculous meningitis
 Viral meningitis
Fungal meningitis
Parasitic meningitis
Non-Infectious meningitis

 MENINGITIS MAY BE

 Acute meningitis < 4 weeks

 Chronic meningitis > 4 weeks
 CAUSATIVE ORGANISMS
 BACTERIA
 IN PREMATURE BABIES AND
NEW BORNS(UPTO 3
MONTHS )
• Group B streptococci
• Listeria Monocytogen
 OLDER CHILDREN
• N.Meningitidis
• S.Pneumoniae
• H.Influenzae type B
 ADULTS
• N.Meningitidis
• S.Pneumoniae
• Listeria Monocytogens
 OTHER BACTERIA
• Staphylococci
• Mycobacterium Tuberculosis
• Pseudomonas
• Treponema Pallidium
 VIRUSES
• Enterovirus
• Herpes simplex virus
• Varicella-zoster virus
• Mumps
 FUNGI
• Cryptococcus Neoformans
• Coccidioides Immitis
• Histoplasma Capsulatum
• Blastomyces Dermatitidis
• Candida Spp.

 PARASITE  NON-INFECTIOUS CAUSES

• E.Histolytica • Malignant condition (cancer)
• Naegleria • Certain Drugs(NSAIDS,Antibiotics)
• Acanthamoeba • SLE
• T.gondii • Inflammatory conditions(sarcoidosis)
 PATHOGENESIS
 Three major pathways exist by which an infectious agents gain access
to the CNS .

1. Invasion of the blood stream

• i.e, Bacteremia,Viremia

2. A Retrograde neuronal pathway

• i.e, olfactory & peripheral nerves

3.Direct contagious spread

• i.e ,otitis,sinusitis,congenital malformations
 SIGN & SYMPTOMS
IN BABIES IN CHILDREN & ADULT
 KERNIG’S SIGN:
It is assessed with the patient
lying supine, with the hip and
knee flexed to 90 degrees. In a
patient with a positive
kerning’s sign, pain limits
passive extensions of the knee.

 BRUDZINSKI SIGN:
A positive brudzinki sign occurs
when flexion of the neck causes
involuntary flexion of the knee
and hip.
 COMPLICATIONS

 Encephalitis
 Deafness
 Epilepsy
 Hydrocephalus
 Cognitive Deficits
 Loss of pupillary reflex
 Abnormal posture
 Decreased level of consciousness
 LABORATORY DIAGNOSIS
SPECIMEN
 CSF : By Lumbar puncture (L3-L4 level)
See for the turbidity

Divide into 4 parts

 For Microbiological Test
 For Pathological Test
 For Biochemical Test
 For Preservation

 BLOOD
 serology & culture

 URINE
 For antigen detection
• S.Pneumoniae
• C.Neoformans
  MICROSCOPY
 STAINING
 GRAM’S STAIN:
• N.Meningitidis : Intracellular, gram negative, diplococci
• S.Pneumoniae : gram positive, diplococci(lanceolated shaped)
• H.Influenzae : gram negative, pleomorphic, coccobacilli
 Z-N STAIN:
• To demonstrate AFB along with LYMPHOCYTE (tuberculous meningitis)
 INDIAN INK: ( For demonstration of capsule of organisms)
• C.Neoformans
• S.Pneumoniae
 WET-MOUNT & GIEMSA STAIN : For Parasite
 QUELLANG REACTION:
• C.Neoformans
• S.Pneumoniae
 CULTURE
 FOR BACTERIA:
N.MENINGITIDIS:
(1)ON SOLID MEDIA:
- Blood agar Small,Translucent,Round,Convex, Bluish-Grey colour,
- Chocolate agar Weak haemolysis
- Muller-Hinton Agar
- Thayer-Martin agar : selective media

(2) ON LIQUID MEDIA:

- Turbidity with little or no surface growth

 S.PNEUMONIAE:
- BA
- CA Small,Dome-Shaped,Glistening with
an area of green discolouration ( α- haemolysis)
 N.MENINGITIDIS ( BA )

• S.PNEUMONIAE ( CA ) • S.PNEUMONIAE(BA )
 H.INFLUENZAE TYPE B
• BA : Shows “SATELLITISM”
• CHOCOLATE AGAR
• LEVINTHAL’S AGAR: -Translucent colonies with distinctive
iridescence
- Produced by capsulated strains
• FIELD’S AGAR : Small, Opaque ,Short colonies

 MYCOBACTERIUM TUBERCULOSIS : (TUBERCULOUS MENINGITIS)

L-J MEDIA : Dry,Rough,Irregular colonies

 FOR VIRAL CULTURE :  FOR FUNGAL CULTURE

- Tissue culture - SDA
- Egg Inoculation - BHI
- Animal inoculation - BIRD SEED AGAR
• L-J MEDIUM • H.INFLUENZAE
BIOCHEMICAL & PATHOLOGICAL FINDINGS IN CSF
 BIOCHEMICAL
REACTION
ORGANISM Catalase Oxidase Nitrate. SUGAR
FERMENTATIO
TEST TEST R N
TEST
N.MENINGITIDIS Glucose/maltose:
Acid+NO Gas
+ ve +ve -- ve Lactose/Sucrose:
NO Reaction

S.PNEUMONIAE -- Ve --ve --
H.INFLUENZAE +ve +ve + ve Glucose/Xylose: Acid
Other sugar : NO Acid
 BILE SOLUBILITY TEST : S.PNEUMONIAE

 OPTOCHIN SENSITIVITY TEST: S.PNEUMONIAE

 INULIN FERMENTATION : S.PNEUMONIAE

 ANIMAL INOCULATION:
• S.Pneumoniae
• For viral culture
  SEROLOGY
 FOR N.MENINGITIDIS
(1)Slide Agglutination Test
(2)(2)Latex Agglutination Test
(3)(3)Haemagglutination Test
 FOR S.PNEUMONIAE :
(1) Latex Agglutination Test
(2) Demonstration of SSS
(3) Immunochromatography
(4) CRP Test (biomarker)
(5) Procalcitonin Level (biomarker)

 FOR H.INFLUENZAE
 FOR L.MONOCYTOGENS Latex agglutination test
 C.NEOFORMANS
 MOLECULAR METHOD : CSF- PCR

LIMULUS TEST :
Test for rapid detection of meningitis that is
caused by Gram negative bacteria, which detects
bacterial endotoxin.
 PRINCIPLE: LAL( Limulus amebocyte lysate) is
an aqueous extract of amoebocytes from horse
shoe crab (Limulus polyphemus)
 LAL reacts with bacterial endotoxin/ LPS
which is membrane component of Gram
negative bacteria.
 ENCEPHALITIS
 Encephalitis is defined as acute,
diffuse inflammation of brain
parenchyma, which leads to cerebral
dysfunction.

 Sometimes, it is associated with

meningitis, which is known as
Meningoencephalitis
infection may result in one of the two
conditions affecting the brain.
 PRIMARY ENCEPHALITIS
 Occurs when a virus / other
infectious agent infects the
brain.
 May be reactivation after
previous illness
 SECONDARY ENCEPHALITIS
(POST INFECTIONAL ENCEPHALITIS)
 It is faulty immune system
reaction in response to a
infection elsewhere in body.
 Occurs 3 weeks after initial
infection.
 CAUSATIVE ORGANISM
 VIRUSES  BACTERIA
 Legionella Pneumophilia
 HERPES VIRUS : HSV, EBV, VZV  Mycoplasma Pneumoniae
 ENTEROVIRUS : Poliovirus &  Listeria
Coxsackievirus Monocytogens
 ARBOVIRUS  FUNGI
- Japanese B virus - Western & Eastern  Candida Spp.
- St. Louis virus equine virus  Cryptococcus Spp.
- La crosse virus - West Nile virus
 Mucor
 RABIES VIRUS
 PARAMYXO VIRUS
- Measles  PARASITE
- Mumps  Toxoplasma gondii
 Naegleria
 SIGNS AND SYMPTOMS
 MILD ENCEPHALITIS
- Fever - Poor Appetite
- Headache - Weakness
 SEVERE ENCEPHALITIS
- Stiff Neck - Mental confusion
- High Fever - Disorientation
- Severe headache - Convulsion
- Memory loss - Problems with Speech
- Hallucination - Coma
 IN INFANTS
-Vomiting - Poor Appetite
- Body stiffness - Poor memory

 BRUDZINSKI SIGN:
 KERNING’S SIGN :
 COMPLICATION
 Paralysis
 Hearing & Vision defects
 Memory Problems
 Speech impairment
 Lack of Muscle coordination
 Coma & Death
 PATHOGENESIS
 Transmission into human depend on causative organism :
• HSV & NAEGLERIA : Respiratory Tract
• ARBOVIRUS : Vector ( Mosquito & Tick )
• ACANTHAMOEBA : Eye & Nasal route
• RABIES : Dog bite
 Spread to CNS : ( 3 Routes )
1. Haematogenous Route
2. Neuronal Route
3. Contagious Route
 Damage to the Brain Parenchyma
 Causes Encephalitis
 ENTEROVIRUS: JAPANESE ENCEPHALITIS:

Pathogenesis : Entry via

aerosol or ingestion->
replicate in oro-
pharynx-> replicate in
Peyer's patches-> 1°
viremia-> 2° viremia in
tissues-> virus in feces
 LABORATORY DIAGNOSIS
 SPECIMENS:
 CSF 4. THROAT SWAB
 BLOOD 5. NASOPHARYNGEAL SWAB
 URINE

 MICROSCOPY:
 VIRAL:
 Herpes virus: Tzank smear Multinucleated giant cells and Ground glass
chromatin and giemsa stained smears and flurescent antibody techniqe
 Rabies virus: Negri bodies
 Measles: multinucleated giant cells in Giemsa stained smears
 BACTERIAL:
 Legionella pneumophilia: Legionella stains poorly with Gram stain,stains positive with silver
 Mycoplasma pneumoniae: Giemsa stain
3. FUNGAL: Candida spp.: Gram stain +ve
Cryptococcus: India ink stain capsulated budding yeast cells

4.PARASITIC: Naegleria fowleri : wright or giemsa stain pink nuclei and blue cytoplasm
Toxoplasma gondii: Periodic acid Schiff Bradyzoites are PAS +ve

 CULTURE:
 VIRAL: Limited utility as culture may be insensitive
 BACTERIAL: Listeria monocytogens: Listeria grows on media such as Mueller-Hinton agar.
Identification is enhanced if the primary cultures are done on agar containing sheep blood, because
the characteristic small zone of hemolysis can be observed around and under colonies.
Legionella pneumophilia: Cultured on charcoal yeast extract with iron & cysteine
 FUNGAL: Candida spp. & Cryptococcus: Sabouraud agar creamy white, smooth colony.
 PARASITIC: Naegleria fowleri: Non nutrient agar Plaques formation
SPINAL TAP: A spinal tap is done by inserting a needle into the spinal column.
Another name for a spinal tap is a lumbar puncture. The CSF fluid taken during a spinal
tap will also be tested to find the cause of encephalitis. It may show which type of virus
or germ is causing the inflammation.
 ISOLATION OF VIRUS:
 HSV : Human Diploid Fibroblast – Typical CPE ( 24-48 hrs)
 RABIES : CPE is minimal so by Immunofluorescence
 ARBOVIRUS : Vero,BHK-21 & Mosquito cell line ( Immunofluorescence)
 SEROLOGY:
 DEMONSTRATION OF IgM ANTIBODY
 IMMUNOFLUORESCENCE
 ELISA
 LATEX AGGLUTINATION TEST
 MOLECULAR METHOD: PCR.
 BRAIN ABSCESS
 Brain abscess (or cerebral abscess) is an abscess caused by inflammation and
collection of infected material, coming from local or remote infectious sources,
within the brain tissue.

A).LOCAL SOURCES B). REMOTE SOURCES

Ear infection, Dental abscess Infection Lung, heart, kidney
of Paranasal sinuses
Infection of the Mastoid air cells of the temporal bone, Epidural
abscess

 The infection may also be introduced through a skull fracture following a

headtrauma or surgical procedures.
 Brain abscess is usually associated with congenital heart disease in young children.
 It may occur at any age but is most frequent in the third decade of life.
 CAUSATIVE ORGANISMS
 BACTERIA  FUNGI

• S.Aureus • Aspergillus
• Candida
• S.Intermidius
• Cryptococcus
• Bacteroides • Mucor
• Fusobacterium • Coccidioides
• Enterobacteriaceae • Histoplasma capsulatum
• Pseudomonas spp • Blastomyces dermatitidis

 LESS COMMON  PARASITE

• N.Meningitidis • Toxoplasma gondii
• S.Pneumoniae • Entamoeba histolytica
• H.Influenzae • Trypanosoma cruzi
• Schistosoma
 SIGN & SYMPTOMS
• Headache
• Drowsiness
• Fever
• Confusion
• Seizures
• Speech difficulties
• Hemiparesis
 STAGES OF BRAIN ABSCESS

1. Early cerebritis
2. Late cerebritis
3. Early Capsule
4. Late Capsule
RADIOLOGY IS IMPORTANT FORDIAGNOSIS OF ALL
CNS INFECTION
 CT-SCAN
 MRI
 CHEST X-RAY