Infections of the nervous system Dr,kibruyisfaw oct , 2012 Areas to be learned Acute meningitis
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Infections of the nervous systemDr,kibruyisfaw
oct, 2012Areas to be learned
Acute meningitis
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Acute Bacterial MeningitisDef. bacterial infection of the subarachnoid spaceMajor presenting feature
Rapidly developing headache, fever, meningism and photophobiaPhysical exam
Nuchal rigidity, Kernig’s sign, Brudzinsk’ sign
Your immediate taskBacterial? Viral? Tuberculous?
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Acute Bacterial meningitisMicrobiology/Causes
Neonates E. coli, GBS, P. mirabilis, L. monocytogenes, Pseudomonas
Children< 5y. N. mening. S pneumoniaeH. Influenzae
Older children and adults < 50 N. mening. and S.pneumo
Adults >50 S. pneumo, G- enteric bacilli,L. mono
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Viral/ Aseptic/ MeningitisEnteroviruses, Mumps, Arboviruses,
HIV,HSV-2, HZV, AdenovirusesTuberculous meningitis
Mycobacterium tuberculosis
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How can you distinguish weather it is bacterial viral or tuberculosis ?
Bacterial/pyogenic/ onset---acute<2days, toxic and ill, drowsy, possible purpuric rash, CSF—turbid or opalescent, cells—500-2000, protein increased, glucose reduced, g/stain—usually pos, wbc--neutrophilia
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Viral/Aseptic/ meningitisAcute<2 days, not toxic , fully conscious, CSF– clear, cells-5-1000—lymph, protein normal or modest rise, glucose normal, g/stain neg, wbc normal
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Tuberculous meningitisSub acute, not toxic, alertness may be depressed, CSF—clear, may form cobweb on standing, cells—50-400, lymphocytes, protein increased, glucose reduced, g/stain neg, wbc-normal
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What diagnostic tests?WBC and diffBlood culturesLP—CSF G/stain, AFB, biochemistry, CSF culture, india ink, cryptococcal antigen, fungal culture, PCR—HSV, VZV,enteroviral, cytology, viral culture,viral serologyImaging—CXR, CT, MRI
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DiagnosisBacterial Typical CSF picture CSF G/stain, culture, antigen detection CSF/bloodViral Enterovirus—in faeces, CSF, throat swab Mumps---CSF, urine, serology Arbovirus—serology, PCR of CSF
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Tuberculosis AFB in CSF smear, CSF PCR, CSF culture
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Investigation and treatmentABM = life threatening = emergencyKey= early dx. And rx.LP in all cases unless papilloedema or neurologic deficit = b/culture and empiric abx
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Indications for empiric antibioticsLP cannot be doneIll or toxicPetechial rashesLP—turbid
When to review therapy?Causative bacteria isolated
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CSF guided action CSF = clear wait for lab. Results CSF = lymphocytic, normal biochemistry = probable viral meningitis – review likelihood other causes of similar CSF changes do virology tests
CSF = lymphocytic, protein raised, glucose reduced, AFB or fungal tests positive – start appropriate therapy
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CSF guided therapyCSF = lymphocytic, protein raised,
glucose reduced, tests for AFB/fungal negative --- tbc still likely –antitbc + for L. mo
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Specific infectionsMeningococcal meningitis and septicemiaEpidemiology
1963--- Meningitis belt b/n latitudes 4 and 16 north w/300-1100ml annual rainfall south of Sahara Belt—high levels of endemicity w/ large superimposed epidemics ----Serogroup A = predominant
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The only form of bact. Mening—epidemics Caused by N. meningitides G- intracellular diplococcus Pathogenic groups –A B C D X Y Z W135 Group B and C predominant in temperate areas The highest burden = Sub-Saharan Africa from Ethiopia to Senegal = meningitis belt
Both endemic and epidemicDry season – groups A C W135
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Organism in nasopharnyx, highest carriage in 15-19 years Transmission –droplet spread or direct contact w/ index case Overcrowding –Pathogenesis Colonization of nasopharyngeal mucosa—local invasion—bacteraemia—intravascular multiplication----- meningeal invasion –SAS inflammation
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Or septicemic presentationRapidly progressive shockDIC---- bleeding into and dysfunctions of
many organs including adrenals =Wterhouse Friederichsen syndrome
Purpuric rashIP—1-3 days
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Clinical featuresAbrupt –fever, vomiting, headache,
irritability, restlessness --signs of meningitis or
Fulminant septicemia – toxicity, drowsiness and shock
Petechial or purpuric rash = 2/3
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ComplicationsWaterhouse-Friederichsen
syndrome= fulminant septicemia w/adrenal cortical failure
Ischemia –tissue damage—loss of finger and/or toes
Hydrocephalus, brain damage, subdural hemorrhage, brain abscess, deafness
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DiagnosisHigh index of suspicionCSF studies
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TreatmentPreferred= ceftriaxone 2 g q24h or
cefotaxime 2 g q4-6hx7-10 daysAlternatives= CAF 4-6 g/dx7-10 daysSteroid= dexamethasone 10 mg iv q6hx4
days
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PreventionRespiratory isolation x 24hChemoprophylaxis Household or intimate contact,
med. PersonnelRif. 600 mg bid x 2 daysCipro 500mg x1 doseCeftriaxone 250mg im x1 dose
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ImmunoprophylaxisConjugate vaccine
Target population= all children at 11-12 years
Anyone > 2 years w/risk = college students, military recruits, asplenia
Polysaccharide vaccine A C Y W135
For outbreaks, age>65