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Neuro Infectious

Neurology

QuestionAnswer
Most common causative of meningitis in adults S. pneumo (also N meningitidis)
When do LP? suspect meningitis; not if suspect abscess
Glucose depressed: usually: bac mening, or TB or fungal
Meningitis general S/S HA, fever, neck / back stiffness, neuro impairment
Meningitis presentation acute (hrs – days), usu w/ fever, HA, stiff neck, lethargy; usu without focal sx
Typical purulent meningitis orgs N. meningitidis, S. pneumoniae, or H. influenzae
Chronic meningitis: orgs TB; fungal
Encephalitis presentation diffuse infxn; confusion, lethargy, often seizures; CSF may be nml
Increased WBC in CSF indicates: inflammation (not necessarily infection)
Pneumococcal meningitis Tx ceftriaxone (if GP diplococci seen, add Vanc, pending cx)
N. meningitidis petechial rash; GN diplococci; often assoc w/DIC
Meningococcal meningitis: nasal carriage eliminated with: Rifampin (alt: cipro or ceftriaxone)
Meningococcal meningitis: DOC Acqueous Pen G
H flu meningitis less common in adults; in setting of otitis or sinusitis; DOC ceftriaxone
Tuberculous meningitis usu gradual onset; listlessness & irritability; CN palsies; active TB elsewhere; CSF inc WBC (100-150), mostly lymphs; abnml CXR; acid-fast normal
Abscess: common orgs streptococcus, staphylococcus or anaerobes
Ring enhancing lesion is usually: abscess or tumor
Abscess tx prolonged IV Abx, surg drainage; monitor tx w/ serial scans; if <2 cm poss medical tx only
Rabies S/S (> 10 days) delirium, painful swallowing, rage alternating with calm
Rabies incubation period >10 days (usu 3-7 wks) (infected animal dies within 5-7 days)
Herpes encephalitis more common in elderly; often medial temporal lobes; tx most pts w/ clin syndrome of viral encephalitis empirically for HSE
Inflammatory response of the brain with neurologic dysfunction = encephalitis
Encephalitis etiology: Usually viral (HSV
Encephalitis pathology: Usually meningoencephalitis; virus invades brain parenchyma
ute migraine: Ergotamine
Encephalitis viral agents in infants = HSV2, CMV, rubella, Listeria mono, T pallidum, Toxo
Encephalitis viral agents in children = Influenza, Japanese encephalitis, eastern equine, Murray valley
Encephalitis viral agents in elderly = St Louis, Listeria mono, West Nile, eastern equine
Encephalitis workup MRI (alt: CT) -> brain bx only with focal findings on MRI & rapid decomp. LP with CSF PCR. FDG-PET or CSF viral cx not typically recommended.
Encephalitis CSF findings: Normal glucose, elevated protein & lymphocytes. Elevated RBCs in HSV
Encephalitis mgmt Acyclovir 10mg/kg Q8h (20mg/kg for infants) to cover HSV. CMV: ganciclovir/foscarnet combo. Tx bac / fungal / vectorborne agent. Tx SIADH if develops
Meningitis pathology: Organism in intravascular space -> inflammation with bac lysis & release of cell wall components into subarachnoid space -> purulent exudates -> meningeal inflammation -> inc B-B barrier permeability
80% of acute bac meningitis in pts >4 wks old & immunocompetent due to: S pneumoniae (
Common ABM agents: SP, N meningitides, L mono, staph; <10% by GNR (E coli, Klebs, enterobacter, Pseudomonas
ABM agents in immunocompromised patients: L mono, S pneumo, Pseudo. Rarely TB
Aseptic meningitis agents Coxsackie, echoviruses, polioviruses, enteroviruses 68-71, sometimes HSV2, mumps, HIV, TB, fungus
Fungal meningitis agents Cryptococcus, candida, Fusarium; rarer Histoplasma, Coccidioides, Paracoccidioides
CSF with normal pressure, 500-1000 WBC, slightly elevated protein, normal glucose = viral meningitis
CSF with elevated pressure, 1-10K WBC, elevated protein, decreased glucose = bacterial meningitis
CSF with elevated pressure, 25-500 WBC, elevated protein, decreased glucose = chronic or TB meningitis
Bacterial meningitis (ABM) mgmt: Hosp within 90 min of clinical sxs -> tx in 60 min. Neuro ICU. IV 3G cef (Rocephin or cefotaxime).
ABM tx for L mono: 3G ceph + amoxicillin
ABM tx for PCN-resistent Pneumococcus: Vanco + 3G ceph
If ABM due to S pneumo or Influenza, give this with 1st dose of Abx: Dexamethasone 15mg/kg Q6h x2-4 days; inhibits interleukins & stabilizes BB barrier
ABM tx for N meningitides (suspected due to rapidly evolving rash): IV benzyl PCN
ABM duration of Abx therapy: S pneumo 10-14 days; N meningitides 3-7 days; H flu 7 days; L mono 14-21 days; GNR 21 days
Fungal ABM tx: Amphotericin B xwks or months +/- flucytosine
TB ABM tx: rifampin, isoniazid, ethambutol, pyrazinamide x18-24 months
Most common agent of meningitis in adults S. pneumo
Encephalitis presentation diffuse infxn; confusion, lethargy, often seizures; CSF may be normal
N. meningitidis petechial rash; GN diplococci; often assoc w/DIC
H flu meningitis: commonly found: less common in adults; in setting of otitis or sinusitis
Tuberculous meningitis S/S usu gradual onset; listlessness & irritability; CN palsies;
Abscess: common orgs streptococcus, staphylococcus or anaerobes
Rabies S/S (> 10 days) delirium, painful swallowing, rage alternating with calm
Rabies incubation period >10 days (usu 3-7 wks) (infected animal dies within 5-7 days)
Herpes encephalitis: commonly found: more common in elderly; often medial temporal lobes
Neonatal meningitis bugs E coli or group B Strep (Strep agalactiae)
Meningitis bug in immunocompromised Cryptococcus (positive India ink test)
Meningitis tx if <3 months old or immunocompromised Add ampicillin for Listeria coverage (to usual regimen of 3G ceph +/- vanc)
Meningitis tx if hospital or post-op: Ceftazidime + vanco + ampicillin
Created by: Abarnard