Infectious and Inflammatory Disorders - UCSDspinwarp.ucsd.edu/NeuroWeb/PPT/infection-45.pdf ·...
Transcript of Infectious and Inflammatory Disorders - UCSDspinwarp.ucsd.edu/NeuroWeb/PPT/infection-45.pdf ·...
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Department of Radiology
University of California
San Diego
John R. Hesselink, M.D.
Infectious and
Inflammatory Disorders
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Intracranial Infection
and Inflammation
Cerebral abscess
Meningitis
Ependymitis
Encephalitis
Cranial neuritis
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Cerebral Abscess
URI - Septicemia - Endocarditis
Sinus & mastoid infections
Immune-compromised patient
Diabetic patient
Congenital heart disease
Trauma, Surgery
Sources/Predisposing Factors
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Brain Abscess
Staph & strep most common
Tuberculosis
Fungal infection
Parasitic infection
Opportunistic organisms if
immune-compromised
Infectious Agents
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History: 45 y/o man with new seizure
453
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Dx: Toxo cerebritis
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History: 16 y/o male
with new onset of seizures
350
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{Page 2} Diffusion
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Dx: Brain abscess -
Streptococcus milleri
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Pyogenic
Brain Abscess
Courtesy of ED Gotsis, PhD, Euromedica, Athens, Greece
Acetate
Alanine
Lactate
Amino
Acids
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History: 87 y/o woman on treatment
for abdominal lymphoma
780 - 14316798
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Dx: Abscess (Nocardia & Gram + rods)
{Page 2}
Acetate Alanine
Lactate Succinate
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History: 41 y/o man with headache,
lethargy & inappropriate behavior
606
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Dx: Streptococcal abscess &
diabetic ketoacidosis
(venous pH = 7.28)
{Page 3}
2
1 3
1
3
2
Ketones (2.2 ppm)
Ketones
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History: 5 y/o girl with seizures
361
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{Page 2}
Diffusion image
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Dx: Amoebic abscesses
{Page 3}
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History: 34 y/o male with
headache & a lung mass
435
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Dx: Aspergillus abscess
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Differential Diagnosis
Clinical presentation
Capsule features
Multiple lesions
Time course
Diffusion Properties
MR Spectroscopy
Abscess & Tumor
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760
History: 27 y/o female
with seizures
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{Page 2}
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Dx: Cysticercosis – colloidal phase
{Page 3}
2 months s/p Rx with
Albendazole & Dexamethasone
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Neurocysticercosis
Larval stage of the pork
tapeworm (Taenia Solium)
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History: 54 y/o woman with chronic seizures
610
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Dx: Calcified diffuse cysticercosis
{Page 2}
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History: 22 y/o man with severe headaches
555
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Dx: Intraventricular cysticercosis
{Page 3}
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History: 32 y.o. woman with headaches
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History: Headaches
{Page 2}
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Dx: Racemose cysticercosis
{Page 3}
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History: 42 y/o female with chronic headaches
549
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Dx: TB meningitis - HIV+
{Page 2}
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History: 54 y.o. man with headaches for 2
months & decreased mental status
132
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Dx: Cocci meningitis
Decreased mental
status {Page 2}
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Meningitis
Organisms Bacteria
Virus (meningoencephalitis)
Tuberculosis
Fungus
Enhancement of basal cisterns
Differential diagnosis
Leptomeningeal seeding of tumor
Encephalitis
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Cerebral Tuberculomas
D 13-17
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{Page 2}
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Complications of Meningitis
Communicating hydrocephalus
Loculated CSF collections
Subdural effusion / empyema
Cerebral infarction
Cerebral abscess
Dural sinus thrombophlebitis
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History: 39 woman with SLE
on chronic immunosuppression
with steroids & methotrexate
701
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Dx: TB meningitis
{Page 3}
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History: 38 y/o man with fever & headaches
254
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Dx: Tuberculous meningitis with vermian
& left temporal lobe abscesses
Fever & headaches {Page 2}
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Leptomeningeal Disease
Meningitis
Fungal, TB, Bacterial, Neurosyphilis
Sarcoidosis
Cysticercosis (Racemose form}
Metastatic disease
Arachnoiditis
Differential Diagnosis
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History: 37 y/o man with nausea & vomiting,
low testosterone, and diabetes insipidus.
362
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{Page 2}
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{Page 3}
Diabetes insipidus
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Dx: Neurosarcoidosis
{Page 4}
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History: 42 y.o. man with chronic
head and neck pain
66
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Head & neck pain {Page 2}
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Dx: Chronic pachymeningeal
inflammation - 2o V/P shunt
{Page 3}
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Encephalitis
A diffuse parenchymal
inflammation of the brain
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Encephalitis
Herpes simplex
Arboviruses
Enteroviruses
Lyme disease
Congenital TORCH agents
Organisms
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History: 27 y.o. man with
increasing confusion & lethargy
5
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Dx: Herpes simplex
encephalitis
Confusion & lethargy
{Page 2}
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Herpes Simplex Encephalitis
Rapid course
Temporal lobes, inferior
frontal & insular cortex
Cortical edema & mass effect
Gyral enhancement
Early therapy critical
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History: 50 y/o female with acute
onset of headache & confusion
540
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Dx: Herpes simplex encephalitis
{Page 2}
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Non-Herpetic
Meningoencephalitis
More benign
Generalized cortical pattern
Better prognosis
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History: A 40 year old man with 2
days of headaches and right facial
weakness and numbness
SC - JZ
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Dx: Lyme meningitis
{Page 2}
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Lyme Disease
A tick-borne illness
Caused by bacterium: Borrelia burgdorferi
Flu-like symptoms
Bull’s eye rash
CNS: facial palsy, meningitis, encephalitis,
polyradiculopathy
Treatment: antibiotics during early stages
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C-53-56
History: 8 year old boy with 1-2 week history of
left eye ptosis, limited EOMs, and ataxia.
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Dx: ADEM
{Page 2}
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Acute Disseminated
Encephalomyelitis (ADEM)
A post-infectious encephalitis
Immune-mediated reaction
Viral agents: measles, chickenpox or
vaccination for rabies or smallpox
Acute demyelinating disease
Mostly a monophasic illness
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History: 61 y/o woman with diabetes &
hypertension presented with aphasia
255
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Aphasia {Page 2}
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Dx: Post-Infectious encephalitis
(Acute disseminated encephalomyelitis)
{Page 3}
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Neonatal Infections
Toxoplasmosis
Other (Treponema, Listeria)
Rubella (measles)
Cytomegalovirus
Herpes simplex
HIV
TORCH
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Congenital Toxoplasmosis
Osborn & Byrd, NCNA 1:105, 1991
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History: Newborn baby
girl (38 wk) with microcephaly
658
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Dx: Congenital CMV with
microcephaly
{Page 2}
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Dx: Congenital CMV
History: 34 week
Premature girl
477
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Congenital Herpes Type 2
Osborn & Byrd, NCNA 1:105, 1991
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HIV Infection
RNA retrovirus
Deficient cell-mediated immunity
Infects monocytes & macrophages
of CNS - microglial nodules
Neurological symptoms in 39%
At autopsy, 75-80% of brains involved
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AIDS Brain Pathology
Human immunodeficiency virus (HIV)
Toxoplasmosis
Cryptococcosis
Progressive multifocal leuko-
encephalopathy (PML)
Cytomegalovirus (CMV)
Lymphoma
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History: 38 HIV+ male with headache
328
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Headaches
{Page 2 }
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Dx: Toxoplasmosis with good
response to anti-toxo medication
Two weeks
following treatment
{Page 3}
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Toxoplasmosis
A protozoan
50% of brain lesions in AIDS
Ring-enhancing masses on CT and MR
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History: 38 y/o HIV+ male
with headache & weakness
505
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{Page 2}
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Dx: Toxoplasmosis
{Page 4}
1 2
2
1
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History: 38 y/o female with
progressive left sided weakness
602
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Dx: HIV & Lymphoma
{Page 2}
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History: 41 y/o man with a right hemiparesis
& speech difficulty
621
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{Page 2}
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Dx: Primary CNS Lymphoma
{Page 3}
CBV
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History: 45 male with AIDS,
headaches & generalized wasting
730
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Dx: Cryptococcal menigitis
{Page 2}
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Cryptococcosis
Most common fungal infection
in AIDS patients
Produces meningitis primarily
Access to brain via VR spaces
Imaging studies negative in 80%
Hydrocephalus, Brain atrophy
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History: 49 y/o man with AIDS
& a right hemiparesis
381
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Dx: Cryptococcosis
Hemiparesis
{Page 2}
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History: 31 y/o male with
multiple neurological deficits
407
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{Page 2}
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Dx: AIDS - PML
{Page 3}
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Clinical Features of PML
Reactivation of latent DNA papovavirus
Immunocompromised host
Defective oligodendrocytes &
myelin maintenance
Progressive neurologic deterioration
No effective therapy - poor prognosis
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History: 48 y/o HIV+ man
with fever, mutism,
ataxia & dysphagia
288
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Dx: PML - Progressive
multifocal leukoencephalopathy
Ataxia & dysphagia
{Page 2}
Gd+
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History: 40 y/o male with headache and fever
233
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16 months later {Page 2}
Now with lethargy & confusion
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Dx: AIDS - HIV encephalitis & brain atrophy
{Page 3}
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History: 35 y/o male with fever & ataxia
511
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Dx: HIV encephalitis
{Page 2}
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Cytomegalovirus
Retinitis
Encephalitis
Ependymitis / Ventriculitis
Neuritis of cranial nerves
Peripheral polyneuropathy
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History: 43 y/o man
with visual deficits
428
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Dx: CMV retinitis with optic
pathway involvement
{Page 2}
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History: 45 y.o. man with
multiple cranial nerve palsies
63
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Dx: AIDS - CMV cranial
nerve neuropathy
{Page 2}
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History: 42 y.o. man with fever and confusion
41
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Fever & confusion {Page 2}
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{Page 3}
Dx: HIV encephalitis +
Tuberculomas (Ca++
)
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Creutzfeldt-Jakob Disease
Caused by a prion – a small non-viral, infectious,
protein particle
Neuronal loss, reactive astrocytosis and formation
of cytoplasmic vacuoles
Rapid cognitive decline, often with psychosis and
delirium, leading to death within 1 year
MRI: symmetrical increased T2 signal in basal
ganglia with restricted diffusion
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History: Elderly patient with
progressive mental decline
Courtesy Ajax George, NYU
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new variant CJD
The
Pulvinar
Sign
Collie, et al. AJNR (2003); 24:1560-1569
Zeidler, et al, Lancet,2000
Bovine spongiform Encephalopathy
Mad Cow Disease