Prof Dr Meral Sonmezoglu Yeditepe University Hospital Acute and chronic meningitis, encephalitis...
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Transcript of Prof Dr Meral Sonmezoglu Yeditepe University Hospital Acute and chronic meningitis, encephalitis...
![Page 1: Prof Dr Meral Sonmezoglu Yeditepe University Hospital Acute and chronic meningitis, encephalitis III.](https://reader038.fdocuments.us/reader038/viewer/2022103123/56649db05503460f94a9e6aa/html5/thumbnails/1.jpg)
Prof Dr Meral SonmezogluYeditepe University Hospital
Acute and chronic meningitis, encephalitis III
Acute and chronic meningitis, encephalitis III
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The two major divisions in the nervous system
are the central nervous system (CNS), composed
of the brain and the spinal cord, and the
peripheral nervous system (PNS), composed of
afferent (input to CNS) and efferent (output to
periphery) neurons.
Within the PNS, major divisions are the somatic
nervous system (controls skeletal muscle) and
in the autonomic nervous system, which has
two branches: the parasympathetic (rest and
digest) and the sympathetic (emergency)
branches.
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Protection of the BrainProtection of the Brain
The brain is protected by bone, meninges, and cerebrospinal fluid (CSF)
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The CSF circulates through the ventricular system
• CSF is produced by the choroid plexus inside the ventricles.
• It circulates through the ventricles.
• From the fourth ventricle, CSF enters the subarachnoid space, between the arachnoid mater and pia mater.
• Reabsorbed from subarachnoid space into venous blood via the arachnoid villi
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Meninges (s. meninx)Meninges (s. meninx)
Three connective tissue membranes external to the CNS – dura mater, arachnoid mater, and pia mater
Functions:
Cover and protect the CNS
Protect blood vessels and enclose venous sinuses
Contain cerebrospinal fluid (CSF)
Form partitions within the skull
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MeningesMeninges
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Dura MaterDura Mater
Tough meninx composed of two fibrous CT layers. Layers separate in certain areas and form dural sinuses. Dural sinuses collect venous blood from the brain.
3 dural septa limit excessive movement of the brain
Falx cerebri – dural fold that dips into the longitudinal fissure
Falx cerebelli – runs along the vermis of the cerebellum
Tentorium cerebelli – horizontal fold extending into the transverse fissure
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Dura MaterDura Mater
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Arachnoid MaterArachnoid Mater
Separated from the dura mater by the subdural space (a narrow serous cavity)
Beneath the arachnoid is a wide subarachnoid space filled with CSF and large blood vessels
Arachnoid villi protrude superiorly and permit CSF to be absorbed into venous blood
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Pia MaterPia Mater
Deepest meninx – delicate CT that clings tightly to the brain and follows convolutions
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Cerebrospinal Fluid (CSF)Cerebrospinal Fluid (CSF)
Watery, similar in composition to blood plasma, but contains less protein and different ion concentrations than plasma
Forms a liquid cushion that gives buoyancy to the CNS organs, prevents the brain from crushing under its own weight
Protects the CNS from blows and other trauma
Nourishes the brain and may carry chemical signals from one part of the brain to another
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Choroid PlexusesChoroid Plexuses
Clusters of interwoven capillaries in each ventricle between the pia mater and a layer of ependymal cells.
Ion pumps allow them to alter the ion concentrations of the CSF
Help cleanse CSF by removing wastes
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Circulation of CSFCirculation of CSF
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Blood-Brain BarrierBlood-Brain Barrier
Protective mechanism that helps maintain a stable environment for the brain
Bloodborne substances in brain capillaries are separated from neurons by:
Continuous endothelium of capillary walls
Relatively thick basal lamina
Bulbous feet of astrocytes
Least permeable capillaries in the body due the nature of the tight junctions between endothelial cells
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Blood-Brain Barrier: FunctionsBlood-Brain Barrier: Functions
Selective barrier that allows nutrients to pass freely
Is ineffective against substances that can diffuse through plasma membranes (fats, gasses, alcohol)
Absent in some areas (vomiting center and the hypothalamus), allowing these areas to monitor the chemical composition of the blood
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MeningitisMeningitis
Meningitis is a clinical syndrome characterized by inflammation of the meninges
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ClassificationClassification
• Depending on the duration of symptoms, meningitis may be classified as acute or chronic.
• Acute meningitis denotes the evolution of symptoms within hours to several days, while chronic meningitis has an onset and duration of weeks to months.
• The duration of symptoms of chronic meningitis is characteristically at least 4 weeks.
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ClassificationClassification
• Meningitis can also be classified according to its etiology.
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MeningitisMeningitis
• Bacterial
• Viral ( aseptic)
• TB
• Fungal
• Chemical
• Parasitic
• ? Carcinomatous
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Classification of MeningitisClassification of Meningitis
• Infectious• Bacterial
• Viral
• Fungal
• Non-infectious• Drug-Induced
• Neoplastic
• Autoimmune
22%
54%
24%
Bacterial Viral Non-Infectious
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Bacterial Meningitis in AdultsBacterial Meningitis in Adults
•Deeks SL. Bacterial meningitis in Canada (1994-2001). Canadian Communicable Disease Report. Dec 2005. 31:23.
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Viral MeningitisViral Meningitis
Enteroviruses85%
HSV3%
Arborviruses10%
Other2%
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Noninfectious..Noninfectious..• Metabolic
• Mitochondrial (Reye’s, MELAS)
• NMS (Neuroleptic malignant syndrome)
• Nutritional deficiency (Wernicke’s)
• Paraneoplastic
• PRES or Malignant hypertension
• Seizures – (non-convulsive status)
• TBI
• Toxic
• Vascular
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MeningitisMeningitis
• Aseptic meningitis is a broad term that denotes a non-pyogenic cellular response, which may be caused by many different etiologic agents
• Many of these cases are found to have a viral etiology and can then be reclassified as acute viral meningitis (eg, enterovirus meningitis, herpes simplex virus [HSV] meningitis).
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Bacterial Bacterial MeningitisMeningitis
• Definition
• Bacterial meningitis is an inflammatory response to bacterial infection of the pia-arachnoid and CSF of the subarachnoid space
• Epidemiology
• Incidence is between 3-5 per 100,000
• More than 2,000 deaths annually in the U.S.
• Relative frequency of bacterial species varies with age.
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MeningitisMeningitis
• Epidemiology
• Neonates (< 1 Month)
• Gm (-) bacilli 50-60%
• Grp B Strep 20-40%
• Listeria sp. 2-10%
• H. influenza 0-3%
• S. pneumo 0-5%
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MeningitisMeningitis
• Epidemiology
• Children (1 month to 15 years)
• H. influenzae 40-60%– Declining dramatically in many geographic regions
• N. meningitidis 25-40%
• S. pneumo 10-20%
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MeningitisMeningitis
• Epidemiology
• Adults (> 15 years)
• S. pneumo 30-50%
• N. Meningitidis 10-35%
– Major cause in epidemics
• Gm (-) Bacilli 1-10%
– Elderly
• S. aureus 5-15%
• H. influenzae 1-3%
• >60 include Listeria, E. coli, Pseudomonas
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MeningitisMeningitis
• Pathogenesis
• Majority of cases are hematogenous in origin
• Organisms have virulence factors that allow bypassing of normal defenses
• Proteases
• Polysaccharidases
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MeningitisMeningitis
• Pathology and Pathogenesis
• Sequential steps allow the pathogen into the CSF
• Nasopharyngeal colonization
• Nasopharyngeal epithelial cell invasion
• Bloodstream invasion
• Bacteremia with intravascular survival
• Crossing of the BBB and entry into the CSF
• Survival and replication in the subarachnoid space
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Nasopharynx -> blood -> subarachnoid space
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Pathophysiology of Bacterial MeningitisPathophysiology of Bacterial Meningitis
• Bacterial colonization within the subarachnoid space
• Initiation of inflammatory response which leads to:• Endothelial damage
• Disruption of the blood-brain barrier
• On a larger scale, this results in:• Cerebral edema
• Cytotoxic
• Vasogenic
• Interstitial
• Increased ICP
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MeningitisMeningitis
• Pathology and Pathogenesis
• Key advances in the pathophysiology of meningitis include the pivotal role of cytokines (eg, tumor necrosis factor-alpha [TNF-alpha], interleukin [IL]–1), chemokines (IL-8), and other proinflammatory molecules in the pathogenesis of pleocytosis and neuronal damage during bacterial meningitis.
• Increased CSF concentrations of TNF-alpha, IL-1, IL-6, and IL-8 are characteristic findings in patients with bacterial meningitis
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MeningitisMeningitis
• Pathology
• Hallmark
• Exudate in the subarachnoid space
• Accumulation of exudate in the dependent areas of the brain
• Large numbers of PMN’s
• Within 2-3 days inflammation in the walls of the small and medium-sized blood vessels
• Blockage of normal CSF pathways and blockage of the normal absorption may lead to obstructive hydrocephalus
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MeningitisMeningitis
• Overall, the net result is vascular endothelial injury and increased BBB permeability leading to the entry of many blood components into the subarachnoid space.
• This contributes to vasogenic edema and elevated CSF protein levels.
• In response to the cytokines and chemotactic molecules, neutrophils migrate from the bloodstream and penetrate the damaged BBB, producing the profound neutrophilic pleocytosis characteristic of bacterial meningitis.
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Pathophysiology of Bacterial MeningitisPathophysiology of Bacterial Meningitis
Complications:
• Seizures
• Hydrocephalus
• Infarction
• Herniation •From van de Beek D Community-acquired bacterial meningitis in adults. 354:1. 44.
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Clinical Presentation of Clinical Presentation of MeningitisMeningitis
• Classic signs ;
• fever, headache, neck stiffness, photophobia, nausea, vomiting, and signs of cerebral dysfunction (eg, lethargy, confusion, decreased level of consciousness coma).
• The triad of fever, nuchal rigidity, and change in mental status is found in only two thirds of patients
• Atypical presentation may be observed in certain groups (elderly, diabetic, neutropenic, immunocompromised hosts..).
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Clinical Presentation of Clinical Presentation of MeningitisMeningitis
• Signs of cerebral dysfunction are common, including confusion, irritability, delirium, and coma. These are usually accompanied by fever and photophobia.
• Signs of meningeal irritation are observed in only approximately 50% of patients with bacterial meningitis, and their absence certainly does not rule out meningitis
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MeningitisMeningitis• Clinical Manifestations – Nuchal rigidity
• Kernig’s
• Pt supine with flexed knee has increased pain with passive extension of the same leg
• Brudzinski’s
• Supine pt with neck flexed will raise knees to take pressure off of the meninges
• Present in 50% of acute bacterial meningitis cases
• Cranial Nerve Palsies
• IV, VI, VII
• Seizures
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Brudzinski’s SignBrudzinski’s Sign
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Kernig’s SignKernig’s Sign
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Amos’s SignAmos’s Sign
Hips & knees flexed
Back arched
Neck in extension
Trunk supported by arms
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MeningitisMeningitis
• Focal neurologic signs may develop as a result of ischemia from vascular inflammation and thrombosis
• Papilledema and other signs of increased ICP may be present.
• Coma, increased blood pressure with bradycardia, and cranial nerve III palsy may be present.
• The presence of papilledema also suggests a possible alternate diagnosis (eg, brain abscess).
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MeningitisMeningitis
•Papilledema
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MeningitisMeningitis
• Clinical Manifestations - Meningococcemia
• Prominent rash
• Diffuse purpuric lesions principally involving the extremities
• Fever, hypotension, DIC
• History of terminal complement deficiency
• Classic findings often absent
• Neonates
• Elderly
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MeningitisMeningitis
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Diagnosis of Diagnosis of MeningitisMeningitis
• Diagnosis
• Assess for increased ICP
• Papilledema
• Focal neurologic findings
• Defer LP until CT scan or MRI obtained if any of above present
• If suspect meningitis and awaiting neuroimaging
• Obtain BC’s and start empiric Abx
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Diagnosis of Diagnosis of MeningitisMeningitis
Obtain CT scan before lumbar puncture in patients with:
• Immunucompromised state
• History of CNS disease
• New onset seizures
• Papilledema
• Altered level of consciousness
• Focal neurologic signs
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Diagnosis of Diagnosis of MeningitisMeningitis
• Obtain blood cultures and give empiric antibiotics if LP is delayed
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• Spinal tap is performed
• needle is inserted into an area in the lower back
• Identification of the type of bacteria
• is important for selection of correct antibiotics.
Diagnosing MeningitisDiagnosing Meningitis
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Lumbar punctureLumbar puncture
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LP-CSFLP-CSF
• Tube # 1 Protein & Glucose
• Tube # 2 Gram stain & Culture
• Tube # 3 Cell count & differential
• Tube # 4 Store ( PCR, viral studies etc)
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Diagnosis of Diagnosis of MeningitisMeningitis
• Diagnosis• CSF Findings :
Opening pressure
Appearance
Cell count & differential
Glucose
Protein
Gram stain & culture
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Bacterial MeningitisBacterial Meningitis
• Opening pressure: high, > 200 mmH20
• Cloudy
• 1000-5000 cells/mm3 with a neutrophil predominance of about 80-95%
• <40mg/dl and less than 2/3 of the serum glucose
• Protein elevated
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Agent Opening Pressure
WBC count per µL
Glucose (mg/dL)
Protein (mg/dL)
Microbiology
Bacterial meningitis
200-300 100-5000; >80% PMNs*
<40 >100 Specific pathogen demonstrated in 60% of Gram stains and 80% of cultures
Viral meningitis
90-200 10-300; lymphocytes
Normal, reduced in LCM and mumps
Normal but may be slightly elevated
Viral isolation, PCR† assays
Tuberculous meningitis
180-300 100-500; lymphocytes
Reduced, <40 Elevated, >100 Acid-fast bacillus stain, culture, PCR
Cryptococcal meningitis
180-300 10-200; lymphocytes
Reduced 50-200 India ink, cryptococcal antigen, culture
Aseptic meningitis
90-200 10-300; lymphocytes
Normal Normal but may be slightly elevated
Negative findings on workup
Normal values 80-200 0-5; lymphocytes 50-75 15-40 Negative findings on workup
•
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MeningitisMeningitis
• Diagnosis
• Rapid Tests
• CIE (Counter immunoelectrophoresis/ latex agglut.)
• PCR
• CT/MRI
• Little role in DIAGNOSIS of menigitis
• Obtain if suspect increased ICP
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MeningitisMeningitis
• Diagnosis
• Additional Tests
• CBC w/ diff
• Blood cultures
• CXR
• Electrolytes and renal function
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Bacterial CulturesBacterial Cultures
• “Gold standard”
• Positive in 75-85% who have not been treated with antibiotics
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MeningitisMeningitis
• Differential Diagnosis
• CNS infections (abscess, encephalitis)
• Viral/ Tb/ Lyme meningitis
• Ricketsial infections
• Cerebral vasculitis
• Subarachnoid hemorrhage
• Neurosyphilis
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Risk and/or Predisposing Factor Bacterial Pathogen
Age 0-4 weeks S agalactiae (group B streptococci)E coli K1L monocytogenes
Age 4-12 weeks S agalactiae E coli H influenzae S pneumoniae N meningitidis
Age 3 months to 18 years N meningitidis S pneumoniae H influenzae
Age 18-50 years S pneumoniae N meningitidis H influenzae
Age older than 50 years S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli
Immunocompromised state S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli
Intracranial manipulation, including neurosurgery
Staphylococcus aureus Coagulase-negative staphylococciAerobic gram-negative bacilli, includingPseudomonas aeruginosa
Basilar skull fracture S pneumoniae H influenzae Group A streptococci
CSF shunts Coagulase-negative staphylococciS aureus Aerobic gram-negative bacilliPropionibacterium acnes
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Fungi Cryptococcus neoformans C immitis B dermatitidis H capsulatum Candida speciesAspergillus species
Viruses Enterovirus PoliovirusEchovirusCoxsackievirus ACoxsackievirus BEnterovirus 68-71
Herpesvirus HSV-1 and HSV-2Varicella-zoster virusEBVCMVHHV*-6HHV-7
Paramyxovirus Mumps virusMeasles virus
Togavirus Rubella virus
Flavivirus Japanese encephalitis virusSt. Louis encephalitis virus
Bunyavirus California encephalitis virusLa Crosse encephalitis virus
Alphavirus Eastern equine encephalitis virusWestern equine encephalitis virusVenezuelan encephalitis virus
Reovirus Colorado tick fever virus
Arenavirus LCM virus
Rhabdovirus Rabies virus
Retrovirus HIV
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MeningitisMeningitis• Treatment
• Emergent empirical antimicrobial therapy• Based on age and underlying disease status
• Empiric antibiotic regimines
• Neonates (<3 months)
– Ampicillin plus a third generation cephalosporin
• Children
– Third generation cephalosporin ( alternative -ampicillin and chloramphenicol)
• Young adults
– Third generation cephalosporin (Ceftriaxone) + Vancomycin
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MeningitisMeningitis
• Treatment
• Empiric Antibiotic Regimines
• Older adults– Ampicillin in combination with third generation ceph.
• Postneurosurgical Pt’s– Vancomycin plus ceftazidime until cultures are
available
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MeningitisMeningitis
• Treatment
• N. Meningitidis
• High dose Pen G
• S. pneumoniae
• Ceftriaxone
• For areas with high level resistance – Vancomycin plus third generation cephalosporin or
rifampin
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MeningitisMeningitis
• Treatment
• Gm (-) Enterics
• Third generation cephalosporins
• L. monocytogenes
• Ampicillin
• S. aureus
• Vancomycin or Nafcillin
• S. epidermidis
• Vancomycin
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TreatmentTreatment
Predisposing Feature Antibiotic(s)
Age 0-4 weeks Ampicillin plus cefotaxime or an aminoglycoside
Age 1-3 months Ampicillin plus cefotaxime plus vancomycin*
Age 3 months to 50 years Ceftriaxone or cefotaxime plus vancomycin*
Older than 50 years Ampicillin plus ceftriaxone or cefotaxime plus vancomycin*
Impaired cellular immunity Ampicillin plus ceftazidime plus vancomycin*
Neurosurgery, head trauma, or CSF shunt
Vancomycin plus ceftazidime
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MeningitisMeningitis
• Treatment
• Duration of Treatment
• Dependent on infecting organism
– Average of 10-14 days
– Gm (-) bacilli for 3 weeks
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MeningitisMeningitis
• Treatment
• Steroids– Shortly before or along with antibiotics. Do not
give steroids after antibiotic treatment.
– de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549-56.
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Corticosteroids in ChildrenCorticosteroids in Children
• Despite the conclusion of the Cochrane review, use is still controversial
• CPS statement:• No recommendations for routine use
• If used, should only be given to children > 6 wks and before or within 1 hr of antibiotics
• Current Capital Health practice is to limit the use of steroids to children presenting with severe sepsis
•Canadian Paediatric Society Statement. Therapy of suspected bacterial meningitis in Canadian children six weeks of age and older. Ped & Child Health. 6:3. March 2001. 147-52. Reaffirmed February 2006.
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ComplicationsComplications
• The long-term neurologic sequelae can be grouped into 3 categories as follows:
• Hearing impairment
• Obstructive hydrocephalus
• Brain parenchymal damage: Most important feared complication of bacterial meningitis. It could lead to sensory and motor deficits, cerebral palsy, learning disabilities, mental retardation, cortical blindness, and seizures.
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MMortality of mortality of meningitiseningitis
• Overall mortality rate from bacterial meningitis has decreased but remains alarmingly high. It is reported to be approximately 25%.
• Among the common causes of acute bacterial meningitis, the highest mortality rate is observed with pneumococcus.
• 19-26% for S pneumoniae meningitis,
• 3-6% for H influenzae meningitis,
• 3-13% for N meningitidis meningitis,
• 15-29% for L monocytogenes meningitis.
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MeningitisMeningitis
• Prognosis
• Pneumococcal Meningitis
• Associated with the highest mortality rate– 19-26%
• Permanent neurologic sequelae– 1/3 of pts
– Hearing loss
– Mental retardation
– Seizures
– Cerebral Palsy
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Vaccination Vaccination
• The use of the HIB vaccination is strongly recommended in susceptible individuals.
• Vaccination against S pneumoniae is strongly encouraged in susceptible individuals, (older than 65 years and with chronic cardiopulmonary illnesses).
• Vaccinations against encapsulated bacterial organisms (eg, S pneumoniae, N meningitidis) are encouraged for those with functional or structural asplenia.
• Offer vaccination with quadrivalent meningococcal polysaccharide vaccine to all high-risk populations, including those with underlying immune deficiencies, those who travel to hyperendemic areas and epidemic areas, and those involved with laboratory work that deals with routine exposure to N meningitidis. College students who live in dormitories or residence halls are at modest risk; inform them about the risk and offer vaccination.
• Vaccination against N meningitidis is recommended for all adolescents aged 11-18 years.
• Vaccination against measles and mumps effectively eliminates aseptic meningitis syndrome caused by these pathogens.
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MeningitisMeningitis
• Vaccinations
• Asplenic pts should have had a pneumoccocal vaccine prior to their splenectomy
• Vaccines available for H. influenza
• Prophylaxis for N. meningitidis contacts
• Rifampin
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PreventionPrevention
• The widespread use of viral vaccines for polio, measles, mumps, rubella and varicella has almost eliminated CNS complications from these in the US.
• Domestic rabies vaccinations have reduced the frequency of rabies encephalitis.
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Prevention IIPrevention II
• Control of encephalitis from arboviruses has been less successful without specific vaccines.
• Control of insect vectors by spraying methods and eradication of insect breeding sites hasreduced incidence of these infections.
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Meningococcal vaccineMeningococcal vaccine
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ChemoprophylaxisChemoprophylaxis
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MeningitisMeningitis
• Conclusion
• Meningitis is an infectious disease emergency
• Mortality is often high but can be prevented with appropriate medical therapy
• If you consider meningitis in your differential, you are committed to an LP and empiric antibiotics
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The characteristic skin rash (purpura) of meningococcal septicemia, caused by Neisseria meningitidis
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•Pneumococcal meningitis in a patient with alcoholism. Courtesy of the CDC/Dr. Edwin P. Ewing, Jr.
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Follow-upFollow-up
• Close follow-up needed after hospital discharge:• Hearing should be assessed 1-2 mo. after d/c using
BEARS testing
• Neuromuscular assessment at the time of d/c should be documented and periodically assessed outpatient to detect any deficiencies
• Learning disabilities, behavior disorders and speech delay require close monitoring after d/c
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•Shock: Sepsis
•Protocol
An Approach to the
Adult Patient with
Suspected Bacterial
Meningitis
Summary:
•From supplement to:
•Van de Beek D. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006; 354:44-53
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•Shock: Sepsis
•Protocol
Indications
Age > 60
Recent seizures
Immunocompromised
Prev CNS disease or hardware
Focal neurological deficits
Papilledema
Altered LOC*
•Summary:
•An Approach to the
•Adult Patient with
•Suspected Bacterial
•Meningitis
•From supplement to:
•Van de Beek D. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006; 354:44-53
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•Shock: Sepsis
•Protocol
•Summary:
•An Approach to the
•Adult Patient with
•Suspected Bacterial
•Meningitis•Corticosteroids
•Give dexamethasone IV before or with 1st dose of
antibiotics
•Contraindications
•Antibiotics w/in 48 hrs
•Shunt
•Head trauma
•From supplement to:
•Van de Beek D. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006; 354:44-53
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•Shock: Sepsis
•Protocol
•Summary:
•An Approach to the
•Adult Patient with
•Suspected Bacterial
•Meningitis
•From supplement to:
•Van de Beek D. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006; 354:44-53
•Contraindications to LP
•Recent seizure
•Signs of herniation at any time
•GCS < 11 or rapidly declining LOC
•Focal neurologic deficits
•Papilledema *
•SOL or brain shift on CT
•Coagulopathy
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•Shock: Sepsis
•Protocol
•From supplement to:
•Van de Beek D. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006; 354:44-53
•Summary:
•An Approach to the
•Adult Patient with
•Suspected Bacterial
•Meningitis
•Empiric Antibiotic Therapy
•Cefotaxime 2g IV or Ceftriaxone 2g IV
•+/- Ampicillin 3g IV
•+/- Vancomycin 1g IV
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CHRONIC MENINGITISCHRONIC MENINGITIS
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• Chronic meningitis is an inflammation of the meninges with subacute onset and persisting cerebrospinal fluid (CSF) abnormalities lasting for at least one month.
• Several non-infectious and infectious etiologies are known to be causative.
• The wide range of different etiologies renders the approach to patients with this syndrome particularly difficult
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Chronic meningitisChronic meningitisCategory Agent
Bacteria M tuberculosis B burgdorferi T pallidum Brucella speciesFrancisella tularensis Nocardia speciesActinomyces species
Fungi C neoformans C immitis B dermatitidis H capsulatum Candida albicans Aspergillus speciesSporothrix schenckii
Parasites Acanthamoeba speciesN fowleri Angiostrongylus cantonensis G spinigerum B procyonis Schistosoma speciesS stercoralis Echinococcus granulosus
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Common infectious causes of chronic Common infectious causes of chronic meningitis and diagnostic approachmeningitis and diagnostic approach
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• Any inflammatory process of the meninges and/or of the brain parenchyma leading to signs and symptoms for more than 4 weeks is termed chronic meningitis and meningoencephalitis, respectively
• Criteria of this diagnosis a pleocytosis in the cerebrospinal fluid is obligatory
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Clinical Picture and ComplicationsClinical Picture and Complications
•Neurologically, these patients present with an insidious onset of headache, mild neckstiffness, usually low grade fever, and – only as time goes by – with focal neurological signs.
•Only in case of vasculitis there may be a sudden onset of neurological focal signs.
•A potentially life-threatening complication is the development of hydrocephalus, be it obstructive or malresorptive, eventually leading to qualitative and quantitative impairment of consciousness.
•Rarely, a chronic inflammatory process may lead to epileptic seizures, according to the underlying pathology of focal or generalized pattern.
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ENCEPHALITISENCEPHALITIS
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EncephalitisEncephalitis
• Encephalitis, an inflammation of the brain parenchyma, presents as diffuse and/or focal neuropsychological dysfunction.
• Encephalitis is distinct from meningitis, though on clinical evaluation the 2 often coexist with signs and symptoms of meningeal inflammation, such as photophobia, headache, or a stiff neck.
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EncephalitisEncephalitis
• Acute encephalitis is most commonly a viral infection with parenchymal damage varying from mild to profound
• Subacute and chronic encephalopathies, most likely toxoplasmosis in immunocompromised patients
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EncephalitisEncephalitis
• Individuals at the extremes of age are at highest risk, particularly for HSE
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EncephalitisEncephalitis• The classic presentation is encephalopathy with
diffuse or focal neurologic symptoms, including the following:
• Behavioral and personality changes, decreased level of consciousness
• Stiff neck, photophobia, and lethargy
• Generalized or localized seizures (60% of children with California encephalitis [CE])
• Acute confusion or amnestic states
• Flaccid paralysis (10% with WNE)
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Infectious etiologies of EncephalitisInfectious etiologies of Encephalitis• Viral agents, such as HSV type 1 and 2 (almost
exclusively in neonates),
• VZV, EBV,
• Measles virus (PIE and SSPE), mumps, and rubella are spread through person-to-person contact.
• Human herpesvirus 6 may also be a causative agent.
• Bacterial pathogens, such as Mycoplasma species, rickettsial or catscratch disease,
• Toxoplasma gondii
• West Nile virus can be transmitted by means of an organ transplant and via blood transfusions.
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Physical ExaminationPhysical Examination• Altered mental status
• Personality changes are very common
• Focal findings, such as hemiparesis, focal seizures, and autonomic dysfunction
• Movement disorders (St Louis encephalitis, eastern equine encephalitis [EEE], western equine encephalitis [WEE])
• Ataxia
• Cranial nerve defects
• Dysphagia, particularly in rabies
• Meningismus (less common and less pronounced than in meningitis)
• Unilateral sensorimotor dysfunction (postinfectious encephalomyelitis [PIE])
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EncephalitisEncephalitis• Laboratory tests (biochemical).
• Viral serology
• CT scan
• EEE
• CSF analysis
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ComplicationsComplications
• Seizures
• Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
• Increased intracranial pressure (ICP)
• Coma
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Encephalitis-treatmentEncephalitis-treatment• The goal of treatment for acutely ill patients is
administration of the first dose or doses acyclovir with or without antibiotics or steroids as quickly as possible
• Look for and treat systemic complications, particularly in HSE, EEE, JE, such as hypotension or shock, hypoxemia, hyponatremia (SIADH), and exacerbation of chronic diseases