Unit VIII Problem 6 Pathology: Meningitis
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1 Unit VIII Problem 6 Pathology: Meningitis - Important terms: Meningitis: it is inflammation of meninges (coverings of the central nervous system) caused by infection. They are classified to: Pachymeningitis: involving the dura matter. Leptomeningitis: involving the pia matter + arachenoid matter. Encephalitis or myelitis: these are infections of cerebral and spinal parenchyma Meningoencephalitis: infection of both meninges and brain parenchyma. - Causes and routes of infection in meningitis: Direct: this happens when there is otitis media or infection of the mastoid sinus. Indirect: bloodborne infections and septicemia from infections elsewhere. Neurosurgical settings: shunt infection, head injury, CSF leak and postoperative. Meningeal carcinomatosis/ lymphomatosis. Ruptured dermoid/ teratoma-chemical irritants. - Infectious meningitis can be: Acute (pyogenic: producing pus): bacterial. Acute (aseptic): viral. Chronic: TB, cyptococcal and spirochetal infections. Note: infectious causes can be bacterial, viral, fungal or protozoal. - Acute bacterial/ pyogenic meningitis: It is the commonest type of meningitis. Organism which are causing pyogenic meningitis in relation to age: Morphology: Gross: Engorged vessels. Exudates in: Parasagittal areas. Sylvian fissure (lateral fissure). Between peduncles. Cisterns. Note: this exudates is producing yellow-tan clouding of meninges. Location of exudates differs: H.influenzae: basal exudates. S.pneumoniae: in cerebral convexities. Fulminant cases: ventricles+adjacent brain parenchyma. Untreated cases: leptomeningeal fibrosis & Inflammation usually does not extend to the brain.
2 The results of inflammation are: Tissue and vascular injury (vasculitis): caused by lysosomal enzymes and free radicals released by granulocytes and monocytes. Vasculitis will cause infarcts. Increased intracranial pressure: due to increased vascular permeability + leakage of CSF and proteins in the interstitial space (cerbral edema). Increased intracranial pressure causes hypoxic-ischemic encephalopathy. - Tuberculous menigitis: Spread: hematogenous. Tuberculoma. Pott s disease of spine. Hydrocephalus is the common complication. Morphology: Gross: Thick exudate (see the image below): it is difficult to see the vessels at the base of the brain because of overlying meningeal inflammation and fibrosis. Tuberculoma (see the image below): it is close to the ventricles causing pressure which will increase intracranial pressure and result in Images below: granuloma causing increased pressure on the spinal cord (left) complete dilatation of ventricles as a result of
3 Microscopically: TB granuloma: epitheliod granuloma composed of epitheliod histiocytes surrounded by lymphocytes and Laghan s giant cells. - Fungal meningitis: Mostly occurring in: immunocompramised hosts. Causative organisms are: Aspergillosis. Mucormycosis. Cryptococcosis: encapsulated spheres (5-15 micrometers in diameter) seen in CSF in india ink stain. What happens in this disease? Granulomatous meningitis: with casseous necrosis and black discoloration due to fungal infection. Blood vessels develop endarteritis obliterans leading to infarction in parenchyma: there will be branching fungal hyphae invading arteries. Morphology: Gross: - Protozoal meningitis (amoebic meningoencephalitis): Naegleria. Acanthamoeba (see the image). Entry through cribriform plate from water.
4 - Viral meningitis (also known as aseptic meningtitis because bacteria are not present): Viruses reach the central nervous sytem through: Bloodstream. Along nerves. Common viruses which might lead to viral meningitis are: HIV Polio Herpes Rabies Cytomegalovirus (CMV). Morphology: Microscopically: Lymphocytes + macrophages: especially around blood vessels. Formation of microglial nodules. Individual cells necrosis to diffuse brain necrosis. Certain viruses cause intranuclear and intracytoplasmic inclusions. - Complications of meningitis: Acute: Papilledema: due to Involvement of cranial nerves (especially optic and vetibulocochlear). Raised intracranial pressure. Inappropriate ADH secretion. Seizures. Subacute: Cerebral abcess: Localized area of supparative inflammation in the brain substance. The cavity contains thick pus formed from necrotic, liquefied brain tissue and large numbers of neutrophils and is surrounded by a fibrogliotic wall. The location of the abcess corresponds to its source. Subdural hygroma. Seizures. Long-term: Deafness. Blindness. Hydrocephalus. Epilepsy. Cognitive impairement. Physical handicap.
5 - Cerebral abcess:
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