Central nervous system infections

Transcription

1 Central nervous system infections Antal Gábor Kondász Med. Resident doctor of infectious diseases Szeged 2017 september 29

2 Stucture of central nervous sytem

3 Localisation of infection Meningitis Encephalitis Myelitis Meningo-encephalo-myelitis Intracerebral absces Epiduralis empyema

4 Meningitis The inflammation of meninx involved the liquorspace No time to lose, dieases required urgent, immediate diagnose and treatment The delay causes the death of the patient or causes serious residual symptoms

5 The routes of the infection Hematogenous Nose and paranasal sinuses Airways Skull fractures Periferial nerv (rabies, HSV, VZV)

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7 Predisposing Elderly people (above 60 years) Alcoholism, liver cirrhosis, malnutriction Chronic renal diseases HIV and other immundeficiencies Diabetes, malignancies Head injuries (neurological surgery) Brain ventricular drainage or shunts Leak of the meningx Community (dorms or army base in early 2000 Neisseria menigitis epidemic in Hungary) Otitis media, sinusitis, mastoiditis Pneumonia (abcessus)

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9 THESE ARE ALARM SIGNS, BUT MISSING ARE NOT EXCLUDE MENINGITIS

10 Signs of meningeal irritation Kernig sign Brudzinski sign Jolt accentuation of headache Maneuver Place patient supine with hip flexed at 90 degrees. Attempt to extend the leg at the knee. Place patient in the supine position and passively flex the head toward the chest. Patient rotates his/her head horizontally two to three times per second. Positive test The test is positive when there is resistance to extension at the knee to >135 or pain in the lower back or posterior thigh. The test is positive when there is flexion of the knees and hips of the patient. The test is positive if the patient reports exacerbation of his/her headache with this maneuver.

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12 CT scan Every time needed: Check the intracranial pressures Some agent causes typical sing Use for differencial diagnosis: Trauma Vascular abnormalities Neoplasms

13 Lumbal puncture Make in experenced hand it s safety procedure with a minimal pain So called a neurologist or a neurosurgeon if you don t have a practice

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15 Cytology Normal Purulent Serosus

16 Laboratory finding

17 Microbiologycal diagnostic The liquor in physiologycal is steril. For the microbiologycal testing need more than 2 ml sample, Need a rapid transport to the labory, Rapid test for the most common bacterial agents have result within 2 hours and this result not changing: NEISSERIA MENINGITIDIS A, C, Y/W135, B/ E. COLI K1, HAEMOPHILUS INFLUENZAE b, STREPTOCOCCUS PNEUMONIAE, B CSOPORTÚ STREPTOCOCCUS Definitive result, with antibiotic sensitivity : Aerob bacterias within 3 days with antibiotic sensitivity Anaerob bacteria within 10 days Virus or Mycobacterium sp. PCR if it possible in the laboratory with in 6-12 hours Mycobacterium sp. cultur within 30 days

18 Tipical bacterial agent of meningitis Organism Site of entry Age range Predisposing conditions Neisseria meningitidis Streptococcus pneumoniae Listeria monocytogenes Coagulase-negative staphylococci Staphylococcus aureus Nasopharynx All ages Usually none, rarely complement deficiency Nasopharynx, direct extension across skull fracture, or from contiguous or distant foci of infection Gastrointestinal tract, placenta All ages Older adults and neonates All conditions that predispose to pneumococcal bacteremia, fracture of cribriform plate, cochlear implants, cerebrospinal fluid otorrhea from basilar skull fracture, defects of the ear ossicle (Mondini defect) Defects in cell-mediated immunity (eg, glucocorticoids, transplantation [especially renal transplantation]), pregnancy, liver disease, alcoholism, malignancy Foreign body All ages Surgery and foreign body, especially ventricular drains Bacteremia, foreign body, skin All ages Endocarditis, surgery and foreign body, especially ventricular drains; cellulitis, decubitus ulcer Gram-negative bacilli Various Older adults and neonates Haemophilus influenzae Nasopharynx, contiguous spread from local infection Adults; infants and children if not vaccinated Advanced medical illness, neurosurgery, ventricular drains, disseminated strongyloidiasis Diminished humoral immunity

19 Empirical therapy in CNS infections Agaist cerebral oedema: Mannitol 3x100 ml / day intravenousus dosing Dexamethason Antiviral therapy: Acyclovir 10 mg/ body mass kg intravenousos dosing Antibiotic therapy: Ceftriaxon v. cefotaxim + ampicillin + vankomycin

20 Empirical antibiotic therapy

21 Microorganism, susceptibility Standard therapy Alternative therapies Escherichia coli and other Enterobacteriaceae Third-generation cephalosporin Aztreonam, fluoroquinolone, meropenem, trimethoprimsulfamethoxazole, ampicillin Pseudomonas aeruginosa Cefepime or ceftazidime Aztreonam, ciprofloxacin, meropenem Acinetobacter baumannii Meropenem Colistin or polymyxin B Haemophilus influenzae Beta-lactamase negative Ampicillin Third-generation cephalosporin, cefepime, fluoroquinolone, aztreonam, chloramphenicol Beta-lactamase positive Third-generation cephalosporin Cefepime, fluoroquinolone, aztreonam, chloramphenicol Staphylococcus aureus Methicillin susceptible Nafcillin or oxacillin Vancomycin, meropenem, linezolid, daptomycin Methicillin resistant Vancomycin Trimethoprim-sulfamethoxazole, linezolid, daptomycin Staphylococcus epidermidis Vancomycin Linezolid Enterococcus species Ampicillin susceptible Ampicillin resistant Ampicillin plus gentamicin Vancomycin plus gentamicin Ampicillin and vancomycin resistant Linezolid

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23 Duration of the therapy

24 Meningoencephalitis Usualy viral infection of the etiologycal agents But some bacterial infection make a same symptoms Empiric terapy same as like in meningitis In diagnostic use PCR and serological testing of the blood and liquor

25 Typical agents and seasonality

26 Suggested initial therapy for agents that cause encephalitis Agent Cytomegalovirus Epstein-Barr Hepatitis B Herpes simplex Human herpesvirus 6 HIV St. Louis encephalitis Influenza JC virus Measles Nipah Varicella-zoster West Nile Specific therapy Ganciclovir plus foscarnet No specific treatment Valgancyclovir Acyclovir Gancyclovir or foscarnet Antiretroviral therapy Interferon-2-alpha Oseltamivir Reversal of immunosuppression if possible Ribavirin Ribavirin Acyclovir No specific treatment

27 Suggested initial therapy for agents that cause encephalitis Agent Mycoplasma pneumonia Listeria monocytogenes Tropheryma whipplei Anaplasma phagocytophilum Ehrlichia chafeensis Rickettsia rickettsii Borrelia burgdorferi Treponema pallidum Mycobacterium tuberculosis Specific therapy Macrolide, doxycycline, or fluoroquinolone Ampicillin plus gentamicin; trimethoprimsulfamethoxazole Ceftiaxone, followed by either trimethoprimsulfamethoxazole or cefixime Doxycyclin Ceftriaxon, cefotaxim Penicillin G 4-drug regimen; consider addition of corticosteroid

28 Mycobacterium tuberculosis meningitis Tuberculous meningitis accounts for about 1 percent of all cases of tuberculosis 5 percent of all extrapulmonary disease in immunocompetent individuals the case-fatality ratio remains relatively high (15 to 40 percent) despite effective treatment regimens Early recognition of tuberculous meningitis is of paramount importance because the clinical outcome depends greatly upon the stage at which therapy is initiated. Empiric antituberculous therapy should be started Cerebrospinal fluid (CSF) findings same like viralmeningitis Serial examination of the CSF by acid-fast stain and culture is the best diagnostic approach. Smears and cultures will yield positive results even days after treatment has been initiated. Nucleic acid amplification testing also may be helpful.

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30 Therapy

31 Thank you for your patience!