Infectious Neurology Alison Ruiz PA-C
Case Presentation 48 y/o F presents to the ER with c/o headache and fever for the past two days. tates started with head pain and then patient developed fever max today of 103.0. c/o rigors. Positive Nausea. No V/D. Headache is diffuse. No photophobia. No previous hx of headaches. Pt states she had a sinus infection 3 weeks ago and finished a two week course of antibiotics about 4 days ago.
History PMH H inusitis Nonsmoker PH No alcohol use None FH inus infections: siblings Asthma mother DM father
Physical Exam Vitals: T 98.0, P 87, R 18, BP 90/58, Pulse ox 99% Abd: soft NT ND NAB. No HM. No CVAT HEENT: PERRL EOMi Ext: No C/C/E Neck: positive nuccal rigidity Lungs; CTA bilat. No W/R/R Neuro: positive Brudzinski sign, negative Kernigs sign No focal neuro deficits CV RRR 12. No murmurs
Differential Diagnosis Meningitis Bacterial Viral Encephalitis Brain abscess Hemorrhage
Classic presentation and PE Findings Classic s/s Fever, stiff neck, headache and altered mental status eizures Kernigs Brudzinskis
Diagnostic testing CBC WBC 20000 Otherwise normal BMG WNL Blood cultures Pending Urinalysis WNL Urine culture Pending CXR Negative CT scan WNL LP WBC 2000mm 3 %Polymorphnuclear cells 90% Glucose 15 mg/dl Protein 400 mg/dl Gram stain positive Cytology negative
Diagnosis???? Meningitis Likely Bacterial based on LP results
Understanding LP Normal Parameters Opening pressures <170 mm CF WBC <5 monomuclear % polymorphonuclear cells 0 Glucose >40 mg/dl Protein <50mg/dL Gram stain negative Cytology negative Bacterial Viral Neoplastic Fungal >300mm <300mm 200mm 300mm >1000/mm 3 <1000/mm 3 <500/mm 3 <500/mm 3 >80% 1%-50% 1%-50% 1%-50% <40mg/dL >40mg/dL <40mg/dL <40mg/dL >200mg/dL <200mg/dL >200mg/dL >200mg/dL Positive Negative Negative Negative Negative Negative Positive Positive
CT scan When and Why? Altered mental status Deteriorating Level of Consciousness Focal neuro deficit eizure Papilledema Immunocompromised state Malignancy Hx of stroke, focal infection, tumor Concern for mass Age >60 y/o
Treatment Antibiotic AAP!!!! Presumptive bacterial meningitis and should not be delayed for neuro imaging or LP IV dexamethasone 0.15mg/kg in peds 10mg in adults Found to improve outcomes in pt s with bacterial meningitis Admission What antibiotic do you use for empiric treatment in ED?
Empiric Treatment of Meningitis Age Potential Pathogens Empiric Treatment 18-50 yrs trep pneumo, N. meningitidis >50 yrs. pneumo, N. meningitidis, Listeria monocytogenes, aerobic gram neg bacilli Ceftriaxone 2g IV + Vancomycin, 15mg/kg (Rifampin if concern for resistance to strep pneumo) Ceftriaxone 2g IV + Ampicillin 2g IV + Vancomycin 15/mg/kg Rifampin if concern for resistance to strep pneumo)
Viral Meningitis Viruses include Non-polio enteroviruses, mumps, CMV, HV, lympocytic chriomeningitis, adenovirus, HIV Distinguished from bacterial or other causes based on LP results May be overlap of findings between bac and viral initially May be predominate amount of neutrophils present in the first 24 hours
Management in Viral meningitis Admission with empiric antibiotic therapy until culture results return OR discharge from the ED with follow up in 24 hours. If known HV-2 meningitis With neurologic deficits (urinary retention, weakness) Treat with Acyclovir 10mg/kg IV q 8 h
Viral Encephalitis Infection of the brain parenchyma, distinguished from viral meningitis in which the infectious agent is in the subarachnoid space Clinically distinct neurologic abnormalities not seen in meningitis
Arbovirus or Rabies Encephalitis
Impaired Immune ystem HZV Encephalitis CMV Encephalitis
Clinical Presentation New psychiatric symptoms Cognitive deficits Aphasia, amnestic syndrome, acute confusional states eizures Movement disorders Often pt will also have meningeal signs and have a coexisting meningitis HZV, Epstein-Barr or CMV will often present with findings outside of the CN as well i.e HM, LAD
Diagnostic Imaging MRI or CT MRI is more sensitive Use CT when MRI is not available Excludes other potential lesions, such as brain abscess hows findings highly suggestive of HV encephalitis Involvement of the medial temporal and inferior frontal grey matter EEG HV encephalitis shows a almost pathognomic wave Will not be done in the ER LP Is the best way from the ED to diagnose Viral cultures
Differential Diagnosis Meningitis, AH evere headache Brain abscess, bacterial meninigitis Fever and headaches Brain abscess, bacterial endocarditis, encephalomyelitis If parenchymal features are present Lyme disease, TB, fungal and neoplastic meningitis Less fulminant meningeal signs
Encephalitis Treatment HV and possibly HZV Acyclovir 10mg/kg IV q8h Diagnosis needs to be made in timely fashion CMV Gancyclovir 5mg/kg IV q12h Outcome is dependent on the neurologic condition at the time of antiviral therapy initiation Pt s in coma prior to therapy tend to do poorly
Intracranial Abscess
Three Routes to Transmit Infection the Brain
Pathogens Otogenic abscesses Most common in sinogenic and odontogenic abscesses From hematogenous spread Usually include anaerobic and microaerophilic streptococci Typical pathogesn due to direct implantation From neurosurgical procedures
Clinical Presentation Rarely appear acutely ill Fever in 50% of the patients Neck stiffness fewer than 50% Hemiparesis and seizure 1/3 of the time Increased ICP Causes vomiting, confusion, obtundation
Focal Neuro igns Frontal lobes Hemiparesis Temporal lobes Visual fields deficits or aphasia Cerebellum Limb incoordination and nystagmus
CT brain with contrast One or several thin, smoothly contoured rings of enhancement surrounding a low density center and surrounded by white matter edema
Other Diagnostic Testing Blood analysis, LP, EEG are nonspecific Obtain blood cultures! Will guide management
Differential Diagnosis May have sudden onset with focal neuro deficits May have prominent fever, stiff neck and confusion May mimic the imaging finding of brain abscess
Treatment
Empiric Treatment Presumed ource Empiric Therapy Otogenic Cefotaxime 2g IV + metronidazole 500mg IV inogenic Penetrating trauma/neurosurg procedure Cefotaxime 2g IV +metronidazole 500mg IV Vancomycin 15mg/kg IV +Ceftazidime 2g IV Hematogenous Cefotaxime 2g IV + metronidazole 500mg IV No obvious source Cefotaxime 2g IV + metronidazole 500mg IV
Case Presentation 28 y/o hispanic male presents to the ER. peaks only panish. Translator states patient has had mild head pain for the past few weeks. He does not typically get headaches so he decided to get it checked out. He came to the emergency room because he doesn t have a doctor. Pain has not kept patient from working. He denies other symptoms. Used Tylenol twice for the pain without relief. No visual changes. No vomiting, photophobia. Unsure if he has had fever. Positive chills, sweats. Moved to Chicago from Mexico 6 months ago
History PMH denies PH none FH doesn t know H drinks alcohol 5-6 drinks 3 times per week Nonsmoker
Physical Exam Vitals: 99.0 po, R 18, P 78, BP 140/89, Pulse Ox 100% HEENT NCAT PERRL EOMi Neck supple full rom. Lungs; CTA bilat. NO W/R/R CV RRR s1s2. NO murmurs Abd; soft NT ND NAB Ext: no C/C/E Neuro: No focal neuro deficits, CN II-XII grossly intact, Muscle strength 5/5 UE and LE bilat. DTR patellar tendon 2+ bilat, brachioradialis 2+ bilat, achilles 2+, triceps 2+ bilat. Pronator Drift WNL, Finger to nose WNL Gait normal
Differential Diagnosis Migraine/Tension Headache Infection Tumor Meningitis, encephalitis Abscess
Diagnostic Tests CBC WBC 14,000 with left shift Hgb 11 BMG Glucose 180, otherwise normal ER WNL Would you do CT?
CT Brain Findings: trong ring enhancing lesion with surrounding edema No mass effect
What is the diagnosis? CN Toxoplasmosis
Toxoplasmosis Acquired from ingestion of uncooked meat and from handling cat feces which carries parasite Toxoplasma gondii Immune compromised patients Fevers, headache, seizures and focal neuro deficits
Treatment Combination of ulfadiazine (sulfonamide) + Pyrimethamine (for protozoal infections) Addition of folinic acid prevents megloblastic anemia
References Tintinalli 1172-1178 Adams 1101