Communicating Communicability: Imaging of CNS Infections Aaron P. Kamer, MD Assistant Professor of Clinical Radiology Neuroradiology Section April 26, 2016 Disclosure Within the past 12 months: I have done nothing to compromise the integrity of this lecture. I have no disclosures to make. Learner Objectives Recognize common imaging appearances of several CNS infections Describe the most effective MR sequences for evaluating several major types of viral, bacterial and other CNS infections. Explain the stages of common CNS infections on imaging. Question What s your favorite type of infection? A. Viral B. Bacterial C. Parasitic D. Other Main Categories Viral Bacterial Other Fungal Parasitic Prion Congenital Infections 1
Unknown 1 66-year-old man with fever H. Fukuoka et al. AJNR Am J Neuroradiol 2010;31:868-873 Unknown 1 A. B. C. D. Viral Meningitis 66-year-old man (case 7) with viral meningitis treated with an antiviral agent. H. Fukuoka et al. AJNR Am J Neuroradiol 2010;31:868-873 Viral Meningitis/Encephalitis How do you catch it? Viral Encephalitis It s an internet sensation VIRAL CNS INFECTIONS 6-year-old female with altered mental status. 2
Viral Encephalitis Viral Encephalitis How do you treat it? How do you catch it? 3-year-old male with fever, AMS. Hx of Takayasu arteritis, AAA. Who catches it? 1 How do you diagnose it? Immunocompromise Febrile Encephalopathy Seizures How do you diagnose it? 3
Case 1. 19 month-old with seizures and fever. Case 2. 40 yo M, seizures. Case 3. 36 yo M, rapid onset AMS. Case 4. Case 4. How do you treat it? 4
CMV - Cytomegalovirus How do you catch it? CMV Source: Radiopaedia - HIV positive adult patient with altered conscious state. CMV Case 1. 50 yo with confusion. History of CMV retinitis. CMV How do you treat it? HIV Encephalitis/Myelitis How do you diagnose it? Cognitive decline Slowly progressive neurologic disability HIV Encephalitis/Myelitis Case 1. 34-year-old male with history of HIV, progressive dementia. 5
HIV Encephalitis/Myelitis Case 1. HIV Encephalitis/Myelitis Case 1. HIV Encephalitis/Myelitis How do you treat it? PML (Progressive Multifocal Leukoencephalopathy) How do you catch it? 6
PML Case 1. Organ transplant, on immunosuppressives. PML Case 2. 44 yo with HIV. PML How do you treat it? Stop Natalizumab Unknown 2 Suspected Stroke A. B. C. D. DWI Pyogenic Abscess Case 3. Should have washed your hands BACTERIAL INFECTIONS 7
Bacterial Meningitis/Cerebritis How do you catch it? Bacterial Meningitis/Cerebritis How do you catch it? Bacterial Meningitis Case 1. 59-yo, evaluate for stroke Bacterial Meningitis Case 2. 12- month-old male Pyogenic Abscess Case 3. 59-yo, evaluate for stroke Pyogenic Abscess Case 3. 8
Pyogenic Abscess Case 3. Pyogenic Abscess Case 4. 11 yo female, motor and sensory deficits Pyogenic Abscess Case 2. Bacterial Meningitis/Cerebritis Case 4. 75 yo M, LUE weakness Bacterial Meningitis/Cerebritis Case 5. Bacterial Meningitis/Cerebritis Case 6. 8 month-year-old with bacterial meningitis. 9
Bacterial Meningitis/Cerebritis Case 6. Bacterial Meningitis/Cerebritis Case 6. Lyme Disease Lyme Disease Lyme Disease: Imaging 66 yo M with known neuroinvasive Lyme disease Lyme Disease: Treatment 10
Unknown 3: 23 M, visiting from India, headache, AMS. Unknown 23 M, visiting from India, headache, AMS. A. B. C. D. Tuberculosis: Imaging Case 1. 23 M, visiting from India, headache, AMS. Tuberculosis How do you catch it? Tuberculosis: Imaging Tuberculosis: Imaging 11
Tuberculosis: Imaging Case 3. HIV+, AFB+ Tuberculosis: Imaging Case 4. Tuberculosis: Imaging Case 4. Tuberculosis: Imaging Case 4. Fungal Infections: Nocardia It s just what I am FUNGI 12
Fungal Infections: Nocardia Fungal Infections: Nocardia Fungal Infections: Histoplasmosis 53 yo M, Fatigue, headaches, doubl e vision, blurred vision. Fungal Infections: Histoplasmosis Fungal Infections: Candida Candidal fungemia. Fungal Infections: Candida 13
Fungal Infections: Aspergillosis Angioinvasive aspergillus post BMT with GVHD, 24 yo with B-cell lymphoma Fungal Infections: Aspergillosis Fungal Infections: Cryptococcosis Case 1. Persistent headache > 2 months Fungal Infections: Cryptococcosis Case 1. Fungal Infections: Cryptococcosis Case 2. Encephalopathy, history of liver transplant. Fungal Infections: Cryptococcosis Case 3. 66-year-old male with history of cryptococcal meningitis, with altered mental status. 14
Fungal Infections: Cryptococcosis Case 3. Parasites: Toxoplasmosis How do you catch it? We all know one PARASITES Parasitic: Toxoplasmosis How do you catch it? Parasites: Toxoplasmosis Case 1. 59 yo male, gradual onset headache and weakness. Renal transplant, prostate ca, history of cutaneous T-cell lymphoma. Parasites: Toxoplasmosis Case 1. 15
Parasites: Toxoplasmosis Case 1. Parasites: Toxoplasmosis How do you treat it? Unknown 4 50 yo hispanic male, fall, seizure. A. B. C. D. sulfadiazine Neurocysticercosis 50 yo hispanic male, fall, seizure. Neurocysticercosis Stages Parasites: Neurocysticercosis Case 1. 36 yo Hispanic male 1. Vesicular 3. Granular Nodular 2. Colloidal Vesicular 4. Nodular Calcified 16
Parasites: Neurocysticercosis Case 1. Parasites: Neurocysticercosis Case 2. 50 yo hispanic male, fall, seizure. Parasites: Neurocysticercosis Case 3. 48 yo Hispanic male, numbness and tingling. Parasites: Neurocysticercosis Case 3. Parasites: Neurocysticercosis How do we treat? Parasites: Neurocysticercosis How do we treat? sulfadiazine 17
Prion Disease Prion Disease Creutzfeld-Jakob Misfolded protein that causes more misfolded protein Transmissible spongiform encephalopathy PRION DISEASE 54 yo M with rapidly progressive dementia. Prion Disease Prion Disease Prion Disease 67 yo with rapidly progressive cognitive decline. 47-yo F with subacute progressive tremor, rigidity, cognitive decline. 18
Prion Disease 47-yo F with subacute progressive tremor, rigidity, cognitive decline. Summary Things we discussed, things to think about in a new way Viral Bacterial Fungal Parasitic Prion Last Question What s your favorite type of infection? A. Viral B. Bacterial C. Parasitic D. Other Thank you! Questions? Aaron P. Kamer, MD apkamer@iupui.edu 19