Transcript CNS Infections

Central nervous system
infection
Dr. Koukeo Phommasone
CNS infection
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Meningitis
Encephalitis
Myelitis
Focal Central Nervous System Syndrome
– Brain abscess
– Subdural empyema
– Epidural abscess
¦¾À¹©¢º¤ CNS infection
• Virus: EV, HSV, VZV, CMV, Mumps, JE, Dengue
• Bacteria: HIB, S. pneumoniae, N. meningitidis,
S. suis, M. tuberculosis…
• Fungi: Cryptococcus
• Protozoa
• Parasites: Angiostrongylus cantonensis, …
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ຶ່ ນພະຍາດຊ
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ຶ່ ັ ນ: Neoplastic diceases,
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ັ້ ີມອາການຄ CNS infection ເຊ
intracranial tumors and cysts, medications, collagen
vascular disorders, and other systemic illnesses
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headache; photophobia;
stiff neck; Kernig’s and
Brudzinski’s signs +;
opisthotonus
Ä¢É (fever)
À¥ñ®¹ö¸ (headache)
¦½ªò®Ò©ó (altered mental status)
Focal neurologicdeficits
Meningismus
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ັ້ າມາຂ
ອາການທ
ັ້ າງເທ
ຶ່ ນ nonspecific, ມັນຂ
ີ ງນ
ີ ັ້ ແມ
ຶ ັ້ ນ
ກັບ pathogenesis, infectious agents and area
of CNS involvement and age of the patient
Meningitis vs Encephalitis
Meningitis
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Fever
Headache
Meningismus
Altered mental status
Encephalitis
• Fever
• Headache
• Altered mental status
Mental status changes early in
the disease course, prior to
coma
Both share many • Focal or diffuse
features
neurologicsigns (seizures
and hemiparesis)
Meningoencephalitis
Definitions of WHO
Bacterial meningitis
• Clinical description
– Acute onset of fever (usually
>38.5 rectal, >38 axillary)
– Headache and
– One of the following signs:
neck stiffness, altered
consciousness or other
meningeal signs
Acute encephalitis syndrome
(AES)
• Clinical case definition
– Acute onset of fever and at
least one of:
• Change in mental status
(including symptoms such as
confusion, disorientation,
coma, inability to talk
• New onset of seizure (
including simple febrile
seizure)
Meningitis and encephalitis
• Life-threatening disease
• Signs and symptoms are not specific
• Physical examination may not be sufficient to accurately
identify patient with meningitis, especially in infants and
young children
• Lumbar puncture result may be difficult to distinguish
bacterial meningitis from viral meningitis
• Suspected bacterial meningitis is a medical emergency
and need empirical antimicrobial treatment without
delay
• Physicians who prescribe the initial dose of antibiotics
should be aware of guidelines for antibiotics and
adjunctive steroids
Focal neurological
signs,
papilloedema,
falling level of
consciousness with
abscess)
falling pulse, rising
BP and/or vomiting
LP contraindication
• Mass in the brain (eg. Brain tumor or
causing raised intracranial pressure
• Skin or soft tissue sepsis at the proposed LP site
• Severe coagulopathy or severe thrombocytopenia
Risk for either mass or raised ICP
recent head injury
a known immune system problem
localizing neurological signs
evidence on examination ofraised ICP
MRI or CT
brain prior to
LP
Brainherniation
Typical CSF in meningitis
Pyogenic
Often turbid
Tuberculosis
polymorphs
mononuclear
mononuclear
Cell count/mm3 90-1000
Protein (g/L)
>1.5
10-1000
1-5
50-1000
<1
glucose
<1/2 plasma
>1/2 plasma
Appearance
Predominant
cells
<1/2 plasma
Often fibrin
web
Viral
Usually clear
Normal opening pressure: 50-190 mmH2O (depends on
age)
Appearance :clear; turbid; yellow or bloody
LP
• Cell count: 0-5/mm3 in children and adult,
maybe up to 32/mm3 (mean of 8-9/mm3) in
neonates
– False positive eleviation of CSF white bloodcell
counts : traumatic LP, intracerebral or
subarchnoidhemorrage
LP done at Mahosot
• Physicians decide to do Lumbar Puncture
according to clinical symptoms/signs
• No contraindication for LP
• Informed written consent
LP doneatMahosot
• Lab staff assist the physician for LP
• CSF drop on agar plate,
• CSF collection in 3 tubes:
• adult: 8ml
• children: 3ml
• Blood collection: (haemoculture,
glucose and serology)
CSF
Cell count,
Glucose,
Protein, GS, ZN,
Auramine, India
ink
Bacteriological
tests
Classical bacteriological
&TB culture
H. influenzae
S. pneumoniae
N. meningitidis
Bacteria PCR
Murine typhus
S. suis
Scrub typhus
Fungus &
parasites
Viral
tests
Cryptococcal Ag & culture
Viral PCR
Viral culture
Rickettsia
Spotted fever
EV, HSV, VZV, CMV, Dengue, JE,
Nipha, Influenxa A
Mumps, measles, TBE, West Nile,
Inluenza B, Panflavivirus
Panbio ELISA: Dengue (NS1, IgM, IgG), JE IgM
Serum
RDT for murine and
scrub typhus
Malaria film
Serology for Angiostrongyluscantonensis and
Gnathostomaspinigerum
Hemoculture
• Total included patients 2003-2009: 840 patients
• Few bacteria isolated from CSF: 6% (67% AB before LP)
• virus positive samples : 15.3%
Viral causes
Tested
POS
%
EV PCR
345 CSF
7
2%
HSV PCR
344 CSF
3
0.9%
VZV PCR
385 CSF
2
0.5%
CMV PCR
243 CSF
4
1.6%
Mumps PCR
344 CSF
2
0.9%
JEV PCR
344 CSF
2
0.9%
JE culture
200 CSF
1
0.5%
JEV IgM
700 CSF
48
6.8%
Dengue
344 sera
4 (3D1,1D4)
1.2%
Treatment of meningitis
Mahosot Microbiology Review
• Antibiotic recommendation
– Ceftriaxone 80-100 mg/kg/day divided into 2 daily
doses (50kg adult 2g IV every 12 h)
– Or in neonates:
• Aged 0-7 days cefotaxime100-150 mg/kg/day (dose
interval every 8-12h) or aged 8-28 days 150-200
mg/kg/day IV (dose interval 6-8h)
Treatment of meningitis
Mahosot Microbiology Review
• And if Listeria is suspected (usually in infant < 1
month old) give ampicillin
Age
0-7 days
8-28 days
Daily dose IV
150 mg/kg/day 200 mg/kg/day 300 mg/kg/day 12 g/day
Dose interval
Every 8h
Every 6-8h
<15 y
Every 6h
>15 y
Every 4 h
Treatment of meningitis
Mahosot Microbiology Review
• If ceftriaxone is not available give
chloramphenicol
Age
0-7 days
8-28 days
<15 y
>15 y
Daily dose IV
25 mg/kg/day
50 kg/day
75-100mg/kg/day
4-6g/day
Dose interval
24h
12-24h
6h
6h
If suspected rickettsial disease add in: oral doxycycline 4 mg/kg
stat followed by 2mg/kg every 12h for 1 week. In adult
doxycycline 200 mg loading dose followed by 100 mg every 12h
Adjunctive treatment with
dexamethasone
• Neurological sequelae are common in survivors of meningitis
(hearing loss, cognitive impairement, developmental delay)
• Adjuvant therapy with dexamethasone reduces the mortality
and neurological sequelae among adults with bacterial
meningitis in the developed world
• There have been few clinical trials in Asian patients – unclear
whether should be given ?
Systemic steroids (dexamethasone, 10 mg IV) are important adjunctive treatment for patients
with suspected bacterial meningitis and should be given with the first dose of antibiotics and
continued every 6 h for 4 days (but unclear whether beneficial in developing countries)
Prevention
• Viral meningitis: Immunoprophylaxis - JEV
• Bacterialmeningitis:Vaccine available for Hib, 7 serotype of S.
pneumoniae and N. meningitidis group A, C, Y and W135
• Chemoprophylaxis for bacterial meningitis patients/contacts
– Haemophulus influenzae
• Eradication of nasopharyngeal colonization of Hib
– Rifampicin 20 mg/kg daily for 4 days (2 days of rifampicin is efficacious as 4
days’ treatment
– Ampicillin and chloramphenicol, unlike ceftriaxone and cefotaxime, do not
effectively eliminate nasopharyngeal colonization
– Rifampicin is Not recommended in pregnant women
• Chemoprophylaxis is not currently recommended for daycare contacts
2 y old or older unless two or more cases occur in the daycare center
within 60 days-period
• For children <2 y, the CDC recommends prophylaxis for daycare
contacts
– Neisseria meningitidis
• Chemoprophylaxis:
– Ceftriaxone IM 250 mg in adult and 125 mg in children
– Ciprofloxacin 500 mg oral in adult single dose
– in adults, rifampin 600 mg bid for 2 days. In children 1 month or older 10
mg/Kg and infant youngerthan 1 month 5m/kg
• Chymoprophylaxis is recommended for household contacts,
daycare center members, any person exposed to the patient’s oral
secretion
• Chemoprophylaxis is not recommended for school, work or
transport contacts
• High dose penicillin or chloramphenicol do not reliably eradicate
meningococci from the nasopharynx of colonized patients
– S. pneumoniae: the risk of secondary pneumococcal
disease in contacts of infected patient has not been
defined
– Streptococcus agalactiae
• All pregnant should be screenat 35-37 weeks gestation for
anogenital colonization with group B streptococci
Microbiology Laboratory
Mahosot Hospital
Thank you for your attention