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CNS Disorders
Dr Shreedhar PaudelApril, 2009
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MENINGITIS
Inflammation of the coverings of the brain• CAUSES– BACTERIAL– VIRAL– TOXINS– MALIGNANCIES
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ACUTE BACTERIAL MENINGITIS
• NEONATAL PERIOD: S. PNEUMONAE, E.COLI• 3 MTHS- 3 YEARS : H. INFLUENZAE,
S.PNEUMONIA, N. MENINGITIDES• > 3 YRS : S. PNEUMONIAE, N. MENINGITIDES• IMMUNOCOMPROMISED HOST: LISTERIA,
MYCOPLASMA, CRYPTOCOCCUS
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ACUTE BACTERIAL MENINGITIS
• PATHOGENESIS– Routes of infection• Hematogenous spread from distant focus of infection• Local spread of infection from contiguous septic foci• Exogenous infection after trauma
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PATHOLOGY– Meninges are infiltrated with inflammatory cells– The cortex of brain shows edema, exudates and
proliferation of microglia– Sub arachnoid space may be filled with purulent
discharge– Exudates may block the foramina of Luschka and
Magendie leading to hydrocephalus– Thrombophlebitis of cerebral vessels may occur
leading to infarction and necrosis– Endotoxic shock and sudden death may be there
if meningococcal meningitis
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CLINICAL FEATURES
SYMPTOMS- Acute onset- Fever/ Irritability- Projectile vomiting- Headache/ Bulging fontanel- Seizure- Altered sensorium/ photophobia- Marked neck rigidity
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SIGNS• PHOTOPHOBIA , • NECK STIFFNESS,• KERNIG’S SIGN ( extension of knee is limited to less
than 135 degree) • BRUDZINSKI SIGN ( the knees get flexed as neck of
the child is passively flexed) • BULDGING FONTANEL,• ALTERATION OF MENTATION • PAPILLEDEMA, • NEUROLOGICAL DEFICIT• Respiration may be Cheyne-Stokes type
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ACUTE BACTERIAL MENINGITIS IN NEONATES AND YOUNG INFANTS
• There will be no signs of meningial irritation till 6 months of age
• Meningotis should be suspected in a newborn in following conditions– Vacant stare– Alternating irritability and drowsiness– Persistent vomiting with fever– Refusal to breast feeding– Poor tone/ poor cry– Shock/ hypothermia/ fever– Seizure/ neurological deficits
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COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS
• CNS COMPLICATIONS– SUBDURAL EFFUSION /EMPYEMA, – BRAIN ABSCESS , – HYDROCEPHALUS,
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COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS……….
Long term neurological deficits- DEAFNESS / BLINDNESS/ APHASIA- HEMIPLAGIA- OCULAR PALSIES
Systemic complications- SHOCK- MYOCARDITIS- SIADH- STATUS EPILEPTICUS
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DIAGNOSIS
• LUMBAR PUNCTURE• CSF FOR BIOCHEMICAL/CYTOLOGICAL
EVALUATION• Turbid CSF with raised pressure, elevated
protein level (>100mg/dl), reduced sugar level (<40 mg/dl or below 50% of blood sugar level), increased cell count (>1000/μL, mostly Neutrophils)
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DIAGNOSIS….
• CSF for microbilogy– Gram stain– Culture/ sensitivity
• LATEX AGGLUTINATION, • ELISA, • PCR• CT SCAN
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ACUTE BACTERIAL MENINGITISDIFFERENTIAL DIAGNOSIS– MENINGISM ( occur in inflammatory cervical lesion,
apical pneumonia, toxemia due to Hemophilus infection or typhoid fever)
– PARTIALLY TREATED BACTERIAL MENINGITIS– ASEPTIC MENINGITIS– TUBERCULOUS MENINGITIS– CRYPTOCOCCAL MENINGITIS– VIRAL ENCEPHALITIS– POLIOMYELITIS– SUB ARACHNOID HEMORRHAGE– LYME DISEASE (Borrelia infection)
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TREATMENT OFACUTE BACTERIAL MENINGITIS
• EMPIRICAL THERAPY– CEFTRIAXONE OR CEFATOXIME OR
COMBINATION OF AMPICILLIN AND CHLORAMPHENICOL FOR 10-14 DAYS
• SPECIFIC ANTIMICROBIAL THERAPY– MENINGOCOCCAL MENINGITIS: PENICILLIN,
CEFOTAXIME OR CEFTRIAXONE– HEMOPHILUS MENINGITIS: CEFTRIAXONE/
CEFOTAXIME
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TREATMENT……..
– STAPHYLOCOCCAL MENINGITIS: CLOXACILLIN OR VANCOMYCIN, • ADDITION OF RIFAMPICIN WILL ENHANCE THE
PENETRANCE OF THE CSF
– LISTERIA: AMIPCILLIN AND GENTAMYCIN– PSEUDOMONAS: CEFTAZIDIME AND
GENTAMYCIN, OR TICARCILLIN AND GENTAMYCIN
• DURATION OF TREATMENT: 10 DAYS EXCEPT FOR STAPHYLOCOCCAL MENINGITIS
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TREATMENT…..
– STERIOD THERAPY• DEXAMETHASONE 0.15 MG/KG IV 6 HRLY FOR 5 DAYS • FIRST DOSE OF STEROID SHOULD PRECEDE 15 MIN
FROM ANTIBIOTICS • DECREASES THE INCIDENCE OF RESIDUAL
NEUROLOGICAL DEFICITS• ESPECIALLY USEFUL IN H. INFLUENZAE INFECTION
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TREATMENT…………
• SYMPTOMATIC TREATMENT– RAISED ICP: OSMOTIC DIURETICS– CONVULSION: DIAZEPAM OR PHENYTOIN– RESTRICTION OF FLUID TO 2/3RD OF
MAINTENANCE TO PREVENT SIADH– NURSING CARE
• TREATMENT OF COMPLICATIONS• FOLLOW-UP AND REHABILITATION
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TUBERCULOUS MENINGITIS
• PRIMARY• SECONDARY• PATHOGENESIS• PATHOLOGY: TUBERCLE, BASE AND
TEMPORAL LOBES• STAGES: PRODROMAL, MENINGITIS, COMA• DIAGNOSIS: LP, CT, BACTEC, PCR
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TUBERCULOUS MENINGITIS
• D/D: PURULENT MENINGITIS, PARTIALLY TREATED,ENCEPHALITIS, TYPHOID ENCEPHALOPATHY, BRAIN ABSCESS, BRAIN TUMOR, CHRONIC SUBDURAL HEMATOMA, AMEBIC MENINGOENCEPHALITIS.
• TREATMENT: 12MTHS• INITIAL 2 MTHS: HRZE• LATER 10 MTHS: HRE
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TUBERCULOUS MENINGITIS
• STEROIDS: DEXAMETHASONE IV- 1-2 WEEKS• ORAL FOR 6 WEEKS AND TAPER SLOWLY• OTHER SUPPORTIVE THERAPY.
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ENCEPHALITIS
• DEFINE• ETIOLOGY/ PATHOLOGY : INCLUSION BODIES• VIRAL: MMR,HSV, CMV, EBV, JAPANEASE,
WEST NILE, RABIES, DANGUE• OTHER: RICKETTSIA, FUNGI, TOXOPLASMA,
BACTERIAL, REYES SYNDROME
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ENCEPHALITIS
• ONSET: SUDDEN • SIGNS AND SYMPTOMS: FEVER, HEADACHE,
VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY , COMA
• DECEREBRATION, DECORTICATION, PALSIES, PLAGIAS,
• EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B• TEMPORAL OR FRONTAL LOBE : HSV
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ENCEPHALITIS
• RAISED ICT• HERNIATION• 6TH NERVE PALSY
• DIAGNOSIS• HISTORY OF EXPOSURE• LP• CSF, PCR
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ENCEPHALITIS
• MANAGEMENT• SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES• HSV: RBC IN CSF, TREATMENT : ACYCLOVIR
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REYE’S SYNDROME
• GENERALISED MYOCARDIAL DYSFUNCTION• LIVER, KIDNEY , CNS• INHIBITION OF B-OXIDATION OF FATTY ACIDS• ASPRIN OTHER SALICYLATES, VIRAL INFECTION• HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA• PRESENTATION:• 2MTHS – 15 YEARS• RAPID PROGRESSION
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REYE’S SYNDROME
• STAGES• I- MILD CONFUSION• II – DELIRIUM• III – COMA• IV – APNEA, NON REACTING PUPIL• DIAGNOSIS:• HYPERAMMONEMIA, DEARRANGED LFT, EEG-
TRIPHASIC WAVES
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REYE’S SYNDROME
• TREATMENT• LOW PROTEIN DIET• TREAT HEPATIC FAILURE• TREAT RAISED ICT• HYPOGLYCAEMIA• VITAMIN K , FFP