CASE 1
• A 32 yrs old gentleman is brought to
ER with history of fever for 3 days,
headache & vomiting for 2 days and
drow...
•
•
•
•
•
•
•

O/E
BP = 110/70 mm Hg
Pulse= 112/min
Temp= 103F
CNS : Neck stiffness +ve
SOMI
+ve
GCS
11/ 15
Plantars
downg...
CSF
•
•
•
•
•

Colour
Appearance
Proteins
Glucose
Cells

whitish
turbid
213 mg/dl
36 mg/dl
1056/cmm
N = 97%
L = 3%
• What is your diagnosis?
• How will you manage?
• What can be the complications in this
case?
• A 23 yrs old lady is brought to ED
with c/o sudden unconsciousness.
• h/o low grade fever and mild
headache for last 1 d...
O/E
• A young lady lying
unconscios
• BP = 80 Systolic
pulse = 90bpm
• Temp = 100oF
• A macular purpuric
rash over legs &
...
CSF R.E.
• Appearance
• Proteins
• Cells

• Glucose

turbid
250 mg/dl
612 /cmm
N = 90 %
L = 10 %
28 mg/dl
• What is your impression?
• What other investigations will you
plan?
• How will you manage her?
• A young girl of age 14 yrs is brought
to ED with c/o severe headache for 1
day, fever for 1 day and irritable
behaviour ...
• What is your diagnosis?
• What is its treatment?
• A 32 yr old gentleman is brought to
ED with c/o low grade fever & easy
fatiguability for 1 month, headache
for 2 weeks a...
O/E
•
•
•
•
•
•
•
•
•

BP = 170/100 mmHg
Pulse = 60bpm
Temp = 99.5oF
CNS:
pupils RRR
SOMI -ve
plantars downgoing
GCS 10/ 1...
Urgent CT brain shows meningeal
enhancement with mild hyrocephalus.
CSF R.E shows:
proteins =210mg/dl glucose =34mg/dl
Cel...
• Same patient presents to ED after 1month
with c/o persistant vomiting. O/E
• pt is fully conscious ,oriented
• Mildly ja...
• Same patient comes to OPD after
3months with c/o vertgo and
instability for 3 days. Clinically there
are features of lef...
• What is your diagnosis?
• How will you manage?
Tuberculomata
• Same patient again brought to ED in
an unconscious state. O/E
• VITALS stable
3/15
• GCS
upgoing
• Plantars
early papill...
what to do now?
• A young lady is brought to ED with
c/o fever for 5 days, headache for 3
days , irrelevant talk f0r last 2 days
& one epi...
O/E
•
•
•
•
•
•

A young lady talking irrelevantly
Temp = 100oF
CNS =
Pt conscious, not oriented
No SOMI
No other +ve find...
• A Vesicular rash is seen over area of
RHC
CSF R.E.
•
•
•
•

Appearance
Proteins
Glucose
Cells

clear
60mg/dl
60mg/dl
100/cmm
L = 88%
N = 12%
• What is your diagnosis?
• How will you manage?
• A 24 yrs old gentleman is brought to
ED with c/o high grade fever
associated with rigors & chills for
last 2 weeks, head...
O/E
•
•
•
•
•

A young man lying unconscious in bed.
BP
= 100/60mmHg
Pulse = 120bpm
Temp = 102oF
CNS:
GCS
5/I5
Tone decrea...
CT BRAIN
Low density lesion
in left
frontoparietal
region with ring
enhancement
• What is your diagnosis?
• How will you manage?
A young boy of age 20 is brought to
OPD with c/o low grade fever for 1
month, restlessness and depressive
mood for 1month ...
O/E
•
•
•
•

BP
120/80 mm/Hg
PULSE
72bpm
TEMPERATURE 102F
CNS
no positive finding
• During hospital stay, pt continued to
deteriorate. Headache & fever did
not settle despite good antibiotics &
analgesics...
• He became incontinent.
• His mental state also deteriorated and he
became disoriented in time, place and
person.
• 5 day...
MRI brain
• Meningeal enhancement
• Focal tuberculomas in right frontal
and parietal region.
• So diagnosis is TBM with
tu...
CNS INFECTIONS
•
•
•
•
•
•

Bacterial infections
Viral infections
Prion diseases
Protozoal infections
Helminthic infections
Fungal infect...
Bacterial infections
•
•
•
•
•
•
•

Meningitis
Suppurative encephalitis
Brain abscess
Tuberculosis
Neurosyphilis
Diphtheri...
Viral infections
•
•
•
•
•
•
•

Meningitis
Encephalitis
Tranverse myelitis
Poliomyelitis
SSPE
Rabies
HIV infection
•
•

•
•

PRION DISEASES
Creutzfeldt-jakob
disease
Kuru
FUNGAL INF.
Meningitis i.e
Cryptococcal or
Candida

PROTOZOAL INF:...
• Acute infection of meninges
• Pt presents with fever,headache, vomiting
and altered mental status.
• O/E there is neck s...
VIRAL MENINGITIS
• The most common cause of meningitis
• Usually benign & self-limiting
• Common viruses causing meningiti...
CLINICAL FEATURES
•
•
•
•
•

Sudden severe headache
Pyrexia
irritability
Meningism
Focal neurological signs occur rarely.
Bacterial Causes of
Meningitis
•
•
•
•
•
•
•
•

In Neonates:
E-coli
Proteus
Group B Streptococci
Listeria monocytogenes
In...
• Bacterial meningitis is less common
but associated with significant
morbidity & mortality.
• Most common causes are S
pn...
TBM
•
•
•
•
•
•
•

SYMPTOMS:
Headache
Vomiting
Low-grade Fever
Lassitude
Depression
Confusion
Behaviour changes

SIGNS:
• ...
• It presents with acute onset of
headache, fever, focal neurological
signs and seizures.
• There may be drowsiness or com...
Bacteria may enter the brain via
penetrating injury. There may be
direct spread from paranasal sinuses
or middle ear. Ther...
Clinical features
• It may present acutely with fever,
headache, meningism & drowsiness.
• Commonly it presents over days ...
•
•
•
•
•

CT scan brain
Lumbar puncture
Blood cultures
PCR of CSF
Baseline labs
CSF R.E
Condition Cell type

Cell count

Normal

0-4*106/l

Lymphocyts

Viral
lymphocyte
bacterial polymorphs
TB
P/L/Mixed...
• Viral meningitis is usually selflimiting.
• Symptomatic treatment is done.
Treatment of pyogenic
meningitis
General T/M:
• Bed Rest
• IV Fluids
• Airway Patency
Specific Antimicrobial
T/M
Antibiotic Regimen is
modified
according to age &
suspected
organism.

Mainstay of T/M is
IV An...
T/M When Cause Of
Bacterial Meningitis is Known
Pathogen
NMeningitidis
Strep
Pneumoniae

Regime of
choice

Alternative

2....
H-Influenza

Cefotaxime

Chloramphenicol

Or
Ceftriaxone
Listeria
Ampicillin
Monocytogen 2g IV 4 hourly +
es
Gentamicin
5m...
T/M of Pyogenic Meningitis
of Unknown Cause
 Pt. with typical Meningococcal Rash:
Benzyl Penicillil 2.4g IV 6 hourly.
 A...
 Pt. with suspicion of Listeria Infection:
Ampicillin
or
Co-trimoxazole

 Pt. with H/O Anaphylaxis to B-Lactams:
Chloram...
T/M according to age of Pt.
 Neonates and infants:
Ampicillin with Cefotaxime

 Older Children and Young Adults
Penicill...
Adjuvant Therapy
1. Mannitol:
250ml IV bolus over 10-20 minutes

2. Glucocorticoids:
Dexamethasone 0.15mg/kg IV 6hourly

3...
Prevention Of
Meningococcal Infection
• Oral Rifampicin 600mg 12 hourly in adults
• Oral Rifampicin 5-10mg/kg 12 hourly in...
Treatment of TBM
•
•
•
•

General measures
ATT
Steroids
Surgical treatment may be required
if hydrocephalus develops.
Viral encephalitis
• Inf Acyclovir 10mg/kg body weight
IV 8hrly for 2-3 weeks.
• symptomatic
Brain abscess
• Antibiotics according to site of
abscess like cefuroxime &
metronidazole for frontal lobe lesion
• Anticon...
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
Cns infections
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Cns infections

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Cns infections

  1. 1. CASE 1 • A 32 yrs old gentleman is brought to ER with history of fever for 3 days, headache & vomiting for 2 days and drowsiness since morning.
  2. 2. • • • • • • • O/E BP = 110/70 mm Hg Pulse= 112/min Temp= 103F CNS : Neck stiffness +ve SOMI +ve GCS 11/ 15 Plantars downgoing
  3. 3. CSF • • • • • Colour Appearance Proteins Glucose Cells whitish turbid 213 mg/dl 36 mg/dl 1056/cmm N = 97% L = 3%
  4. 4. • What is your diagnosis? • How will you manage? • What can be the complications in this case?
  5. 5. • A 23 yrs old lady is brought to ED with c/o sudden unconsciousness. • h/o low grade fever and mild headache for last 1 day. No history of vomiting or fits.
  6. 6. O/E • A young lady lying unconscios • BP = 80 Systolic pulse = 90bpm • Temp = 100oF • A macular purpuric rash over legs & abdomen • CNS • GCS 7/15 Plantars upgoing • SOMI +ve fundi intact
  7. 7. CSF R.E. • Appearance • Proteins • Cells • Glucose turbid 250 mg/dl 612 /cmm N = 90 % L = 10 % 28 mg/dl
  8. 8. • What is your impression? • What other investigations will you plan? • How will you manage her?
  9. 9. • A young girl of age 14 yrs is brought to ED with c/o severe headache for 1 day, fever for 1 day and irritable behaviour for 3 hrs.
  10. 10. • What is your diagnosis? • What is its treatment?
  11. 11. • A 32 yr old gentleman is brought to ED with c/o low grade fever & easy fatiguability for 1 month, headache for 2 weeks and LOC for 1 day.
  12. 12. O/E • • • • • • • • • BP = 170/100 mmHg Pulse = 60bpm Temp = 99.5oF CNS: pupils RRR SOMI -ve plantars downgoing GCS 10/ 15 REST OF EXAM NORMAL
  13. 13. Urgent CT brain shows meningeal enhancement with mild hyrocephalus. CSF R.E shows: proteins =210mg/dl glucose =34mg/dl Cells = 230/cmm with 88% lymphos
  14. 14. • Same patient presents to ED after 1month with c/o persistant vomiting. O/E • pt is fully conscious ,oriented • Mildly jaundiced • Labs: Bilirubin = 4-5 mg/dl ALT = 60U/L • WHAT WILL YOU DO?
  15. 15. • Same patient comes to OPD after 3months with c/o vertgo and instability for 3 days. Clinically there are features of left cerebellar lesion. • What can be the cause? • What will be your management plan?
  16. 16. • What is your diagnosis? • How will you manage?
  17. 17. Tuberculomata
  18. 18. • Same patient again brought to ED in an unconscious state. O/E • VITALS stable 3/15 • GCS upgoing • Plantars early papilloedema • Fundi • CT brain Obstuctive hydrocephalus
  19. 19. what to do now?
  20. 20. • A young lady is brought to ED with c/o fever for 5 days, headache for 3 days , irrelevant talk f0r last 2 days & one episode of GTCF.
  21. 21. O/E • • • • • • A young lady talking irrelevantly Temp = 100oF CNS = Pt conscious, not oriented No SOMI No other +ve finding
  22. 22. • A Vesicular rash is seen over area of RHC
  23. 23. CSF R.E. • • • • Appearance Proteins Glucose Cells clear 60mg/dl 60mg/dl 100/cmm L = 88% N = 12%
  24. 24. • What is your diagnosis? • How will you manage?
  25. 25. • A 24 yrs old gentleman is brought to ED with c/o high grade fever associated with rigors & chills for last 2 weeks, headache for 6 days and 1 episode of GTC fits followed by drowsiness.
  26. 26. O/E • • • • • A young man lying unconscious in bed. BP = 100/60mmHg Pulse = 120bpm Temp = 102oF CNS: GCS 5/I5 Tone decreased on right right plantar upgoing fundi bilateral papilloedema
  27. 27. CT BRAIN Low density lesion in left frontoparietal region with ring enhancement
  28. 28. • What is your diagnosis? • How will you manage?
  29. 29. A young boy of age 20 is brought to OPD with c/o low grade fever for 1 month, restlessness and depressive mood for 1month and vomiting with severe frontal headache for 7 days.
  30. 30. O/E • • • • BP 120/80 mm/Hg PULSE 72bpm TEMPERATURE 102F CNS no positive finding
  31. 31. • During hospital stay, pt continued to deteriorate. Headache & fever did not settle despite good antibiotics & analgesics. • 5 days later he got rt 6th nerve palsy. • MRI brain advised.
  32. 32. • He became incontinent. • His mental state also deteriorated and he became disoriented in time, place and person. • 5 days later he got rt 6th nerve palsy. • No h/o fits • MRI brain advised.
  33. 33. MRI brain • Meningeal enhancement • Focal tuberculomas in right frontal and parietal region. • So diagnosis is TBM with tuberculomata
  34. 34. CNS INFECTIONS
  35. 35. • • • • • • Bacterial infections Viral infections Prion diseases Protozoal infections Helminthic infections Fungal infections
  36. 36. Bacterial infections • • • • • • • Meningitis Suppurative encephalitis Brain abscess Tuberculosis Neurosyphilis Diphtheria Tetanus
  37. 37. Viral infections • • • • • • • Meningitis Encephalitis Tranverse myelitis Poliomyelitis SSPE Rabies HIV infection
  38. 38. • • • • PRION DISEASES Creutzfeldt-jakob disease Kuru FUNGAL INF. Meningitis i.e Cryptococcal or Candida PROTOZOAL INF: • Malaria • Toxoplasmosis • Trypanosomiasis HELMINTHIC INF: • Cysticercosis • Hydatid disease • Schistosomiasis
  39. 39. • Acute infection of meninges • Pt presents with fever,headache, vomiting and altered mental status. • O/E there is neck stiffness & signs of meningeal irritation. • It may be bacterial, viral ,fungal, protozoal or due to non-infective causes..
  40. 40. VIRAL MENINGITIS • The most common cause of meningitis • Usually benign & self-limiting • Common viruses causing meningitis are enteroviruses, herpes simplex, EBV or varicella zoster. • Mostly occurs in children & young adults.
  41. 41. CLINICAL FEATURES • • • • • Sudden severe headache Pyrexia irritability Meningism Focal neurological signs occur rarely.
  42. 42. Bacterial Causes of Meningitis • • • • • • • • In Neonates: E-coli Proteus Group B Streptococci Listeria monocytogenes In Pre-school Child: H-Influenza N-Meningitidis Streptococcus Pneumoniae Mycobacterium Tuberculosis In Older Children and Adults: • • • • • • N-Meningitidis S Pneumoniae Listeria M tuberculosis S aureus H-Influenza
  43. 43. • Bacterial meningitis is less common but associated with significant morbidity & mortality. • Most common causes are S pneumoniae, N meningitidis and H influenzae. • Pt presents with fever, headache, dowsiness & neck stiffness. Rash may be seen in meningococcemia.
  44. 44. TBM • • • • • • • SYMPTOMS: Headache Vomiting Low-grade Fever Lassitude Depression Confusion Behaviour changes SIGNS: • Meningism ( may be absent) • Nerve palsies • Focal hemisphere signs • Papilloedema • Deterioration of conscious level
  45. 45. • It presents with acute onset of headache, fever, focal neurological signs and seizures. • There may be drowsiness or coma. • Meningism occurs in many cases. • Most imp cause is Herpes simplex.
  46. 46. Bacteria may enter the brain via penetrating injury. There may be direct spread from paranasal sinuses or middle ear. There may be hematogenous spread from septicemia in which case multiple abscesses may form.
  47. 47. Clinical features • It may present acutely with fever, headache, meningism & drowsiness. • Commonly it presents over days or weeks with fever, features of raised ICP , seizures and focal signs.
  48. 48. • • • • • CT scan brain Lumbar puncture Blood cultures PCR of CSF Baseline labs
  49. 49. CSF R.E Condition Cell type Cell count Normal 0-4*106/l Lymphocyts Viral lymphocyte bacterial polymorphs TB P/L/Mixed Fungal lymphocyte malignant lymphocyte glucos protein e <60% Upto of BSR 0.45g/l 10-2000 Normal N 1000-5000 Low N/ incr. 50-5000 Low Increas ed 50-500 Low Increas 0-100 low N /incr.
  50. 50. • Viral meningitis is usually selflimiting. • Symptomatic treatment is done.
  51. 51. Treatment of pyogenic meningitis General T/M: • Bed Rest • IV Fluids • Airway Patency
  52. 52. Specific Antimicrobial T/M Antibiotic Regimen is modified according to age & suspected organism. Mainstay of T/M is IV Antibiotics.
  53. 53. T/M When Cause Of Bacterial Meningitis is Known Pathogen NMeningitidis Strep Pneumoniae Regime of choice Alternative 2.4g IV 4hourlyFor 5-7 days Ampicillin Chloramphenicol Benzyl Penicillin Cefuroxime Cefotaxime 2g IV 6hourly or Ceftriaxone 2g IV 12hourly Chloramphenicol
  54. 54. H-Influenza Cefotaxime Chloramphenicol Or Ceftriaxone Listeria Ampicillin Monocytogen 2g IV 4 hourly + es Gentamicin 5mg/kg IV daily Ampicilin + Cotrimoxazol
  55. 55. T/M of Pyogenic Meningitis of Unknown Cause  Pt. with typical Meningococcal Rash: Benzyl Penicillil 2.4g IV 6 hourly.  Adults (18-50 Yr) without typical rash: Cefotaxime 2g IV 6 hourly or Ceftriaxone 2g IV 12 hourly  Pt. with penicillin resistant Pneumococcal Infection: Vancomycin 1g IV 12 hourly or Rifampicin 600mg IV 12 hourly
  56. 56.  Pt. with suspicion of Listeria Infection: Ampicillin or Co-trimoxazole  Pt. with H/O Anaphylaxis to B-Lactams: Chloramphenicol + Vancomycin
  57. 57. T/M according to age of Pt.  Neonates and infants: Ampicillin with Cefotaxime  Older Children and Young Adults Penicillin G + Ceftriaxone  Older Pt. (>50 Yrs): Ampicillin + Ceftriaxone
  58. 58. Adjuvant Therapy 1. Mannitol: 250ml IV bolus over 10-20 minutes 2. Glucocorticoids: Dexamethasone 0.15mg/kg IV 6hourly 3. Antiepileptics: Diazepam/Phenytoin/Barbiturates
  59. 59. Prevention Of Meningococcal Infection • Oral Rifampicin 600mg 12 hourly in adults • Oral Rifampicin 5-10mg/kg 12 hourly in children • Ciprofloxacin 500mg in adults (Alternative) Vaccines: For prevention of diseases caused by Meningococci of Gp. A & C.
  60. 60. Treatment of TBM • • • • General measures ATT Steroids Surgical treatment may be required if hydrocephalus develops.
  61. 61. Viral encephalitis • Inf Acyclovir 10mg/kg body weight IV 8hrly for 2-3 weeks. • symptomatic
  62. 62. Brain abscess • Antibiotics according to site of abscess like cefuroxime & metronidazole for frontal lobe lesion • Anticonvulsants may be required • Surgical treatment
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