Acute CNS infection
• What is it?
• What causes it?
• What happens in the system?
• How to recognize it?
• How to prove it?
• How to treat it?...
Significance
• Significant morbidity & mortality in
children [1.2m cases worldwide]
• Diagnosis, challenging in young chil...
• Fever with altered sensorium
• Virus > bacteria > fungi & parasite
• Meningitis
• Meningoencephalitis
• Brain abscess
• ...
Pyogenic meningitis
Etiology
• < 2months
• Maternal flora, NICU/PNW flora;
• GBS, GDS, gram-ve, listeria, HIB,
• 2m-12m
• Pneumococci, meningo...
Reasons for infection
• Less immunity
• Contact with people with invasive disease
• Occult bacteremia [infants]
• Immunode...
Risk of infection
• Pneumococci
OM, sinusitis, pneumonia, CSF rhinorrhea.
• Meningococci
contact with adults, nasopharynge...
Pathogenesis
• Colonisation of nasopharynx
• Prior/concurrent viral URTI
• Bacteremia
• Hematogenous dissemination
• Conti...
Why few only get meningitis?
• Defective opsonic phagocytosis
– Developmental defects
– Absent preformed anticapsular anti...
Pathogenesis
• Bacteria enter through choroid plexus of LV
• Circulate to extra cerebral CSF &
subarachnoid space
• Rapidl...
Pathology
• Thick exudate covering all areas
• Ventriculitis, arteritis, thrombosis
• Vascular occlusion, sinus occlusion....
Clinical features
• Nonspecific
– Fever,anorexia,myalgia,arthralgia,headache,
– Purpura , petechiae, rash, photophobia.
• ...
ICT signs
 Headache, vomiting, drowsy, Fits
 Ptosis, squint,
 AF bulge, widened sutures
 Hypertension, bradycardia
 S...
• Focal neurological deficit
• Cranial neuropathy
– 3rd nerve
– 6th nerve
– 7th nerve
– 8th nerve
Diagnosis
• LP & CSF analysis
– Gram stain
– Culture
– Cell count
– Glucose, protein
– [Contraindications for LP]
• Blood ...
CSF analysis
• Cell count
– Normal
• NB >30/mm3
• Child >5/mm3
– Meningitis >1000/mm3
• Turbid 200-400/mm3
• Early; lympho...
CSF analysis in prior antibiotic
therapy
• Culture, gramstain altered
• Pleocytosis, protein, glucose unaltered
Traumatic LP
• Cell count, protein level altered
• Glucose, bacteriology unaltered.
Condition Pressure
mm-h2o
Cell count/mm3 Glucose
mg/dl
Protein
mg/dl
microbiology
Normal 50-80 <5,lymphocyte >50, 75% of
b...
Treatment
• Rapidly progressive [ ~24h]
LP  antibiotics
ICT , FND  CTbrain & antibiotics
Manage shock, ARDS
• Subacute c...
Supportive care
• Monitoring
– Vitals
– BUN,electrolytes,HCO3,IO, CBC,Platelets,Ca
– Periodic neurologic assessment
• PR,s...
Antibiotic therapy
• Vancomycin & cefataxime/ceftrioxone
– Pneumococci,meningococci,HIB.
• Ampicillin / cotrimaxazole I.V
...
Duration of therapy
 Pneumococci : 7-10 days
 Menigococci: 5-7 days
 HIB; 7-10 days
 E.coli,Pseudomonos ; 3 weeks
 An...
Repeat LP
• After 48h
• For ; resistant pneumococci,
gram-ve meningitis
Corticosteroids
• Rapid bacterial killing
• Cell lysis
• Release of inflammatory mediators
• Edema
• Neutrophilic infiltra...
Complications
• ICT, Herniation
• Fits, Cranial N palsy
• Dural Vein sinus thrombosis
• Subdural effusion
• SIADH
• Perica...
Prognosis
• Mortality >10% [more in pneumococci]
• Prognosis poor in
– Infants
– Fits >4days
– Coma, FND on presentation
•...
Prevention
• Meningococci
– Rifampacin for close contacts [10mg/kg/day q12h for
2days]
– Quadrivalent vaccine for high ris...
Thank you
TBM
• Subacute / ?chronic meningitis
• From lymphohematogenous dissemination
• Caseous lesion in cortex / meninges
• Disch...
• Brainstem affected
• Cranial N dysfunction
• Hydrocephalus
• Infarcts
• Cerebral edema
• SIADH
• Dyselectrolytemia
Features
• 6m-4yrs
• 3 stages
• Prodrome stage; 1-2 wks, nonspecific
symptoms, stagnant development
• Abrupt stage;letharg...
Diagnosis
• Contact with adult TB
• Mx nonreactive 50%
• CSF – lymphocytes
• Glucose <40mg/dl
• Protein high: 400-5000mg/d...
Thank you
Meningoencephalitis
• Acute inflammation of meninges & brain
tissue
• CSF – pleocytosis
• Gram stain & culture negative
• Mostly self limiting
Etiology
• Enterovirus
• Arbovirus
• Herpes virus
Pathogenesis
• Direct invasion & destruction by virus
• Host reaction to viral antigens
• Meningeal congestion
• Mononucle...
Structures affected
• HSV; temporal lobe
• Arbovirus; entire brain
• Rabies; basal parts
Clinical features
• Depends on parenchymal involvement
• Preceding mild febrile illness & exantheme
• Acute onset of high ...
DD
• Meningitis of various organisms
Diagnosis
• CSF: lymphocytic predominance
– Protein: normal,high in HSV
– Glucose: normal,low in mumps
– Culture of organi...
Treatment
• Acyclovir for HSV
• Non aspirin analgesic
• Nursing in a quiet room
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
Cns infection in chidren
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Cns infection in chidren

  1. 1. Acute CNS infection
  2. 2. • What is it? • What causes it? • What happens in the system? • How to recognize it? • How to prove it? • How to treat it? • How to prevent?
  3. 3. Significance • Significant morbidity & mortality in children [1.2m cases worldwide] • Diagnosis, challenging in young children • High incidence of sequalae
  4. 4. • Fever with altered sensorium • Virus > bacteria > fungi & parasite • Meningitis • Meningoencephalitis • Brain abscess • Common symptoms photophobia, neckpain/rigidity, fits, stupor • Diagnosis by CSF
  5. 5. Pyogenic meningitis
  6. 6. Etiology • < 2months • Maternal flora, NICU/PNW flora; • GBS, GDS, gram-ve, listeria, HIB, • 2m-12m • Pneumococci, meningococci, HIB[now less] • Pseudomonos, staph.aureus, CONS.
  7. 7. Reasons for infection • Less immunity • Contact with people with invasive disease • Occult bacteremia [infants] • Immunodeficiency • Splenic dysfunction • CSF leak , Meningomyelocele • CSF shunt infection
  8. 8. Risk of infection • Pneumococci OM, sinusitis, pneumonia, CSF rhinorrhea. • Meningococci contact with adults, nasopharyngeal carriage • HIB Contact in daycare center
  9. 9. Pathogenesis • Colonisation of nasopharynx • Prior/concurrent viral URTI • Bacteremia • Hematogenous dissemination • Contiguous spread from sinus, otitis, orbit vertebral trauma, meningocele.
  10. 10. Why few only get meningitis? • Defective opsonic phagocytosis – Developmental defects – Absent preformed anticapsular antibodies – Deficient complement/properdin system – Splenic dysfunction
  11. 11. Pathogenesis • Bacteria enter through choroid plexus of LV • Circulate to extra cerebral CSF & subarachnoid space • Rapidly multiply in CSF • Release of inflammatory mediators • Neutrophilic infiltrates • Increase vascular permeability • Altered BBB • Vascular thrombosis
  12. 12. Pathology • Thick exudate covering all areas • Ventriculitis, arteritis, thrombosis • Vascular occlusion, sinus occlusion. • Cortical necrosis, cerebral infarct • Subarachnoid hemorrhage • Hydrocephalus • ICT, inflammation of spinal nerves
  13. 13. Clinical features • Nonspecific – Fever,anorexia,myalgia,arthralgia,headache, – Purpura , petechiae, rash, photophobia. • Meningeal signs – Neck rigidity, backache. – Kernig sign – Brudzinski sign – Crossed leg sign
  14. 14. ICT signs  Headache, vomiting, drowsy, Fits  Ptosis, squint,  AF bulge, widened sutures  Hypertension, bradycardia  Stupor, coma  Abnormal posturing  Papilloedema [only in chronic ICT]
  15. 15. • Focal neurological deficit • Cranial neuropathy – 3rd nerve – 6th nerve – 7th nerve – 8th nerve
  16. 16. Diagnosis • LP & CSF analysis – Gram stain – Culture – Cell count – Glucose, protein – [Contraindications for LP] • Blood culture
  17. 17. CSF analysis • Cell count – Normal • NB >30/mm3 • Child >5/mm3 – Meningitis >1000/mm3 • Turbid 200-400/mm3 • Early; lymphocytic predominance • Later; neutrophilic predominance • low in severe sepsis
  18. 18. CSF analysis in prior antibiotic therapy • Culture, gramstain altered • Pleocytosis, protein, glucose unaltered
  19. 19. Traumatic LP • Cell count, protein level altered • Glucose, bacteriology unaltered.
  20. 20. Condition Pressure mm-h2o Cell count/mm3 Glucose mg/dl Protein mg/dl microbiology Normal 50-80 <5,lymphocyte >50, 75% of blood level 20-40mg Bacterial meningitis 100-300 100-1000, >75% neutrophils <40mg 100-500 Gram stain+ve Partially treated meningitis N / elevated 5-1000, Lymphocytes? N /decreased 100-500 Gramstain , c/s maybe -ve Antigens +ve Viral meningitis Normal Less cells, lymphocytes N, less in mumps <200 TBM More <500, lymphocytes <40 100-3000 Stain –ve Culture ± ve Fungal More 5-500 N More? Culture
  21. 21. Treatment • Rapidly progressive [ ~24h] LP  antibiotics ICT , FND  CTbrain & antibiotics Manage shock, ARDS • Subacute course [4-7d] • Assess for ICT, FND • Antibiotics  CT  LP
  22. 22. Supportive care • Monitoring – Vitals – BUN,electrolytes,HCO3,IO, CBC,Platelets,Ca – Periodic neurologic assessment • PR,sensorium,power,cranial N ex, head circ, • Supportive care – IVF  restrict for ICT,SIADH, more for shock – ICT ETI & ventilation,frusemide,mannitol – Seizures  diazepam,phenytoin
  23. 23. Antibiotic therapy • Vancomycin & cefataxime/ceftrioxone – Pneumococci,meningococci,HIB. • Ampicillin / cotrimaxazole I.V – Listeria • Ceftazidime & aminoglycoside – Immunocompromised
  24. 24. Duration of therapy  Pneumococci : 7-10 days  Menigococci: 5-7 days  HIB; 7-10 days  E.coli,Pseudomonos ; 3 weeks  Antibiotics started before LP [partially treated meningitis] ; ceftrioxone 7-10 days.
  25. 25. Repeat LP • After 48h • For ; resistant pneumococci, gram-ve meningitis
  26. 26. Corticosteroids • Rapid bacterial killing • Cell lysis • Release of inflammatory mediators • Edema • Neutrophilic infiltration • 1-2h before antibiotics • Dexamathasone q6h for 2 days. • Less fever, less deafness.
  27. 27. Complications • ICT, Herniation • Fits, Cranial N palsy • Dural Vein sinus thrombosis • Subdural effusion • SIADH • Pericarditis, Arthritis • Anemia, DIC
  28. 28. Prognosis • Mortality >10% [more in pneumococci] • Prognosis poor in – Infants – Fits >4days – Coma, FND on presentation • Neurological sequalae 20% – Behavior changes 50% – Deafness [pneumo,HIB], visual loss – MR,fits,
  29. 29. Prevention • Meningococci – Rifampacin for close contacts [10mg/kg/day q12h for 2days] – Quadrivalent vaccine for high risk children • HIB – Rifampacin for contacts for 4days – Conjugate vaccine • Pneumococci – Heptavalent conjugate vaccine
  30. 30. Thank you
  31. 31. TBM • Subacute / ?chronic meningitis • From lymphohematogenous dissemination • Caseous lesion in cortex / meninges • Discharge of TB bacilli in CSF • Thick exudate infiltrate blood vessels • Inflammation,obstruction,infarct.
  32. 32. • Brainstem affected • Cranial N dysfunction • Hydrocephalus • Infarcts • Cerebral edema • SIADH • Dyselectrolytemia
  33. 33. Features • 6m-4yrs • 3 stages • Prodrome stage; 1-2 wks, nonspecific symptoms, stagnant development • Abrupt stage;lethargy,fits,meningeal signs focal ND,cranial neuropathy,hydrocephalus. Encephalitic picture • Coma stage; posturing,hemi/paraplegia,poor vital signs
  34. 34. Diagnosis • Contact with adult TB • Mx nonreactive 50% • CSF – lymphocytes • Glucose <40mg/dl • Protein high: 400-5000mg/dl • AFB +ve 30%
  35. 35. Thank you
  36. 36. Meningoencephalitis
  37. 37. • Acute inflammation of meninges & brain tissue • CSF – pleocytosis • Gram stain & culture negative • Mostly self limiting
  38. 38. Etiology • Enterovirus • Arbovirus • Herpes virus
  39. 39. Pathogenesis • Direct invasion & destruction by virus • Host reaction to viral antigens • Meningeal congestion • Mononuclear infiltration • Neuronal disruption • Neuronophagia • Demyelination
  40. 40. Structures affected • HSV; temporal lobe • Arbovirus; entire brain • Rabies; basal parts
  41. 41. Clinical features • Depends on parenchymal involvement • Preceding mild febrile illness & exantheme • Acute onset of high fever, headache, irritability,lethargy,nausea,myalgia • Convulsions,stupor,coma • Fluctuating FND,emotional outburst • Ant.horn cell injuryflaccid paralysis [west nile,entero virus]
  42. 42. DD • Meningitis of various organisms
  43. 43. Diagnosis • CSF: lymphocytic predominance – Protein: normal,high in HSV – Glucose: normal,low in mumps – Culture of organism [entero V] – Viral antigen by PCR – Culture from NPswab,feces,urine • EEG: focal seizures [temporal];HSV • CT/MRI: swollen brain parenchyma
  44. 44. Treatment • Acyclovir for HSV • Non aspirin analgesic • Nursing in a quiet room

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