Pathology of Meningitis & CNS infections.

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Pathology of Meningitis, CNS infections, increased cerebral pressure, brain herniations etc. for pre clinical medical students.

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Pathology of Meningitis & CNS infections.

  1. 1. Applied Faith with PMA (Positive Mental Attitude) Faith is state of mind through which your aims, desires, plans and purposes may be translated into their physical or financial equivalent. But Faith without work is dead so BIBLE says.. You should not simply have faith, you must add to your faith hard and consistent work.
  2. 2. Scenario: Meningitis <ul><li>ABC breathing spontaneously rr 18/min 4l O2 via mask, sats 90%; pulse 110 bpm reg small volume; BP 90/60 mmHg T39.6C </li></ul><ul><li>GCS - E2V3M4 </li></ul><ul><li>Detailed check - petechiae non blanching rash trunk, buttocks, Neck stiffness </li></ul><ul><li>Small contusion L temperoparietal area </li></ul><ul><li>Capillary refill time > 3 secs, peripheral cyanosis+ </li></ul><ul><li>Brudzinski sign positive </li></ul><ul><li>Ix skin scraping from lesion : gram negative diplococci ; CSF gram negative diplococci; FBC wcc 18 (polymorhic leucocytosis ) </li></ul>
  3. 3. Neck Stiffness: * Pathogenesis: Meningeal irritation.
  4. 4. Brudzinski Sign of Meningitis: * Pathogenesis: Meningeal irritation.
  5. 5. Kernig’s Sign of Meningitis: * Pathogenesis: Meningeal irritation.
  6. 6. Pathology of Meningitis Dr. Venaktesh M. Shashidhar Associate Professor & Head of Pathology
  7. 7. Case: <ul><li>38 Year Fijian male </li></ul><ul><li>Headache, Photophobia since 2 months. </li></ul><ul><li>Past history of diabetes – irregular treatment. </li></ul><ul><li>3 days back, drowsy, seizure, vomiting. </li></ul><ul><li>On examination: Bil. Papillary edema </li></ul><ul><li>Responded to Mannitol + steroids </li></ul><ul><li>Died 3 rd day in hospital - respiratory arrest.. </li></ul>
  8. 8. Meningitis: <ul><li>Inflammation of Meninges. </li></ul><ul><li>Leptomeningitis – Subarachnoid & Pia. </li></ul><ul><li>Pachymeningitis – Dura (Local trauma) </li></ul><ul><li>Meningoencephalitis – + Brain. </li></ul><ul><li>Aetiologic Types: </li></ul><ul><ul><li>Infective – Septic & Aseptic (B, V, F & TB) </li></ul></ul><ul><ul><li>Chemical – Drugs. </li></ul></ul><ul><ul><li>Carcinomatous – metastasis. </li></ul></ul>
  9. 9. Septic Meningitis: common causes S. pneumoniae , N. meningitidis , Mycobacteria, Cryptococci Adults N. meningitidis , S. pneumoniae Children Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae Infants Group B Streptococci, Escherichia coli , Listeria monocytogenes Neonates Causes Age
  10. 10. Septic Meningitis
  11. 11. Septic Meningitis
  12. 12. Septic Meningitis
  13. 13. Septic Meningitis
  14. 14. Septic Meningitis
  15. 15. Septic Meningitis
  16. 16. Pneumococcal Meningitis: Retraction of dura reveals leptomeninges which are edematous and have multiple small hemorrhagic foci (red) note greenish pus covering brain.
  17. 17. Septic Meningitis
  18. 18. Septic Meningitis-Microscopy
  19. 19. Septic Meningitis-Spinal fluid
  20. 20. Septic Meningitis-Spinal fluid
  21. 21. Viral Meningitis: Perivascular cuffs of lymphocytes and Microglial nodules
  22. 22. HIV Meningoencephalitis: Perivascular Lymphocytes Microglial nodule and multinucleated giant cells
  23. 23. HIV Encephalitis: Perivascular lymphocytic cuff, Microglial nodule & Giant Cells.
  24. 24. Herpes Encephalitis: Destruction of inferior frontal and anterior temporal lobes – necrotizing inflammation
  25. 25. Septic Meningitis - Organisms Organism causing meningitis vary with the age of the patient
  26. 26. Meningitis: <ul><li>Clinical Features: </li></ul><ul><ul><li>Headache + Neck stiffness. </li></ul></ul><ul><ul><li>Neurological deficits. </li></ul></ul><ul><li>Complications: </li></ul><ul><ul><li>Acute : Encephalitis, Cerebral infarction, Edema, herniation. </li></ul></ul><ul><ul><li>Late: Abscess, subdural empyema, epilepsy. </li></ul></ul><ul><ul><li>Leptomeningeal fibrosis and consequent hydrocephalus </li></ul></ul>
  27. 27. Brain Abscess: Cerebral abscess. Ring enhancement of developing pseudocapsules, budding of ‘daughter’ lesions, and marked hypodensity of adjacent white matter reflecting severe edema are all characteristic of cerebral abscesses on CT or MR study.
  28. 28. Brain Abscess:
  29. 29. Brain Abscess: CT Scan Ring enhancement. Surrounding area of inflammation & edema
  30. 30. Hydrocephalus:
  31. 31. Infarction Meningoencephalitis: Mucormycosis in a Diabetic.
  32. 32. CSF-Examination Norm Septic Viral TB Opalescent (cob-web) Low High > lymph Clear normal High > Lymph Turbid Low High > Poly Clear colorless 2.7-4.0 (n) 0.1-0.4(n) 0-4 lympho Appearance Glucose Protein Cells
  33. 33. <ul><li>What is a Problem? </li></ul><ul><li>Gap between where you are now and where you want to be. (Hayes 1989) </li></ul><ul><li>How do you solve Problem? </li></ul><ul><li>Mental activity leading from where you are to a more desired ‘goal state’ (Kurfiss 1988) </li></ul>
  34. 34. Clinical details: <ul><li>38 Year Fijian male </li></ul><ul><li>Headache, Photophobia since 2 months. </li></ul><ul><li>Past history of diabetes – irregular treatment. </li></ul><ul><li>3 days back, drowsy, seizure, vomiting. </li></ul><ul><li>On examination: Bil. Papillary edema </li></ul><ul><li>Responded to Mannitol + steroids </li></ul><ul><li>Died 3 rd day in hospital - respiratory arrest </li></ul><ul><li>Brain sections after limited autopsy. </li></ul>
  35. 35. Autopsy <ul><li>Marked inflammtory infiltrate in meninges </li></ul><ul><li>Superficial Cerebral edema (cortex) </li></ul>
  36. 36. Meningitis - Cryptococci <ul><li>Round capsulated fungal organisms </li></ul><ul><li>Lymphocytic infiltrate around </li></ul>
  37. 37. Cryptococcal Encephalitis: Tiny refractile yeasts
  38. 38. Cryptococcal Meningitis: Special stains for cryptococci: PAS; Silver stain India Ink: Double refractile spherules with clear halo
  39. 39. Cryptococcal Meningitis: <ul><li>chronic basal leptomeningitis. </li></ul><ul><li>Opaque thick fibrotic </li></ul><ul><li>CSF obstruction - hydrocephalus. </li></ul><ul><li>Gelatinous material within the subarachnoid space and small cysts within the parenchyma (&quot;soap bubbles&quot;) </li></ul><ul><li>Specially in the basal ganglia. </li></ul>
  40. 40. Cryptococcal meningoencephalitis:
  41. 41. Cryptococcal meningoencephalitis:
  42. 42. Summary: <ul><li>Leptomeningitis, Pachymeningitis. </li></ul><ul><li>Head ache, Neck stiff ness. </li></ul><ul><li>Common causes, organisms. </li></ul><ul><li>Septic, Viral & TB – CSF findings. </li></ul><ul><li>Infective, Chemical Carcinomatous </li></ul><ul><li>Complications – Acute / Chronic </li></ul><ul><li>Edema, herniation, infarction, abscess, hydrocephalus. </li></ul>
  43. 43. Kernictirus:
  44. 44. Kernictirus:
  45. 45. Formerly, when religion was strong and science weak, men mistook magic for medicine. Now when science is strong and religion weak, men mistake medicine for magic…!
  46. 46. CPC-3.7– CNS –Tumors/men. <ul><li>Pathology - Core Learning Issues: </li></ul><ul><ul><li>Pathology of common Primary and secondary CNS tumours in different age groups. </li></ul></ul><ul><ul><li>Over view of epilepsy – include rare causes like neurofibromatosis, sturge weber, tuberous sclerosis - x . </li></ul></ul><ul><ul><li>Genetic basis for idiopathic epilepsy - x </li></ul></ul><ul><ul><li>Increased intracranial pressure – Pathogenesis & pathology. </li></ul></ul><ul><ul><li>Meningitis – Overview, common types & Pathology. </li></ul></ul><ul><li>Basic science - Core Learning Issues: </li></ul><ul><ul><li>Causes ‘break through’ seizures in patients with epilepsy </li></ul></ul><ul><ul><li>Mechanism of action for seizures caused by drug/alcohol withdrawal </li></ul></ul><ul><ul><li>Mechanism of action for seizures caused by drug overdose (cocaine, amphetamine, tricyclic antidepressants) </li></ul></ul><ul><ul><li>Mechanism of action for seizures caused by metabolic disturbance : hypoglycaemia; hypo + hyper natraemia; hypo- and hypercalcaemia; uraemia </li></ul></ul>
  47. 47. 28y M, Fever, meningitis ? type <ul><li>Viral </li></ul><ul><li>Fungal </li></ul><ul><li>Bacterial </li></ul><ul><li>Carcinomatous </li></ul><ul><li>Pick’s disease </li></ul>
  48. 48. 28y M, Fever, meningitis ? type <ul><li>Viral </li></ul><ul><li>Fungal </li></ul><ul><li>Bacterial </li></ul><ul><li>Carcinomatous </li></ul><ul><li>Pick’s disease </li></ul>
  49. 49. 60 Year rapid dementia… <ul><li>A 66-year-old woman vocalist complains of difficulty remembering her favorite songs. This problem continues to worsen over the next several months, and the patient becomes increasingly withdrawn from her family. When examined, she evidences dementia and gait disturbance. MRI demonstrates mild cerebral atrophy. Analysis of CSF shows no inflammatory cells and normal levels of glucose and protein. An EEG reveals periodic spike-wave complexes. One month later, the patient is bedridden and nonresponsive. A brain biopsy is performed and the results are shown. </li></ul>
  50. 50. 66y Woman rapid dementia… ? diagnosis <ul><li>Primary Amyloidosis. </li></ul><ul><li>Alzheimers disease. </li></ul><ul><li>Creutzfeldt-Jakob disease </li></ul><ul><li>Multi-infarct dementia </li></ul><ul><li>Pick’s disease </li></ul>
  51. 51. 28y M, Fever, meningitis CSF ? type <ul><li>Viral </li></ul><ul><li>Fungal </li></ul><ul><li>Bacterial </li></ul><ul><li>Carcinomatous </li></ul><ul><li>Pick’s disease </li></ul>Cells - Lymphocytosis Glucose – Normal Protein – High Appearance - Clear
  52. 52. 28y M, Fever, meningitis CSF ?type <ul><li>Viral </li></ul><ul><li>Fungal </li></ul><ul><li>Bacterial </li></ul><ul><li>Carcinomatous </li></ul><ul><li>Pick’s disease </li></ul>Cells - Neutrophils Glucose – Low Protein – High Appearance - Turbid
  53. 53. Normal Intracranial pressure (mmH2O) ? <ul><li>0-10 </li></ul><ul><li>< 200 </li></ul><ul><li>200-400 </li></ul><ul><li>< 500 </li></ul><ul><li>>500 </li></ul>
  54. 54. Raised Intracranial Pr. ?Early Symp. <ul><li>Tachycardia </li></ul><ul><li>Bradycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Shock </li></ul><ul><li>Diplopia </li></ul>
  55. 55. Case-1 <ul><li>An 80-year-old man was admitted to the hospital unresponsive and febrile. Several years earlier, he had been diagnosed as having an “organic brain syndrome” and he had also sustained a subdural hematoma. The past several days, family members noted that he was becoming increasingly lethargic and did not eat or drink. On admission, the patient had purulent material in the pharynx. His neck was stiff. There was a pleural rub on the left. Brain MRI showed mild dilatation of the ventricles. A CSF was cloudy with 300 WBC (96% polys, 4% lymphocytes). Protein was 1080 mg/dl and glucose was 2 mg/dl. Gram stains revealed gram-positive diplococci. Blood cultures grew pneumococcus. Treatment with ampicillin and gentamicin was started. The patient remained unresponsive and had a cardiorespiratory arrest one day after admission. </li></ul>
  56. 56. Case-3: What is the most likely organism? <ul><li>Bacterial meningitis </li></ul><ul><li>Candida albicans </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>CMV encephalitis </li></ul><ul><li>Neonatal HSV encephalitis. </li></ul>1 2 3 4 5
  57. 57. Case-2 <ul><li>A 56-year-old woman was admitted to the hospital with fever, aching, dizziness and disorientation. She was an insulin dependent diabetic and had a history of hypertension. One month earlier, she had the left adrenal gland removed for an adenoma that had caused Cushing’s syndrome. She was receiving replacement corticosteroids. Mental status deteriorated and she became comatose and had intractable seizures. CSF, on admission, had 17 cells, all lymphocytes, protein 53 mg/dl and glucose 77 mg/dl. CSF cultures were negative. Urine cultures grew Candida albicans. Blood cultures were negative. Initially, brain MRI was normal. Later, it revealed diffuse encephalomalacia. </li></ul>
  58. 58. Case-3: What is the most likely organism? <ul><li>Bacterial meningitis </li></ul><ul><li>Candida albicans </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>CMV encephalitis </li></ul><ul><li>Neonatal HSV encephalitis. </li></ul>1 2 3 4 5
  59. 59. Case-3 <ul><li>29-year-old truck driver was investigated for persistent malaise, cough and diarrhea. Chest x-rays revealed pneumonia with pleural effusion. Fiberoptic bronchoscopy with lung biopsy revealed pneumocystis. He also had diarrhea due to cryptosporidiosis. Helper T-cells were diminished to undetectable levels. He was discharged on Bactrim, Flagyl and antibiotics. Six weeks later, he developed headache, obtundation and seizures. CSF had 11 WBC’s, all lymphocytes, protein 137 mg/dl and glucose 26 mg/dl. Cryptococcal antigen was positive. </li></ul>
  60. 60. Case-3: What is the most likely organism? <ul><li>Bacterial meningitis </li></ul><ul><li>Candida albicans </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>CMV encephalitis </li></ul><ul><li>Neonatal HSV encephalitis. </li></ul>1 2 3 4 5
  61. 61. Case-4 <ul><li>A 56-year-old woman was admitted to the hospital with fever, aching, dizziness and disorientation. She was an insulin dependent diabetic and had a history of hypertension. One month earlier, she had the left adrenal gland removed for an adenoma that had caused Cushing’s syndrome. She was receiving replacement corticosteroids. Mental status deteriorated and she became comatose and had intractable seizures. CSF, on admission, had 17 cells, all lymphocytes, protein 53 mg/dl and glucose 77 mg/dl. CSF cultures were negative. Urine cultures grew Candida albicans. Blood cultures were negative. Initially, brain MRI was normal. Later, it revealed diffuse encephalomalacia. </li></ul>
  62. 62. Case-4: What is the most likely organism? <ul><li>Bacterial meningitis </li></ul><ul><li>Candida albicans </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>CMV encephalitis </li></ul><ul><li>Neonatal HSV encephalitis. </li></ul>1 2 3 4 5
  63. 63. Case-5 <ul><li>A 56-year-old woman was admitted to the hospital with fever, aching, dizziness and disorientation. She was an insulin dependent diabetic and had a history of hypertension. One month earlier, she had the left adrenal gland removed for an adenoma that had caused Cushing’s syndrome. She was receiving replacement corticosteroids. Mental status deteriorated and she became comatose and had intractable seizures. CSF, on admission, had 17 cells, all lymphocytes, protein 53 mg/dl and glucose 77 mg/dl. CSF cultures were negative. Urine cultures grew Candida albicans. Blood cultures were negative. Initially, brain MRI was normal. Later, it revealed diffuse encephalomalacia. </li></ul>
  64. 64. Case-5: What is the most likely organism? <ul><li>Bacterial meningitis </li></ul><ul><li>Candida albicans </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>CMV encephalitis </li></ul><ul><li>Neonatal HSV encephalitis. </li></ul>1 2 3 4 5
  65. 65. A pleasing Personality with PMA (Positive Mental Attitude) Assembling a attractive personality is a must. Your personality is your greatest asset or greatest liability. For it embraces everything that you control, Mind body soul & spirit. Learn to be pleasant even when others are unpleasant to you. Some bring happiness where ever they go & some whenever…!
  66. 66. Pathology of: Raised Intracranial Pressure
  67. 67. Raised ICP <ul><li>Pressure of CSF within cranium. </li></ul><ul><li>Limited space - Cranial vault </li></ul><ul><li>Normal -2 to 15 mm of Hg </li></ul><ul><li>>30 mm of Hg - poor prognosis </li></ul>
  68. 68. Raised ICP: Etiology <ul><li>Cerebral Edema. </li></ul><ul><li>Cerebral venous obstruction. </li></ul><ul><li>Mass lesions - Tumors, Hematoma. </li></ul><ul><li>Obstruction to CSF. </li></ul><ul><li>Impaired absorption of CSF. </li></ul>
  69. 69. Raised ICP: Clinical Features <ul><li>Headache. </li></ul><ul><li>Impaired consciousness. </li></ul><ul><li>Papilledema. </li></ul><ul><li>Vomiting. </li></ul><ul><li>Bradycardia. </li></ul><ul><li>Arterial hypertension. </li></ul>
  70. 70. Raised ICP: Clinical Features
  71. 71. Raised ICP: Complications <ul><li>Temporal coning. </li></ul><ul><li>Tonsillar coning. </li></ul><ul><li>Duret hemorrhages. </li></ul><ul><li>3rd/6th nerve lesion - Uni/bilat. </li></ul><ul><li>Ipsilateral Hemiparesis (UMN) </li></ul><ul><li>Bilateral extensor plantar responses </li></ul>
  72. 72. Brain Herniation in Raised ICP: <ul><li>Subfalcine – Cingulate gyrus below falx cerebri. </li></ul><ul><li>Uncal herniation tentorial hiatus. </li></ul><ul><li>Caudal dispacement of brain stem . </li></ul><ul><li>Tonsillar herniation through foramen magnum. </li></ul>
  73. 73. Uncal herniation:
  74. 74. Raised ICP: Complications <ul><li>Temporal coning. </li></ul><ul><li>Tonsillar coning. </li></ul><ul><li>Duret hemorrhages. </li></ul><ul><li>3rd/6th nerve lesion - Uni/bilat. </li></ul><ul><li>Ipsilateral Hemiparesis (UMN) </li></ul><ul><li>Bilateral extensor plantar responses </li></ul>
  75. 75. Tonsillar or Cerebellar coning:
  76. 76. Temporal / uncal coning: (CN3)
  77. 77. Temporal / uncal coning: (CN3/6)
  78. 78. Duret Hemorrhages: (Tonsillar Coning)

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