Bohomolets Neurology Infectious Dx of CNS

INFECTIOUS INFECTIOUS DISEASES OF DISEASES OF

CENTRAL NERVOUS CENTRAL NERVOUS SYSTEMSYSTEM

INFECTIOUS INFLAMMATORY DISEASES OF CENTRAL

NERVOUS SYSTEM

Subacute sclerosing

leukoencephalitis (demyelinating

leuko- and panencephalitis)

Arachnoiditis of brain

Meningitis Encephalitis

Poliomyelitis

Myelitis

MENINGITIS

CLASSIFICATION OF MENINGITIS

By etiology

Bacterial

Viral

Primary

Secondary

By pathogenesis

By the character of inflammatory process and changes in liquor

Purulent

Serous

Serous-fibrinogenous

Hemorrhagic

By clinical course

Fulminant

Acute

Chronic

Subacute

By localization of the process

Basal

Convexital

light

By degree of severity

medium

severe

extremely severe

Clinical signs of meningitis

– fever

– high body temperature

– leucocytosis in blood with shift of the formula to the left,

– erythrocyte sedimentation rate

(EST)

Syndrome of infectious disease

II

Meningeal symptoms

1. General hyperesthesia and hyperesthesia of organs of senses

2. Reactive pain phenomena: – Bechterew’s zygomatic symptom – feeling of pain when you press on eyeballs, points of outlet of branches of trigeminal, occipital nerves

3. Muscular tonic tensions:– rigidity of occipital muscles, long muscles of the back – Kernig’s symptoms, Brudzinski’s upper, media, lower symptoms

Meningeal syndromeIIII

– headache – vomiting– spasms– psychomotor excitement– impairment of consciousness

Meningeal syndrome

General brain symptoms

IIII

Purulent meningitis

Neutrophilic pleocytosis (thousands of cells per 1 mm3)

Lymphocytic pleocytosis (tens or hundreds of cells per 1 mm3)

Detection of pathogenic factor

Syndrome of inflammatory changes in liquor

Serous meningitis

IIIIII

Pathogenesis of meningitis

Ways of infection of membrane

Open craniocerebral trauma, which is combined with liquoria

Perineural or lymphogenous spread of pathogenes in case of presence of purulent infection (sinusitis, otitis etc)

Hematogenous spread from primary sources of infection

Pathogenesis

Inflammation and edema of brain membranes (and adjacent brain tissue)

Discirculation in brain and membranes vessels

Hypersecretion of liquor and delay of its resorption

High intracranial pressure and hydrocephalus

Damage of membranes and roots of cranial and spinal nerves

In the shortest term possible it’s necessary to diagnose meningococcal infection only on the basis of clinical signs: acute beginning, fever, hemorrhagic rash.

For the patient’s life hyperdiagnostics is much better than not timely diagnosis

Diagnostics

• Liquor. Moderate pleocytosis (1-5 thousand or 10-12 thousand cells per 1 mm3) with cellular-proteinous dissociation, minor decrease of glucose level. The colour of liquor is like water with milk. When pleocytosis is more than 5-6 thousand per 1 mm3 , liquor gets a yellowish shade.

• Express-diagnostics – bakterioscopy of thick drop of blood, blood smears and liquor. Colouring by gram already after 30 minutes allows to find out gram-negative diplococcuses.

• Inflammatory changes in peripheral blood.

• Clinical signs of meningitis

▪ meningococcal meningitis: cephalosporins of third generation, penicillin 300 000 units per 1 kilo of mass (18-24 mln units per 24 hours) ≈ 8 days. To cancel when cytosis is less than 100 cells, when lymphocytes are less than 75 % - Аmpicillin (200-400 mg/1 kilo of mass) - sulfonamides - dehydration

- antipyretics (pirabutol, reoperin, ibubrophen) - seduxen (in case of psychomotor excitement)

Treatment

PNEUMOCCOCAL MENINGITIS

(adults get this disease more often)

• The beginning is very acute

• Marked general-infectious symptoms.

• High temperature.

• Phenomena of meningoencephalitis are increasing very fast with involving of cranial nerves.

• Phenomena of brain tumor are increasing fast. There is often observed wedging of brain stem into great occipital foramen.

• On the third and fourth days hemorrhagic rash appears (face, mucous membrane of oral cavity).

• In liquor – sharp decrease of glucose level

• Antibiotics (penicillin, levomycetin, cephalosporins)

• Antiinflammatory drugs• Antitumor drugs

TREATMENT

STAPHYLO-, STREPTOCOCCAL

MENINGITIS

They are aggravation of primary purulent diseases (otitis, sinusitis etc.)

• Beginning is very acute

• Marked meningeal symptoms.

• High temperature up to 40 °.

• Impairment of consciousness

• Sepsis

• In liquor – neurophilic pleocytosis, sharp increase of protein.

• Intravenously high doses of penicillin, cephalosporin

Treatment

SEROUS MENINGITIS

Acute lymphocytic

choriomeningitis

Parotitic

Caused by Coxsackie

viruses

• Beginning is subacute• meningeal symptoms are not very marked

• Cranial nerves (ІІ, ІІІ, V, VIII) are involved

• Meningeal posture• Conductive disorders (paresis)• Root pains• Liquor: xanthochromic, high pressure,

moderate lymphocytic pleocytosis (200-400 in 1mm3), high level of protein, low level of glucose. In fibrinous film – microbacteria of tuberculosis

Тuberculous (basal) meningitis

• Not less than 4 antituberculous drugs

TREATMENT

ARACHNOIDITIS

These are inflammatory or reactive local or spread changes of pia matters of brain as a result of endured or subacute neuroinfections

CLASSIFICATION

OF ARACHNOIDITIS

By morphologic changes

adhesive cystic

By localization

of posterior cranial fossa

of cerebellopontine angle

cerebral spinal

convexital basal

optico-chiasmic

Clinical picture of arachnoiditis

general cerebellar impairments (due to intracranial hypertension)

focal impairments (depend on localization of the process)

- headache–vomiting, nausea–congestive disks of optic nerves or their atrophy– vertigo– epileptic attacks

Clinical peculiarities of some cerebral arachnoiditis

Convexital arachnoiditis

– jacksonian epileptic attacks

– asymmetry of reflexes,

more rarely paresis of limbs

– conductive sensory impairments

Optico-chiasmic – headaches in forehead area, eye-sockets/orbits, bridge of nose – loss of eyesight– bitemporal hemianopsia or concentric narrowing of eyesight fields – bitemporal atrophy of discs of optic nerves (more rarely congestive)

– anosmia

– sleep disorders, changes of carbohydrate-salt metabolism

Of posterior cranial fossa

– general cranial symptoms prevail

– pains in back of the head

– vomiting

– vertigo

– anosmia

– congestive disks of optic nerves

Of cerebellopontine angle

– Tinnitus (ear noise)

– loss of hearing

– unsteadiness, vertigo

– paresis of mimic muscles

– trigeminal neuralgia

– slight pyramidal lesions

Craniography pneumoencelography investigation of eye-ground Perimetry CT, MRI of brain electroencephalography echoelectroencephalography

METHODS OF INVESTIGATION

Conservative: antiinflammatory dehydration resolving drugs Symptomatic treatment

Surgical: - operation in case of cystic and adhesive arachnoiditis

TREATMENT

ENCEPHALITIS

Encephalitis is an inflammation of brain parenchyma. Not only infectious, but also infectious-allergic and toxic diseases are considered to be encephalitis. That is why not only inflammation and swelling, but also hemorrhages, necrosis, demyelinization and degeneration are typical for pathomorphologic changes.

By clinical course

Progressive-remitting

acute

chronic

subacute

By clinical picture

−Standard forms

− asymptomatic

− abortive

− fulminant

Primary

With unknown virus (lethargic)

arboviral (tick-borne/vernal, mosquito)

еnterovirus, in case of hydrophobia

necrotic (herpetic, cytomegalovirus)

Secondary

• parainfectious (in case of measles, rubella, epimic parotitis, chicken pox, flu)

• postvaccinal, serum

• caused by microbes, rickettsia, toxoplasma

If neurologic focal signs are absent, and general cerebral, asthenic or vegetative-distonic (after infectious disease) symptoms prevail in neorologic status – infectious encephalopathy, caused by discirculatory-dystrophic changes

General cerebral:Headache, vomiting, spasms, psychomotor disorders, impairment of consciousness

General infectious:High temperature, inflammatory changes inj blood, catarrhal phenomena of upper respiratory tracts and gastrointestinal tract,

focal:(depend on localization of the process)

Clinical manifestations of encephalitis

Chronic stage:Parkinsonian syndrome

Acute stage:High body temperature, pathologic sleepiness, oculomotor disorders, vegetative, vestibular, psychic impairments

Epidemic encephalitis

Stage of recoveringStage of reconalescence Period of residual effects (permanent atrophic paresises, Kojewnikoff’s epilepsy)

Acute stage• The first period of fever: weakness, headache, pain in muscles, meningeal syndrome; • the second period of fever: peripheral paresises of muscles of arms and neck, bulbar syndrome

Tick-borne(vernal) encephalitis

Ethiology. HSV of 1 and 2 type

Pathogenesis. Central nervous system gets infected by virus through olfactory bulbs or ganglions of trigeminal nerve. Virus spreads hematogenicly or by perineural areas. Provocateurs of virus manifestation are: intercurrent diseases, prscription of cytostatics, HIV infection etc. It gets to central nervous sytem hematogenicly if hemaencephalitic barrier (HEB) is impaired (by perineural fissures– herpes zoster)

Herpetic encephalitis

Herpetic encephalitis

Pathomorphology- is characterized by hemorrhagic changes in nerval tissue with appearance of focuses of distruction, with further developing of cysts, mainly in grey sunstance (frontal, temporal, parietal lobes)

Clinical picture of herpetic encephalitis

1. Early stage of clinical course

Meningeal type – in 50 %• fever• general infectious effects• severe headache • impairment of consciousness

Cortical type –in 20% of cases• non adequate behaviour• disorientation • elements of amnesia In 5-7 days - fever

Clinical picture of herpetic encephalitis

1.Early stage of clinical course

Stroke-like type – in 10% of cases• sudden generalized spasms • loss of consciousness (up to coma)

• fever

Brainstem type – in 5% cases

• diplopia• disarthria• dysphonia

• alternating hemiaparesis

Clinical picture of herpetic encephalitis

• general cranial and liquor-hypetensive symptoms

• lesion of cranial nerves

• paresis of limbs

• huperkinesias, episyndrome

• severe impairments of higher cortical functions (aphasia, apraxia, hallucinations, loss of intellect, bulbar syndrome)

CT of brain – signs of swelling MRI of brain – signs of swelling+ nidi of

hyperintensive signal Electroencephalography (EEG) –

increase of vascular readinessEye ground – swelling of DON; in 1,5-2

months. Atrophy

DIAGNOSTICS OF HSV

Resuscitation department (in acute stage)

antiviral immunoglobulins dehydration, desensitization resolving

TREATMENT

This is toxico-infectious lesion of nervous sytem, which is developping on peack of the flu

Grippal enecephalitis (secondary)

pathomorphology- ▪ swelling of brain▪ small hemorrhages, diapedic hemorrhages ▪ perivascular infiltrations

Grippal encephalitis (secondary)

Clinical picture– marked general cerebellar symptoms– meningeal symptom with domination of rigidity of occipital muscles– cerebral symptoms: aphasia. Oculomotor impairments, lesion of VІІ, ІІІ, ІХ-ХІІ pairs of cranial nerves, pyramidal insufficiency– changes in eye ground: congestion, sometimes neuritis, loss of acuty of eye-sight– Liquor: bloody, xanthochromic, transparent

Grippal encephalitis (secondary

Treatment– bed rest– calcium drugs– antihistaminic– antiviral– desintoxicating

In case of absence of focal sisns, but with presence of asthenic, cephalgic, general cerebellar and hypertensive syndromes, grippal encephalopathy is diagnosed