CNS$INFECTION$ − Encephalopathy))

Department)of)Neuroscience)&)Behavioral)Medicine) ! Diffuse$brain$problem$
Encarnita)Raya;Ampil,)M.D.) ! Behavioral$and$personality$changes$as$initial$presentation$
First)Semester)A.Y.)15;16) " Acute$confusional$episode$
Additional)Notes)from)Untoshible)2014) " Delirium$
$ ! Alteration$of$consciousness$$
Infection$in$the$Central$Nervous$$ " ARAS$$$Cerebrum$
• Etiologic)Agents) ! Seizures$usually$generalized$$
− Bacteria$$ ! Focal$neurologic$deficits$are$usually$absent$but$when$they$
− Fungi$$ are$$present$they$are$usually$bilateral$$
! Cryptococcal$meningitis$–$very$fatal$ " Consider$brain$abscess$over$meningitis$or$encephalitis$
− Virus$$ " Encephalopathy$
− Others$ # Behavioral$ and$ personality$ changes$ +$ alteration$ of$
! Spirochetes$$ consciousness$or$generalized$seizure$or$both$→$$*$
! Rickettsia,$Mycoplasma,$Chlamydia$$ " Encephalitis$
" More$ commonly$ encountered$ in$ patients$ with$ poor$ # Fever$+$behavioral$and$personality$changes$
immune$system$ # Fever$+$alteration$of$consciousness$
! Parasite$(Helminths,$Protozoa)$$$ # Fever$+$generalized$seizures$
• Location) " MeningoTencephalitis$$
− Arranged$from$inside$to$outside$ # Meningitis$+$Encephalitis$
! Brain$Parenchyma$$ # Infection$ of$ the$ meninges$ that$ are$ located$ near$ the$
" Encephalitis$–$diffuse,$affects$entire$brain$ cerebral$hemisphere$$
" Abscess$–$focal$ − Increased)Intracranial)Pressure)))
! Subarachnoid$Space$$ ! Headache$/$Vomiting$with$$
" Meningitis$ –$ diffuse,$ affects$ leptomeninges$ " Papilledema$–$blurred$margins$of$optic$fundus$
(pia+arachnoid)$ " Diplopia$with$internal$squint$$
! Subdural$Space$$ # Lateral$rectus$palsy$2°$to$$abducens$nerve$lesion$
" Between$arachnoid$and$dura$ # Abducens$Nerve$Palsy$without$headache$or$vomiting$
" Subdural$empyema$$ tells$you$that$there$is$a$lesion$in$the$pons$
! Epidural$Space$$ > CN$1,$2$=$Cerebral$$
" Between$dura$and$skull$ > CN$3,$4$=$Midbrain$
" Epidural$abscess$$ > CN$5,$6,$7,$8$=$Pons$
! Venous$Sinuses$ > CN$9,$10,$11,$12$=$Medulla$$
" Drainage$of$the$brain$parenchyma$$ # Abducens$nerve$has$a$very$long$course$
" Formed$by$the$outer$dura$and$the$inner$dura$$ # Findings$are$usually$bilateral,$sometimes$unilateral$
" Lined$by$the$ependymal$cells$$ " Deterioration$in$the$level$of$consciousness$$
" Arachnoid$ villi$ and$ arachnoid$ membrane$ projects$ into$ " Bulging$fontanel,$separation$of$sutures,$rapid$enlarging$
venous$$sinuses$(drainage)$$ head$$size$$
" Venous$sinus$thrombophlebitis$ $
# Cavernous$sinus$–$more$anterior$ MENINGITIS$
# Transverse$sinus$–$more$posterior$ • General$Clinical$Presentation$
• Routes)of)Infection) − FEVER$+$Meningeal$irritation$$
" Emissary$veins$$ − FEVER$+$Encephalopathy$$
# Found$inferior$to$cranial$bones$$ − FEVER$+$↑ICP$$
# May$spread$infection$(sinusitis$/$mastoiditis)$ • According$To$Duration$Of$Symptoms$And$Pathogens$$
# Retrograde$spread$ − Acute$
− Hematogenous$–$major$route$ ! Virus$
" Nasopharynx$(m/c)$ ! Bacteria$
" Upper$respiratory,$lungs$(m/c)$ − Subacute$&$Chronic$
! Less$commonly$ ! Mycobacterial:$Tuberculosis$
" GIT$ ! Fungal:$Cryptococcal$neoformans$
" Skin$ ! PartiallyTtreated$Acute$bacterial$meningitis$
− Direct$spread$from$contiguous$structure$ • CSF$Analysis$
! Otitis$ − Procedure$ of$ choice$ in$ the$ diagnosis$ of$ meningitis$ of$ any$
! Mastoiditis$(mastoid$bone)$ etiology$$
! Sinusitis$ − Obtain$CSF$from$lumbar$puncture$
! Dental$caries$(abscess$formation)$ Normal$CSF$Findings$ Abnormal$
− Direct$implantation$of$pathogenic$organism$ Opening$ <200$mmH2O$ %$
! Trauma$ Pressure$ (Be$suspicious$already$at$180)$ $
! Neurosurgical$procedure$(iatrogenic)$ Gross$ Clear,$colorless$ cloudy$
! Congenital$defect$$$ Appearance$ (Like$water)$ $
• Presentation) Total$ Cell$ 0T5$lymphocytes$or$monocytes$ %$
− Meningeal$Irritation$ Count$ (WBC$is$increased$in$infection)$
! Subarachnoid$ Space$ T$ most$ common$ Protein$ 15T45%$MG%$ %$
location$of$the$pathology$ Sugar$ 45T75%$MG%$
! Triad$ >50%$of$RBS$ &$
" Headache$/$Vomiting$$ (Compare$ CSF$ Sugar$ to$ peripheral$
" Nuchal$rigidity$(stiffness)$ Random$Blood$Sugar$[N:$50T60%])$
# Passive$flexion$of$the$neck$causes$pain$and$resistance$$ (Divide$CSF$sugar$to$Peripheral$RBS)$
" (+)$Brudzinski$/$(+)$Kernig$ $
$ Viral$ Bacterial$ TB$ Fungal$ $
Opening$ N$/$%$ %$ %$ %$ $
pressure$ • Identification$of$Causative$MicroTOrganism$$
Appearance$ Clear$ Cloudy$ Cloudy$ Cloudy$ − Gram$stain$$
Cloudy$ Purulent$ − Culture$bacteria$$
WBC$ %$ %$ %$ %$ − Bacterial$antigen$$
Lympho$ PMN$ Lympho$ Lympho$ − AFB$stain$$
Protein$ N$/$%$ %$ %$ %$ − TB$Bactec$$
Sugar$ N$ &$ &$ &$ − TB$Culture$$
Tests$ Viral$assay$ Gram$stain$ AFB$ India$Ink$ − India$ink$stain$$
Culture$ Culture$ TB$Bactec$ CALAS$ − Culture$or$Sabouraud’s$medium$$
Culture$ Culture$ − Latex$ particle$ agglutination$ test$ for$ Cryptococcal$ $antigen$
Saboraud’s$ (CALAS)$$
− Acute$Bac.$Meningitis$–$increase$PMN$(early),$Lympho$(late)$ − Polymerase$Chain$Reaction$(PCR)$$
− Hypoglycorrhachia$=$Pleocytosis$(elev$lympho)$+$Low$Sugar$
$
Bacterial$Meningitis$

• Pathophysiology$(Increased$ICP$and$Hydrocephalus)$ proinflammatory$cytokines$(TNF$and$ILT1)$that$disrupt$the$
− Despite$ the$ availability$ of$ effective$ antimicrobial$ therapy,$ BBB$and$allow$the$passage$of$WBC$and$protein.$
bacterial$ meningitis$ continues$ to$ be$ a$ potentially$ fatal$ − Factors$contributing$to$Intracranial$Pressure$$
illness.$ Initiation$ of$ bacterial$ meningitis$ usually$ depends$ on$ ! Free$volume$of$the$brain$parenchyma$$
host$ acquisition$ of$ a$ new$ organism$ by$ colonization$ of$ the$ ! CSF$volume$
nasopharynx$ of$ bacteria$ into$ the$ bloodstream$ (bacteremia)$ ! Blood$volume$$
and$,$respiratory$tract,$skin,$etc.$local$invasion.$Once$bacteria$ • Pathologic$Changes$
gain$access$to$the$intracvascular$space,$they$must$overcome$ − Acute)Meningitis)
additional$ host$ defense$ mechanisms$ to$ survive.$ Once$ ! Pure$pia$arachnoiditis$(Leptomeningitis)$$
meningeal$ pathogens$ penetrate$ into$ the$ SAS,$ host$ defense$ ! Subpial$encephalopathy$$
mechanisms$are$inadequate.$$$ ! Inflammatory$or$vascular$involvement$of$cranial$nerves$$
− Bacterial$meningitis,$like$any$other$disease$states,$increases$ ! Thrombosis$of$meningeal$veins$
the$permeability$of$the$BBB,$leading$to$vasogenic)edema.$$ " venous$drainage$is$$impaired$$$hemorrhage$$$stroke$
− Cytotoxic)cellular)edema$occurs$secondary$to$swelling$of$the$ ! Ependymitis,$choroids$plexitis$$
cellular$elements$of$the$brain$most$likely$as$a$consequence$ " Inc$CSF$production$=$Inc$$ICP$
of$ the$ release$ of$ toxic$ factors$ from$ neutrophils$ and/or$ ! Cerebellar$or$cerebral$hemisphere$herniation$$
bacteria.$$(dysfunctional$cell$mechanism)$ " d/t$inc$ICP$$
− Interstitial) edema$ occurs$ secondary$ to$ obstruction$ of$ CSF$ − Subacute)and)Chronic)Meningitis)
flow$from$SAS$to$blood,$as$in$hydrocephalus.$$ # Pathology$is$the$subarachnoid$space$&$the$ventricles$
− The$ most$ common$ pathogens$ responsible$ for$ bacterial$ # Subacute$TB/Fungal$Meningitis$
meningitis$colonize$the$nasopharynx.$$ > inflammatory$exudates$worse$at$base$of$the$brain$
! From$ the$ nasopharynx,$ by$ hematogenous$ route,$ the$ ! Hydrocephalus$$
organism$ will$ go$ via$ the$ choroid$ plexus/capillaries$ to$ the$ " Cloudy$ fluid,$ increase$ of$ cells$ instead$ of$ clear$ and$
brain$parenchyma$and$then$to$the$meninges.$$ colorless$ water$ caused$ blockage$ of$ flow$ and$
! They$will$proliferate/reproduce$in$the$subarachnoid$space.$ accumulation$of$flow$proximal$to$the$blockage$
− Antibiotics$ lyse$ the$ bacterial$ cell$ wall$ and$ it’s$ components$ ! Subdural$effusion$
will$be$present$in$the$subarachnoid$space.$$ " Common$in$children,$acts$like$$brainstem$tumor$$
! Bacterial$ components$ that$ will$ stimulate$ the$ ! Venous$or$arterial$infarction$$
 " Behaves$ clinically$ like$ $stroke,$ sudden$ onset$ of$ focal$ − Pneumococcal$Meningitis$
deficits$$ ! Often$preceded$by$infection$in$the$lungs,$ears,$sinuses$or$
" Inflammatory$Arteritis$ $heart$valves$$
# Inflammatory$ changes$ in$ meningitis$ that$ affect$ the$ ! Alcoholics,$ splenectomised$ patients,$ elderly,$ sickle$ cell$
arteries$ $anemia,$and$basilar$skull$fracture$
# Obstruction$of$the$arteries$mimics$stroke$clinically$ " Splenectomised$ patients$ should$ receive$ pneumococcal$
" Cranial$ nerves$ in$ the$ subarachnoid$ space$ are$ irritated$ vaccines$ because$ they$ are$ very$ susceptible$ to$ have$
and$become$compressed$ pneumococcal$meningitis$$
# Anatomically,$ the$ base$ of$ the$ brain$ is$ related$ to$ the$ ! Cranial$nerve$abnormalities$$
CNs$and$the$artery$that$forms$the$Circle$of$Willis.$ " Invasion$of$the$nerve$by$purulent$exudate$$
# CNs$ that$ pass$ through$ the$ subarachnoid$ space$ and$ " Ischemic$ damage$ as$ nerve$ traverses$ the$ subarachnoid$
when$ there$ is$ inflammatory$ exudates$ in$ the$ space$influenza$meningitis$
subarachnoid$space$$$CN$Deficits$ " Vasospastic$ innervation$ of$ CN$ $$ dysfunctional$ CN$ $$
" CN$ 8$ Deficit$ –$ m/c$ neurological$ deficit$ of$ untreated$ CN$deficits$/$weakness$
bacterial$meningitis$ − H.$Influenza$Meningitis$
− Late)Effects)or)Sequelae) ! Usually$follows$after$upper$respiratory$and$ear$infection$
! Meningeal$fibrosis$$ ! in$children$―$Seizures$are$common$
" Around$optic$nerve$$$blindness$ • Purulent$Meningitis$$
" Around$spinal$cord$&$roots$$$myelopathy,$neuropathy$ − Diagnosis:$Routine$CSF$Examination$
! Chronic$meningoencephalitis$with$hydrocephalus$$ Opening$Pressure$ %$
! Persistent$hydrocephalus$in$the$child$$ Gross$Appearance$ Cloudy,$turbid,$purulent$
• Etiology$ WBC$ %$$mostly$PMNs$(thousands)$
Neonate$ • Group$B$Streptococcus$ Protein$ %$
• Escheria)coli) Glucose$ &$(<50%$RBS)$
Children$ • Haemophilus)influenzae(***)) Tests$ for$ Precise$ Gram$Stain$
• Neisseria)meningitidis(**)$ Etiological$Determination$ Culture$and$Sensitivity$
Adults$ • Streptococcus)pneumoniae(*)$ Bacterial$Antigens$
>$50$y/o$ • Enteric$gram$negative$bacilli$ − Cranial$CT$Scan$
Neurosurg$ Patients$ • Staphylococci$ ! Not$for$diagnosis$$$view$enhancement$in$the$meninges$
(Cranial$Trauma)$ • Gram$negative$bacilli$
Immunosuppressed$ • Neutropenia$
Patients$ − Gram$negative$enteric$bacilli$
(commonly$ cancer$ − Staphylococcus)
patients$ d/t$ • Immunoglobulin$deficiency$
chemotherapy)$ − Streptococcus)pneumonia)
− Haemophilus)influenzae)
− Neisseria)meningitidis)
• TTlymphocyte$and$Macrophage$Deficits$
− Listeria)monocytogenes)
(*)$3$most$common$etiologic$organisms$
− Neonate$ $
! Transfer$of$bacteria$from$mother$to$child$during$delivery$ − Cranial$MRI$
" GBS:$found$in$the$vaginal$flora$ ! Done$to$confirm$if$the$patient$develops$complications$like$
" E.$coli:$pathogen$in$UTI$ hydrocephalus,$infarct,$edema,$inflammation$
− Neurosurgical$Patients$ ! (R)$shows$unilateral$enhancement$on$the$left$brain$
! Staphylococcus:$normal$flora$of$the$skin$$$barrier$broken$
• Clinical$Features$in$Adults$and$Children$
− Meningococcal$Meningitis$
! Seen$in$epidemics$$
! Transmissible;$colonize$the$nasopharynx$
! Only$ meningitis$ that$ requires$ the$ isolation$ of$ patient$ at$
$least$for$the$first$24$hours$without$antibiotics$given$$
! Must$be$recognized$immediately$
! Evolution$is$rapid$$
" Delirium$ and$ stupor$ may$ supervene$ in$ a$ matter$ of$
$hours$$
! Petechial$ or$ purpuric$ rash$ or$ by$ large$ ecchymoses$ and$ $
$lividity$of$the$skin$of$the$lower$parts$of$the$body$$ − Gross$photograph$of$the$base$of$the$brain$in$an$acute$case$
" Violaceous$in$nature$ of$ pneumococcal$ meningitis$ showing$ abundant$ purulent$
! Circulatory$shock$$ exudate$especially$prominent$in$the$cisterns.$
! WaterhouseTFriedrich$Syndrome$/$$ ! Exudates$gravitate$to$the$bottom$of$the$brain$
Hemorrhagic$$Adrenalitis$/$$
Fulminant$Meningococcemia$
" DIC$$
" Thrombocytopenia$$
" Septic$shock→$BP$will$go$down$$
# Meningococcal$ meningitis$ is$ the$ only$ meningitis$
wherein$ the$ BP$ can$ go$ down,$ most$ of$ the$ cases$ the$
BP$remains$normal$
$
• Pathology$ Nosocomial$$ Gram(T)$Enterobac,$$ Meropenem$+$
− Confirms$ specific$ etiological$ agent$ and$ presence$ of$ (postT$ P.$aeruginosa,$$ Vancomycin$
inflammation$ neurosurgery$or$ Staphylococcus$
posttraumatic$
brain$injury)$
Ventriculitis,$$ S.$epidermidis,$$ Meropenem$+$
Shunt$Infection$ S.$aureus,$$ Vancomycin$
Gram(T)$enterobac,$$
P.$aeruginosa$
RD TH
Immunocompro L.$monocytogenes,$$ 3 $or$4 $gen$
mised$or$older$ Gram(T)$enterobac,$$ Cephalosporin$+$
patients$ P.$aeruginosa,$$ Ampicillin$+$
(impaired$ Pneumococci$ Vancomycin$
cellular$
$ immunity)$
• Treatment$ $
− Fundamental$Principles$
− Antibiotics$ Commonly$ Used$ in$ the$ Treatment$ of$ Bacterial$
! Always$treat$medical$emergency$$
Meningitis$in$Children$and$Adults$
" Do$CSF$exam$ASAP$
Antibiotic$ Children$ Adult$
! Prompt$and$appropriate$antibiotic$therapy$$
Ampicillin) 300T400$mg/kg/d$q$4h$ 12T15$g/d$q$4T6h$
! Cerebral$metabolism$should$be$protected$$
Ceftriaxone) 80T100$mg/kg/d$q$12h$ 4$g/d$q$12h$
! Monitor$ increased$ intracranial$ pressure$ by$ clinical$ signs,$
Cefotaxime) 300$mg/kg/d$q$6h$ 12$g/d$q$4h$
including$ blood$ pressure,$ serial$ measurements$ of$ head,$
and,$if$available,$intracranial$sensors$$ Ceftazidime) 6$g/d$q$8h$ T$
! Prevention$and$control$of$seizures$$ Cefepime) T$ 4$g/d$q$12h$
! Fluid$ management$ should$ strive$ for$ normovolemia$ of$ Forfomycin) 15$g/d$q$8h$
$SIADH$and$the$hypovolemia$of$dehydration$$ Meropenem) 6$g/d$q$8h$
! Control$ of$ hyperpyrexia$ because$ the$ increases$ cerebral$ Penicillin)G) 250,000$u/kg/d$or$20T40$million$units/d$q$4T6$h$
$metabolic$demand$$ Nafcillin) 200T300$mg/kg/d$q$4h$ 9T12$g/d$
− Antibiotic$Penetration$into$CSF$from$Blood$ Rifampin) 600T1200$mg/d$q$12h$
Antibiotic$ Normal$Meninges$ Meningitis$ Gentamycin) /) 6$mg/kg/d$q$8h$
Pen)G) Poor$ FairTgood$ Tobramycin)
Ampicillin) Poor$ FairTgood$ TMP;SMX) 15T20$mg/kg/d$of$TMP$q$8h$
Nafcillin) Poor$ Fair$ Metronidazole) 1500T2000$mg$q$8h$
Ticarcillin)/)Piperacillin) Fair$ FairTgood$ Vancomycin) 60$mg/kg/d$q$6h$ 2T3$g/d$q$6T12h$
Ceftriazone) Fair$ Good$ $
Cefotaxime) Fair$ Good$ − Antibiotic$Therapy$With$Known$Bacterial$Pathogen$
Ceftazidime)) Fair$ Good$ N.$meningitidis$ Penicillin$G$or$Ampicillin$
Gentamycin) Poor$ PoorTfair$ Ceftriaxone$or$Cefotaxime$for$
Amikacin) Poor$ Poor$ penicillinT$resistant$strains$
Tetracycline) Poor$ Fair$ S.$Pneumoniae$
Doxycylline) PoorTfair$ Fair$ • penicillinT$ Penicillin$G$or$Ceftriaxone$(or$
Chloramphenicol) Good$$ Good$ susceptible$ Cefotaxime$or$Cefepime)$
Rifampicin) Fair$ Good$ • penicillinT$tolerant$$ Ceftriaxone$(or$Cefotaxime$or$
Vancomycin) Poor$ FairTgood$ (MIC$0.1T$1$ug/ml)$ Cefepime)$or$Meropenem$
Erythromycin) Poor$ PoorTfair$ • penicillinT$resistant$$ Ceftriaxone$(or$Cefotaxime$or$
Sulfonamides) FairTgood$ Good$ (MIC$>1ug/ml)$ Cefepime)$+$Vancomycin$or$Cefotaxime$
Clindamycin) Poor$ Fair$ (Ceftriaxone$or$Cefepime)$+$Rifampicin$
or$Meropenem$
Aprofloxacin) Good$ Good$
H.$influenzae$ Ceftriaxone$or$Cefotaxime$
Ofloxacin) Good$ Good$
S.$agalactiae$$ Penicillin$G$or$Ampicillin$+$an$
! Chloramphenicol$$
(Group$B$strep)$ aminoglycoside$or$Cefotaxime$
" Good$penetration$of$BBB$even$with$no$inflammation$
$ Gram$(T)$ Ceftriaxone$or$Cefotaxime$or$Cefepime$
− Initial$Empiric$Antibiotic$Therapy$Of$Bacterial$Meningitis$ Enterobacteriaceae$ or$Meropenem$
Age$Group$/$ Typical$Pathogen$ Recommended$ P.$aeruginosa$ Meropenem$or$Cefepime$
Clinical$Setting$ $ Initial$Antibiotic$ Staphylococci$
Newborns$ Gram$(T)$enterobac$$ Cefotaxime$+$ • methicillinT$ Nafcillin$or$Oxacillin$or$Cefazolin$or$
$ (E.$coli,$Klebsiella,$ Ampicillin$ susceptible$ Fosfomycin$or$Vancomycin$or$Linezolid$
Enterobacter,$ $ • methicillinT$resistant$ Vancomycin$
Proteus)$ Listeria$ Ampicillin$+$gentamicin$or$TMPTSMX$or$
Group$B$strep$$ monocytogenes$ meropenem$
(S.$agalactiae)$ ! L.$monocytogenes$$
Infants$and$ N.$meningitidis,$$ Ceftriaxone$or$ " Not$frequently$mentioned$$
children$ S.$pneumoniae,$$ Cefotaxime$+$ " Present$in$patients$who$are$immunocompromised$(very$
H.$influenza$ Vancomycin$ young$and$very$old).$$
Healthy$adults,$ S.$pneumoniae,$$
RD TH
3 $or$4 $gen$ " The$ only$ antibiotic$ that$ is$ effective$ is$ ampicillin,$ alone$
immunocompet N.$meningitidis,$$ Cephalosporin$+$ or$with$aminoglycosides.$
ent,$communityT L.$monocytogenes$ Ampicillin$+$ ! Patients$who$had$trauma$or$neurosurgical$operation$
acquired$ Vancomycin$ " Pathogen$=$Staphylococcus$$
" Give:$vancomycin$
 − Chemoprophylaxis$of$Meningococcal$Meningitis$ − Spectrum$Of$Complications$In$Pneumococcal$Meningitis$
Rifampicin$ Diffuse$Brain$Edema$ %,$n=87$
• Adults$ 600$mg$every$12$h$for$2$days$PO$ Hydrocephalus$ 25$(28.7)$
• Infants$≥$1$month$ 10$mg/kg$every$12$h$for$2$days$PO$ Arterial$Cerebrovascular$Complication$ 14$(16.1)$
• Infants$<$1$month$ 5$mg/kg$every$12$h$for$2$days$PO$ Venous$Cerebrovascular$Complication$ 19$(21.8)$
Ciprofloxacin,$adults$ 500$mg$as$single$dose$PO$ Spontaneous$Intracranial$Hemorrhage$ 9$(10.3)$
single$dose$=$easiest$to$give$ − Subarachnoid$Bleeding$(d/t$Vasculitis)$ 8$(9.2)$
Ceftriaxone$ − Subarachnoid$ &$ Intracranial$ Bleeding$ (d/t$ 2$(2.3)$
• adults$and$children$≥$ 250$mg$as$single$dose$IM$(or$IV)$ Vasculitis)$
15$years$ − Intracerebral$ Bleeding$ (d/t$ Sinus$ 1$(0.9)$
• children$<$15$years$ 125$mg$as$single$dose$IM$(or$IV)$ Thrombosis)$
− Dexamethasone$ − Intracranial$Bleeding$(Unknown$Etiology)$ 3$(3.4)$
! Rationale:$$
Cerebritis$ 4$(4.6)$
" May$ decrease$ intracranial$ pressure$ by$
decreasing$meningeal$ inflammation$ and$ brain$ water$ Seizures$ 24$(27.6)$
content$$ Cranial$Nerve$Palsies$ 4$(4.6)$
" May$ decrease$ sensorineural$ hearing$ loss$ and$ other$ Spinal$Cors$Dysfunction$(Myelitis)$ 2$(2.3)$
neurologic$complications$$ Hearing$Loss$ 17$(19.5)$
# d/t$release$of$inflammatory$substances$ Septic$Shock$ 27$(31.0)$
" May$ modulate$ production$ of$ cytokines,$ which$ in$ Disseminated$Intravascular$Coagulation$ 20$(23.0)$
turn,$lessens$the$meningeal$inflammatory$response$$ Renal$Failure$Requiring$Hemofiltration$ 10$(11.5)$
# When$ antibiotics$ lyse$ the$ bacterial$ cells,$ Acute$Respiratory$Distress$Syndrome$ 6$(6.9)$
inflammatory$ substances$ are$ released.$ $
Dexamethasone$ prevents$ complications$ wrought$ d/t$ − Mortality$Rates$Of$Bacterial$Meningitis$In$Adults$
release$of$these$inflammatory$substances$ Pneumococcal$Meningitis$ 20T35%*$
! Indication:$$ Meningococcal$Meningitis$ 3T10%$
" H.$influenzae$meningitis$$ Listeria$Meningitis$ 20T30%$
" May$ be$ considered$ in$ pneumococcal$ and$ Staphylococcal$Aureus$Meningitis$ 20T40%$
meningococcal$ $meningitis,$ although$ its$ efficacy$ for$ Gram$negative$Meningitis$ 20T30%$
these$infections$is$$unproven$$ ! In$ a$ recent$ study,$ dexamethasone$ significantly$ reduced$
" Partially$treated$meningitis$NOT$an$indication$$ the$ mortality$ rates$ of$ pneumococcal$ meningitis$ in$ adults$
" Inflammatory$ exudates$ are$ the$ ones$ that$ will$ give$ the$ to$14%$(34%$in$the$placebo$group)$
complications.$$ $
! Regimen$$ Tuberculous$Meningitis$$
" Dose:$ 0.6$ mg/kg/day$ in$ four$ divided$ doses,$ IV,$ for$ the$ • Pathogenesis$$
first$$two$days$of$antibiotic$therapy$or$0.8$mg/kg/day$in$ − Bacterial$seeding$of$the$meninges$and$subpial$region$$
two$$divided$doses$$ ↓$$
" Administer$at$time$of$or$shortly$before$the$first$dose$of$ Formation$of$tubercles$$
antibacterial$therapy$$$ ↓$$
# Given$for$2T3$days$ Rupture$of$one$or$more$of$the$tubercles$$
" Dexamethasone$ should$ be$ given$ 30$ minutes$ before$ ↓$$
starting$any$antibiotics.$$ Discharge$of$bacteria$into$subarachnoid$space$
# In$adults,$give$10$mg$every$6$hours$for$4$days.$$ − High$ index$ of$ suspicion$ with$ chronic$ manifestations$ )e.g.$
# Purpose:$ when$ the$ bacteria$ lyses$ to$ produce$ chronic$HA)$
inflammation,$ the$ steroids$ are$ already$ present,$ ! Exudates$gather$at$the$base$of$the$brain$
diminishing$the$inflammatory$response.$$ ! Location$of$the$circle$of$willis$and$cranial$nerves$is$at$the$
• Course$and$Prognosis$ base$of$the$brain$
− Cerebral$Complications$In$Adults$With$Bacterial$Meningitis$$ ! StrokeTlike$signs$and$symptoms$
Complication) Frequency) ! Cranial$nerve$weakness$
Brain$edema$with$the$risk$of$herniation$ 10T15%$ • Pathology$
• Risk$ for$ respiratory$ arrest$ d/t$ foramen$ − Small$discrete$white$tubercles$are$scattered$over$the$base$of$
magnum$herniation$ the$cerebral$hemisphere$$
Cerebrovascular$involvement$ 15T20%$ − Meningeal$tubercles$$
− Cerebral$ arterial$ complications:$ arteritis,$ ! Central$ zone$ of$ caseation$ surrounded$ by$ epithelioid$ cells$
vasospasm,$ focal$ cortical$ hyperperfusion,$ and$ some$ giants$ cells,$ lymphoma,$ plasma$ cells$ and$
disturbed$cerebral$autoregulation$ connective$tissue$
− Septic$ sinus$ thrombosis$ and$ cortical$ • Clinical$Staging$Of$Patients$
venous$thrombosis$ Stage$1:$ • NonTspecific$symptoms$and$signs$
Hydrocephalus$ (communicating$ or$ obstructive$ 10T15%$ Early$ • No$clouding$of$consciousness$
type)$ Vestibulocochlear$ involvement$ (hearing$ • No$neurologic$deficits$
impairment,$vestibulopathy)$ • Mild$fever,$mild$HA,$minor$nuchal$rigidity$
Cranial$nerve$palsies$(2,$3,$6,$7,$8)$ ~10%$ Stage$2:$ • Lethargy$or$behavioural$changes$
Cerebritis$ <10%$ Intermediate$ • Meningeal$irritation$
Sterile$subdural$effusion$ ~2%$ • Minor$neurologic$deficits$such$as$CN$palsies$
Rarely$ as$ a$ consequence$ of$ meningitis:$ brain$ $ • Facial$nerve$palsies,$shallow$nasolabial$fold$
abscess,$subdural$empyema$ Stage$3:$ • Stupor$or$coma$
$ Late$ • Seizures$
$ • Severe$neurologic$deficits$such$as$paresis$
$
$
• CSF$findings$ − Southwestern$part$in$the$US$→$Coccidioides$immitis$$
Opening$Pressure$ %$ − Midwestern$part$in$the$US$→$Histoplasma$capsulatum$$
WBC$ %$$50T500$/$cu$mm$ − Other$fungi:$Candida$albicans,$Aspergillus,$Zygomycetes$$
Predominance$of$lymphocytes$ • CSF$Findings$
Protein$ %$$100$–$200$mg/dl$ Opening$Pressure$ %$
Glucose$ &$<40$mg/dl$ WBC$ %$$lymphocytic$pleocytosis$
Tests$ for$ Precise$ (+)$AFB$Stain$ Protein$ %$
Etiological$Determination$ Culture$and$Sensitivity$ Glucose$ &$$
TB$Bactec$ Tests$ for$ Precise$ (+)$India$Ink$
• Prognosis$ Etiological$Determination$ (+)$CALAS$
− Overall$mortality$rate$of$10%$ Sabouraud$Glucose$Agar$
− HIV$(+)$mortality:$21%$ − CALAS$Cryptococcal$Antigen$Latex$Agglutination$
− Neurological$sequelae$ ! most$specific$and$sensitive$test.$$
! Diminished$intellectual$function$ • Treatment$
! Psychotic$disturbances$ − Guidelines$ for$ Treatment$ of$ Cryptococcal$ Meningitis$
! Recurrent$seizures$ Patients$Without$HIV$Infection$
! Visual$and$oculomotor$disorder,$deafness$ ! Immunocompetent$patients$(BIII)$$
! Hemiparesis$ " Induction$course:$(2$weeks)$
• Treatment$ # Amphotericin$B$(0.5T1$mg/kg/d)$
First$2$months$ Isoniazid$ 10T15$mg/kg/d$ # Flucytosine$(100$mg/kg/d)$$
Rifampicin$ 10T20$mg/kg/d$ " Consolidation$therapy$(8T10$weeks)$
Pyrazinamide$ 25T30$mg/kg/d$ # Fluconazole$(400$mg/dL)$$
Ethambutol$ 15T25$mg/kg/d$ ! LP$after$2$weeks$of$treatment$$to$assess$strelization$status$$
Streptomycin$ 15T40$mg/kg/d$ " Repeat$to$determine$if$infection$has$been$eradicated$
Next)7;10)months) Isoniazid$ 10T15$mg/kg/d$ − Patients$with$HIV$Infection$$
Rifampicin$ 10T20$mg/kg/d$ ! Induction$course:$(2$weeks)$$
Total)Time:)9;12)months$(versus$pulmo$TB:$6,$4$months)) " Amphotericin$B$(0.7T1$mg/kg/d)$$
• Major$Adverse$Effects$of$Antituberculous$Drugs$(!)$ " Flucytosine$(100$mg/kg$in$4$divided$doses$per$day)$$
Isoniazid$ *Hepatic$toxicity$ ! Consolidation$therapy$(8$weeks)$$
Peripheral$ neuropathy$ (can$ be$ prevented$ " Fluconazole$(400$mg$OD)$
with$pyridoxine)$ ! Maintenance$therapy$
Phenytoin$toxicity$ " Fluconazole$(200$mg$OD)$
# Indefinite$/$lifetime$maintenance$therapy$
Rifampicin$ *Hepatic$toxicity$
Interstitial$nephritis$ Phase$ Drug$ Adverse$Effects$
Ethambutol$ Optic$neuropathy$ Initial$ 4T8$ Amphotericin$B$ *Nephrotoxicity$
weeks$ (Gold$Standard)$ Anaphylaxis$
Pyrazinamide$ *Hepatic$toxicity$
Arthralgia$with$hyperuricemia$ Flucytosine$ Bone$marrow$suppression$
Streptomycin$ Vestibular$toxicity$ Maintenance$ Fluconazole$ *Hepatotoxic$
Stevens$Johnson$Syndrome$
• Treatment$
Anaphylaxis$
− Corticosteroid$$
$
! Dexamethasone:$0.4$mg/kg$for$a$week$and$then$tapering$
TB$Meningitis$ Fungal$Meningitis$
doses$for$3$weeks$
− Prednisone$1T2$mg/kg/d,$or$its$equivalent,$for$6T8$weeks$to$ • If$ not$ • Less$severe$clinical$picture$
reduce$ vasculitis,$ inflammation$ and$ ultimately$ intracranial$ treated$ • LP$is$not$done$as$urgently$
pressure$$ properly$ • More$chronic$course$
− Hydrocephalus:$ventriculoTperitoneal$shunt$$ patient$ will$ − HA+Fever$x$months$
! To$decrease$ICP$ die$ in$ − May$not$develop$usual$meningeal$signs$
months$ • Need$for$high$index$of$suspicion$
− Supportive$measures$$
− Segregation$from$source$of$infection$$ $
$ Viral$Meningitis$
Cryptococcal$Meningitis$ • Pathogenesis$
• Pathogenesis$ − Steps$in$Hematogenous$spread$of$virus$to$CNS$
! Entry$into$host$$
" Inoculation$$
" Respiratory$$
" Enteric$route$$
! Growth$in$extraneural$tissues$$
! Viremia$$
! Viral$crossing$from$the$blood$$
" Small$vessels$to$brain$(ENCEPHALITIS)$$
" Choroid$plexus$to$CSF$(MENINGITIS)$$
• Etiology$
Viral$ • Enterovirus$(Coxackie,$Echovirus)$
Meningitis$ • Mumps$
• H.$Simplex$type$2$
• Lymphocyte$Chriomeningitis$(LCM)$
$ • Adenovirus$
− Susceptible$ patients:$ immunocompromised$ (e.g.$ s/p$ kidney$ Viral$ • ArthropodTborne$(Japanese$B$Encephalitis)$
transplant$given$immunosuppresants)$
Enephalitis$ • HSVT1$(labial)$m/c$in$encephalitis$
 • HSVT2$(genitals)$m/c$in$the$neonate$$ − Introduced$from$outside$$
• Varicella$zoster$virus$(H.$Zoster)$ ! Compound$fractures$of$skull$
• Cytomegalovirus$ ! Intracranial$operation$
• EBV$ ! Bullet$wounds$$
• HIV$ − Unknown$source$(20%)$$
• Other$viruses$causing$viral$meningitis$ • Etiology$
• Diagnosis$ − Most$common$$
− CSF$analysis$$ ! Anaerobic$and$microaerophilic$streptococci$$
! Clear$colorless$ ! Fusobacterium$species$$
" Maybe$bloody$in$herpes$simplex$encephalitis$$ ! B$haemolytic$streptococci$$
! Slight$ to$ moderate$ pleocytosis$ with$ either$ ! Staphylococcus$aureus$$
polymorphonuclear$or$mononuclar$predominance$$ − Less$common$$
! Proteins$ mild$ to$ moderate$ increase$ occasionally$ elevated$ ! Actinomyces$$
IgG$concentration$$ ! Bacteriodes$$
! Glucose$ normal$ except$ in$ mumps,$ herpes$ simplex$ and$ ! Haemophilus$influenzae$$Etiologic$Organism$$
lymphocytic$choriomeningitis$decreased$$ − Organisms$
− A$completely$normal$CSF$does$NOT$rule$out$encephalitis$$ ! Streptococci$(anaerobic)$
− PCR$$ " Metastatic$from$lung$and$paranasal$sinuses$
− Viral$culture$$ ! Staphylococcus$$
• Pathology$$ " Accidental$or$surgical$trauma$
− Parenchymal$ brain$ infection,$ almost$ invariably$ associated$ ! Enterobacteriaceae$(E.$coli$and$Proteus)$$
with$meningeal$inflammation$$ " Otitic$infection$
! Perivascular$ and$ parenchymal$ mononuclear$ cell$ infiltrate$ • Clinical$Features$
(lymphocyte,$plasma$cell$and$macrophages)$$ − High$ index$ of$ suspicion$ for$ (+)$ focus$ of$ infection,$ focal$
! Microglial$nodule$$ neurologic$deficits,$increased$ICP$
! Neuronophagia$$ ! May$or$may$not$have$fever$
− H.$Simplex$encephalitis$ ! Patients$ with$ cyanotic$ congenital$ heart$ disease$ may$ have$
! Hemorrhage$ focus$ of$ infection$ (right$ to$ left$ shunt$ in$ TOF)$ and$ may$
" (+)$RBC$in$nonTtraumatic$lumbar$tap$ develop$FNDs$and$Inc$ICP$
! Necrotizing$encephalitis$ − Headache$$
! Most$severe$along$inferior$and$medial$surface$of$temporal$ − Drowsiness,$confusion$$
lobes$and$orbitofrontal$gyri$$ − Focal$or$generalized$seizures$$
! Cranial$MRI$will$be$useful$in$detection$ − Focal$neurologic$defect$$
" High$index$of$suspicion$for$H.$Simplex$Encephalitis$if$(+)$ ! Depend$on$the$location$of$the$abscess$
lesions$ in$ the$ temporal$ and$ frontal,$ inferior$ or$ medial,$ Location)of)abscess) Focus)of)Infection)
unilateral$or$bilateral,$especially$if$there’s$hemorrhage,$ Otitis$media$&$Mastoiditis$ Cerebellum$
necrosis$ Temporal$Lobe$
• H.$Simplex$Encephalitis$ Frontal$Sinusitis$ Frontal$Lobe$
− Common$sporadic$viral$encephalitis$$ Abscess$ from$ nearby$ Usually$solitary$
− Hemorrhagic$lesions$(temporal$and$frontal$lobe)$$ infections$
− Cowdry$A$inclusions$$ Abscess$ from$ distant$ Metastatic,$ Multiple$
− Culture$ infections$ (e.g.$ abscesses$
− PCR$$ endocarditis)$
− Rx$$ $
− EEG$$ − Increased$intracranial$pressure$$
! Lateralize$ periodic$ high$ voltage$ spikes$ or$ slow$ waves$ − Temporal$profile:$$
coming$every$2$or$3$seconds$ ! Insidious$onset$$
• Japanese$B$Encephalitis$ " Gradual.$Takes$time$to$develop$
− M/C$cause$of$arbovirus$encephalitis$worldwide$ ! Slowly$progressive$course$$
− Route$of$transmission:$from$culex$mosquito$bite$ − Fever$and$leucocytosis$
− Affects$basal$ganglia,$thalamus,$and$brainstem$nuclei$ ! Not$consistently$present$$
− No$treatment,$only$supportive$therapy$ " Why:$infection$is$encapsulated$=$localized$
• Treatment$ ! Slight$fever$is$present$in$the$early$invasive$phase$$
− Acyclovir$ ! Normal$temperature$as$abscess$becomes$encapsulated$$
! Indications:$ $
" Herpes$simplex$$ • Pathology$$
# Varicella$Zoster$$ Early$ 1T3$ Local$ inflammatory$ response$ surround$
! Dose:$ Cerebritis$ days$ the$ adventitia$ of$ blood$ vessels$
" 10$mg/kg/d$IV$q$8$hour$for$10T14$days$$ beginning$ edema$ with$ small$ necrotic$
$ area$
BRAIN$ABSCESS$ Late$ 4T9$ Edema$ reaches$ its$ maximum$ with$ an$
• Pathogenesis$$ Cerebritis$ days$ increase$in$the$size$of$the$necrotic$area$
− Hematogenous$$ Early$ 10T13$ Necrotic$ area$ is$ isolated$ from$ the$
! Cardiopulmonary$malfunction$$$ Capsule$ days$ adjacent$ parenchyma$ by$ consolidation$
" Bacterial$endocarditis,$CHD$$ Formation$ of$the$collagen$network$around$it.$
" Pulmonary$arteriovenous$malformation$$ Late$ 14/+$ Nature’s$ attempt$ to$ protect$ the$
− Direct$extension$from$diseases$of:$$ Capsule$ days$ surrounding$ tissues$ from$ injury$ with$
! Paranasal$sinuses$$ Formation$ more$reactive$inflammatory$changes.$
! Middle$ear$and$mastoid$cells$$ $
• Staging$ Sample)Cases)
Pre;Contrast)CT) Post;Contrast)CT) Pathology) • CASE$1$
Stage$I:$Early$Cerebritis$ − 15$y/o$male$$
• Irregular$area$of$ • +/T$ • Perivascular$ PMN$ − For$ the$ past$ 3$ days:$ fever,$ headache,$ anorexia,$ muscle$ and$
low$density$ enhancement,$ infiltrate$ joint$$pains,$general$malaise$$
• May$ be$ patchy$ • Marked$ cerebral$ − PE$$
or$ringTlike$ edema$ around$ ! BP$100/70$$
lesion$ ! T$39°C$$
Stage$II:$Late$Cerebritis$ ! Resistance$on$passive$neck$flexion$
• Large$ area$ of$ • Typical$ ring$ • Mixed$ poly/mx$ − Analysis$
low$density$ enhancement$ infiltrate$ ! (+)$CNS$infection$
• May$ be$ solid$ if$ • Maximal$ size$ of$ ! Normal$BP,$febrile$
small$ necrotic$center$ ! (+)$Meningeal$Irritation$
• Hard$ to$ tell$ if$ • Fibroblasts$ around$ ! DX:$Acute$meningeal$irritation$with$fever.$
it’s$ a$ tumor$ or$ necrotic$center$ • CASE$2$
abscess$ so,$ • Maximal$ cerebral$ − 55$y/o$male$bank$executive$$
excise$ edema$ − Non$hypertensive,$nonTdiabetic$$
Stage$III:$Early$Capsule$ − While$ dancing$ during$ a$ class$ reunion:$ sudden$ severe$
• Faint$ ring$ • Ring$ • Maturing$ collagen$ generalized$$headache$followed$by$vomiting$$
separates$ low$ enhancement$ capsule$ (less$ − No$loss$of$consciousness,$no$convulsion$observed$$
density$ necrotic$ May$ be$ thinner$ developed$ on$ − PE$$
center$ from$ low$ on$ ventricular$ ventricular$side)$ ! BP$120/80$$
density$ side$ • Less$ inflammation$ ! T$37°C$$
surrounding$ Vascularity$ around$ ! Severe$pain$and$resistance$on$passive$neck$flexion$
edema$ capsule$at$max$ − Analysis$
Stage$IV:$Late$Capsule$ ! Normal$BP,$afebrile.$$
! No$history$of$trauma.$$
• Faint$ ring$ • Ring$ • Completed$
! Sudden,$severe,$afebrile:$$
separates$ low$ enhancement$ collagen$capsule$
" Consider$subarachnoid$hemorrhage$
density$ necrotic$ (usually$ • Reactive$ gliosis$
! DX:$Acute$meningeal$irritation$without$fever.$
center$ from$ low$ thin/dense)$ with$less$edema$
• CASE$3$
density$ • May$ be$ thinner$
surrounding$ − 25$y/o$obese$male$$
on$ ventricular$
edema$ side$ − On$water$therapy$for$a$month$$
− Developed$fever,$headache$and$vomiting$a$few$days$PTC$$
• Treatment:$
− PE$$
− Medical$Mx$–$early$+$late$cerebritis$=$no$capsule$formation$
! T$39°C$$
− Sugical$Mx$–$early$+$late$capsule$formation$$
! NE:$(+)$nuchal$rigidity$$
− Antibiotic$therapy$$
− CSF$findings$
! Pen$G$20T24$million$units$$
! Opening$pressure:$280$mmH2O,$slightly$turbid$$
! Chloramphenicol$4T6$grams$$
! WBC:$1500$(all$neutrophils),$Protein:$100$mg%$$
! Metronidazole$
! Sugar:$10$mg%$$
" Loading$dose:$15$mg/kg$
− Analysis$
" Maintenance$dose:$7.5$mg/kg$q$6$h$$
! Neutrophilic$infiltration$
! Third$generation$cephalosporin$(ceftriaxone)$$
! DX:$Acute$bacterial$meningitis$
! Vancomycin$1$gram$q$12$
• CASE$4$
" To$maintain$serum$concentration$of$20T40$mg/dL$$
− 75$y/o$recently$retired$female$from$USA$$
− Increased$ICP$$
− 3$months$PTA$patient$had$limited$food$intake$$
! Affects$the$skull$and$the$brain$parenchyma.$$
! Brain$parenchyma$will$yield$and$lead$to$herniation.$ − 1$week$PTC$developed$fever,$headache,$productive$cough$$
− Threatening$temporal$or$cerebellar$herniation$$ − PE$
" Most$ fatal$ herniation:$ at$ foramen$ magnum$ $$ the$ ! Febrile$
cerebellar$tonsils$will$encroach$on$the$medulla$and$can$ ! Dyspneic$with$coarse$crackles$over$both$lung$fields$$
cause$respiratory$arrest$ ! NE:$(+)$nuchal$rigidity$CXR:$bilateral$pneumonia$$
" Intravenous$mannitol$$ − CSF$Findings$
" Dexamethasone$6T12$mg$q$h$$ ! Pleocytosis$with$predominance$of$neutrophils$$
! Increased$ protein$ and$ diminished$ sugar$ Given$ parenteral$
− Aspiration$abscess$=$stereotactic$$
IV$antibiotics$$
− Open$removal$of$abscess$$ rd$
! Excision$ − Course$in$the$ward:$3 HD$$
! Only$if$abscess$is$solitary,$superficial,$well$encapsulated$$ ! Neurologic$status$deteriorated$with$GCS$of$3$$
! Associated$with$a$foreign$body$$$ ! Became$ hypotensive$ with$ diminished$ urine$ output$ and$
was$$advised$hemodialysis$$
• Prognosis$$
− Analysis$
− Good$if$detected$and$treated$early$$
! Elderly$patient$(+)$Bilateral$pneumonia$
− Mortality$rate$has$declined$from$30%$in$the$preTCT$era$$
! Nuchal$rigidity$suggests$meningitis.$$
− In$infants:$mortality$approaches$50%$$
! CSF$findings$suggest$acute$bacterial$meningitis.$$
− Usual$causes$of$death$$
" Consider$Streptococcus$pneumonia$as$etiology$
! Cerebral$herniation$$
! Patient$developed$sepsis.$$
! Fulminant$ meningitis$ when$ abscess$ ruptures$ into$ the$
− Meningeal$Irritation$
ventricles$or$subarachnoid$space$$$
! Abscess$ that$ ruptures$ produce$ meningitis.$ (increased$
mortality$rate)$Meningitis$itself$will$not$develop$abscess.$$
 Altered&Consciousness&

Functional&

Encephalopathy&

(>)&Fever& (+)&Fever&
• CASE$5$
− 25$y/o$male$employee$$
− 2$months$PTC$$ Metabolic>Endocrine& Encephalitis&
Toxic&
! Intermittent$low$grade$fever,$headache,$anorexia$ Nutritional&DeIiciency&(B1,&B6,&B12)&
− 1$month$PTC$ $
! More$severe$headache,$vomiting$and$persistence$of$fever$ $
− 1$week$PTC$ Summary$
! “double$vision”$ • Infections:$Structural$Lesion$
− PE$ − Diffuse$Lesion$
! BP$100/70$$ ! Meningitis$
! T$38°C$$ ! Encephalitis$
! Sleepy$but$oriented$and$follows$commands$correctly$$ " May$be$acute,$subacute,$chronic$
! No$ papilledema,$ right$ eye$ does$ not$ move$ on$ looking$ to$ − Focal$Lesion$
the$right$$otherwise$all$eye$movements$are$normal$$ ! Abscess$
! No$nuchal$rigidity$$ " May$be$Chronic$
− Analysis$ • Pathogens$
! Note$increased$ICP$ − Virus$
− Bacteria$
Acute& Chronic& − Fungi$

(+)& (>)& Mass&

Trauma& Trauma& (neoplasm,&
abscess,&
(+)& hematoma,&
Epidural& (>)&Fever& granuloma)&
Hematoma& Fever&
Subdural& Chronic&
Hematoma& Meningitis&
CVA& Acute& Hydrocephalus&
Subarachnoid& Meningitis&
Hemorrhage& Subarachnoid&
Intracerebral& Hemorrhage&
/&Contusion& Cerebral&
Hematoma& Hemorhhage&
Cerebral&
Infarct&

$
− Management$Plan$
! Do$Cranial$CT$Scan$or$MRI$
! If$negative,$do$CSF$Examination$
" If$(+)$fever,$do$CSF$exam$first$
• CASE$6$
st
− 20$year$old$1 $year$La$Salle$college$student$admitted$under$
a$ psychiatrist$ because$ of$ behavioural$ changes$ following$
breakTup$with$girlfriend$
− Patient$deteriorated$under$antiTdepressant$treatment$
− EEG:$epileptiform$discharges$over$left$temporal$areas$
− CSF$Findings$
! Lymphocyte$pleocytosis$
! Increased$protein$
! Normal$sugar$
− Cranial$MRI$
! Increased$signal$over$both$temporal$head$regions$
! Worst$on$left$
− Developed$ fever$ and$ generalized$ seizures$ which$ were$
difficult$to$control$in$the$subsequent$2$weeks$
− Treatment$
! IV$Acyclovir$x$3$weeks$
! Anticonvulsants$
− FollowTup$after$1$year$
! No$residual$neurologic$and$cognitive$deficits$
− DX:$Viral$Infection,$most$likely$d/t$Herpes$Virus$