Neuroinfecons - Warszawski Uniwersytet Medyczny...Bacterial • Pneumococci - Streptococcus...
Transcript of Neuroinfecons - Warszawski Uniwersytet Medyczny...Bacterial • Pneumococci - Streptococcus...
Neuroinfec*ons
A. Localiza*on§ Meningi*s-inflamma*onofmeninges§ Encephali*s-braininflamma*on§ Myeli*s-spinalcordonflamma*on
B. E*ology§ Bacterial§ Viral§ Fungal§ Parasi*c§ Priondiseases
C.Accordingtocerebro-spinalfluidcharacter§ Purulent§ Non-purulent
Classifica*on
Bacterial
• Pneumococci-Streptococcuspneumoniae-Gram-posi*vebacteria
• Meningococci-Neisseriameningi*dis-Gramnega*vebacteria
• Haemophilusinfluenzae• Mycobacteriumtuberculosis• Borreliabugdoferi
S.pneumoniae,H.influenza-carriersinthenasalcavity
bacteriemia
seedingofthebacteriatodifferentloca*ons,thisgivesriseto:
SepsisPurulentmeing*sDisseminatedpneumonia
Symptomsofbacterialmeningi*s/encephali*s
• headache• nausea• vomi*ng• photophobia• highbodytemperature• disordersofconsciousness• petechiae• convulsions• symptomsofcranialnervedamageandfocalbraindamage
Brainabscess
• E*ology:staphylococci,streptococci,baccillianaerobicbacteria
• Secondarytosomepurulentinflamma*on-nasalsinuses,middleear,infectedfracturesoftheskull.
Symptoms
• headache,signsoffocalbraininjurydependingontheloca*on,
• diagnos*ctests:computedtomography,magne*cresonanceimagingofthebrain
• Treatment:surgerywithsimultaneousan*bio*ctherapy
Tuberculousmeningi*s(Mycobacterium
tuberculosis)
• Sourceofinfec*on:asickman• Therouteofinfec*on:blood-derivedmostlyfromtheprimaryfocusinthelungs,lymphnodesororgantuberculosis
• Rareincidence• Peoplewithimmunodeficiency.
SymptomsProdromalstage:• increasedbodytemperature• chills• weakness• nightsweats• headaches• nausea• vomi*ngDevelopedstageofthedisease:• symptomsofmeningi*s• damagetothecranialnerves• focalsymptoms• rarelyseizures
Lymedisease• Neuroboreliosis–bacteria-Borreliaspirochete,thesymptomsofnervoussysteminvolvementmayoccuratanystageofthedisease(early/late)
• Radiculopathy,mononeuropathies• Meningi*s• Encephali*s• CranialnervepalsiesSymptoms:• asymptoma*cinfec*on• mildasep*cmeningi*s• headache,photophobia,necks*ffness,fever
Viral
• Enteroviruses-polio,echo,coxsackie• Paramyxoviruses-mumpsvirus,measles• HerpesViruses-HSVtype1and2,CMV,Epstein-Barrvirus
• Tick-borneencephali*s(TBE)virus• Rabiesvirus
• Subtypesof*ck-borneencephali*s(TBE):• European• Siberian• Far-east
• Mortality infec*on subtype of the Far East - 15-20%, theremaining1-4%
• 10-12000newcasesofTBEintheworldeachyear
• AccordingtotheNa*onal Ins*tuteofHygiene inPoland,theaverage annual incidence of approx. 0.7-0.9 /100 000 -approx.260cases
Epidemiology-TBE
TBEvirus• TBEistypicallycharacterizedbyabiphasiccourse:
– PhaseI:non-specificflu-likesymptomsandthelatencyperiod– PhaseII:meningi*s,meningi*sandencephali*s,orinflamma*onofmeninges,
brainandspinalcord
• Pa*entswitTBEviralinfec*on:• 30%donotdevelopclinicalsignsandsymptoms• 30%-50%experienceonly1phaseofthedisease• 30%ofpa*entsdevelop2phase-CNSac*vity.
• M>F• allagegroups• Moresevereintheelderly• Even46%ofpa*entsinthePhase2TBEdevelopinglatecomplica*ons
• The diagnosis of TBE is only on the basis of signs andsymptomswhichmaybeeasilyoverlooked.
• In children with neurological symptoms, residing in areasendemic forTBEvirus->serological tests for thepresenceofan*-TBE.
2phaseofTBEviralinfec*on-symptoms
• Fever,whosevalueocenexceeds40°C.• Meningi*saccompaniedmainlyheadache,nausea,
vomi*ng,dizzinessandnecks*ffness.• Encephalomenigi*sisaccompaniedmainlycerebellarsigns
andsymptoms,whichusuallybelongsataxia.• Otherneurologicalsymptoms-meningealsigns,confusion,
convulsions,slurredspeech,tremors.• Paralysisofthespinalnerveswasobservedin11-15%of
pa*ents.• Occurenceparesisoflimbsinpa*entswithinflamma*onof
themeninges,thebrainandspinalcord,upperlimbsaremoreaffectedthenlower
• Seizuresarerare
LaboratorytestsSignsofinfec*oninbloodserum• Leukocytosis,whichismuchhigherthanotherformsofviral
meningi*s(6600-14600/mm3)• ElevatedESR(upto100mm/hr.)• ElevatedCRPCerebrospinalfluid(CSF)• RarelytheviruscanonlybedetectedinasampleofCSF,notin
blood• Pleocytosis(predominanceoflymphocytes)to5000/mm3,higher
numberofrod-shapedgranulocytes(60%-70%)thenlimphocytes(30%-40%)
• Protein50-200mg/dl• Increasedra*oofalbuminintheCSFtoalbuminserum-
impairmentoftheblood-CSFtransfer
• ThediagnosisofTBE-detec*onofspecifican*bodies• Typically,IgMandIgGan*bodiesarepresentinthefirst
serumsampleswhenthesymptomsfromtheCNSappear• ItisraretodetectonlyIgMan*bodiesinthefirstserum
sample.Inthiscase-repeatthetest.ThepresenceofIgMan*bodiesisnotenoughtoestablishthediagnosis.
• Afewdayslater,IgMandIgGan*bodiesaredetectedintheCSF.
• IgMan*bodiescanbedetectedinserumforseveralmonths.
• IgGan*bodiespersistforthelife*meofthepa*ent.
TBEinchildrenTBEinchildrenhaslessseverecoursethaninolderpa*ents,but• about20%-30%oftheaffectedchildrendevelop
encephalomeningits• about25%developlong-termdisturbanceinafen*onand
concentra*ondeficits• about2%sufferfrompermanentconsequencesof
neurologicaldiseaseLong-termconsequencesofTBEinfec*oninchildrenareunknown,whichunderlinestheimportanceofanaccuratediagnosis.
§ Ataxia, confusion, double vision, urinary reten*on and mildlimbparesis
§ Quadriplegia,coexis*ngparalysisoftherespiratorymuscles,dysphagia,dysarthria
Long-termsymptomsofTBE
TBEtreatment• Theresultsofthelaboratorytestsdidnotaffectthe
treatment-areusedtodis*nguishbetweentheTBEandtheotherinfec*ons
• TBEinfec*on-noan*viraltreatment.• treatment-onlysymptoma*c:
– maintainingfluidandelectrolytebalance– ensureadequatesupplyofcalories– analgesicsandan*pyre*cs– administra*onofan*convulsantdrugs-ifnecessary– useofphysiotherapyinfectedlimbsinordertopreventmuscle
atrophy– useIGV-goodresults
• Themosteffec*vepreven*onofTBEvaccina*on
TBEvirusvaccina*onThetwovaccines:• Encepur• FSMEImmunInjectStandardscheme:• Idoseof0.5ml• IIdose-0.5ml,acer1-3months• IIIdose-0.5ml,9-12monthsacertheseconddoseShortenscheme:• Idoseof0.5ml• Theseconddoseonday70.5ml• IIIdoseof0.5mlin21days• Revaccina*onevery3-5years
CSFexamina*onCellnumber Celltype protein glucose
normal <5 limphocytes <45mg% >40mg%
purulent >200 granulocytes abovenormal <normal
purulent <200 limphocytes normalor>normal
normal
tuberculosis <200
limphocytes
>normal
<normaltuberculosis
Symptomsofpurulentmeningi*sinadults
– headache,nausea,vomi*ng– photophobia,hypersensi*vitytosounds– anxietythenprogressivelossofconsciousness,confusion,coma
– abnormalrhythmofsleepandwakefulness– thephysicalexamina*on:necks*ffnessandposi*vesignsofmeningealsyndrome(Brudziński,Kernig)
MeningealsignsBrudzińskisign:Neck:thepa*entlyingonhisback->neckflexion->limbsflexioninthekneeandhipjointsSymphyseal:pressureonthepubicsymphysiselicitsareflexflexionofthehipandknee,andabduc*onofthelegKernigsign:posi*vewhenthethighisflexedatthehipandkneeat90degreeangles,andsubsequentextensioninthekneeispainful(leadingtoresistance)
NuchalrigidityistheinabilitytoflextheneckforwardduetorigidityoftheneckmusclesAmosssign:indica*onofpainfulflexionofthespineinwhichitisnecessarytosupportasilngposi*onbyextendingthearmsbehindthetorsoandplacingitsweightonthehands.
Meningealsigns
• meningealsymptomsusuallyareabsent• tenseandarchedfrontfontanelle• hyperacusisskin• anxiety• groans• convulsions
Symptomsofpurulentmeningi*sininfants
Viralmeningi*sencephali*s
• thesummermonthsandearlyfall• relatetoyoungpeopleupto40yearsofage• veryrareininfants• usuallymild,withoutpermanentsequelae• some*mesaccompaniedbyinflamma*onofthebrain(encephalomeningi*s,meningoencephali*s)
Viralencephali*s-e*ology
• Virusesoriginallyneurotrophic:rabiesvirus,arboviruses(exo*cencephali*svirus)
• Infec*ousdiseasescomplicatedbyencephali*s:measles,mumps,rubella,chickenpox,shingles,flu
• Otheradenoviruses,rotaviruses,enteroviruses• Encephali*scausedbytheherpessimplexviruses:– Herpe*cencephali*s– Herpessimplexencephali*s(HSE)
CSFfluidinviralencepali*s
• changesasinlymphocy*cmeningi*s• inuntreatedHSEmortalityrateof60-80%,recoverywithoutresidual2.5%ofpa*ents
• drugofchoice:acyclovir(Zovirax)10mg/kg.every8hours
Bacterialmeningi*s
• Life-threa*ngcondi*on-shouldbetreatedassoonaspossible
• Beforetreatment:1.Lumbarpuncture-ifthereisnocontraindica*ons–cytologicalandbiochemicaltests,latextests,directprepara*on,culture,PCR• 2.Bloodtest-to2tubeswith2differents*tchesforculture
• latextests,PCR.
Actualdiagnos*cguidelines
Fromthefirstcontactwiththedoctortogiveempiricaltherapyis*me<3hours
inthecaseofmeningococcale*ologyfor30minutes.
An*bio*cs-giveni.v.,maximumdoses(limitedpenetra*onintotheCNS).
Fortheempiricaltherapyatleasttwoan*bio*cs
RecommendedtreatmentAge Etiology Antibiotics
Infants Perinatal infections
E.coli, Streptococcus agalactiae, Listeria monocytogenes,Klebsiella sp, and others, Gram minus intestinal bacilli
Ampicilin and Cefotaksym or Ampicilin and aminoglikozyd
Infants- nosocomial infections Streptoccoci, Gram minus intestinal bacilli , Pseudomonas aeruginosa
Ceftazidim and vancomicin
Infants 1-3 mo Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae and some pathogens from infants group
Cefotaxim or ceftriaxon and vanconicin, sometimes ampicilin
3 mo- 5mo Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae
Cefotaxim or ceftriaxon and vanconicin
5-50 yr Neisseria meningitidis, Streptococcus pneumoniae
Cefotaxim or ceftriaxon and vanconicin
>50yr Neisseria meningitidis, Streptococcus pneumoniae Streptococcus agalactiae, Listeria monocytogenes Haemophilus influenzae
Cefotaxim or ceftriaxon and vanconicin and ampicilin
TimeofstandardtreatmentBacteria Duration Neisseria meningitidis 7 days Haemophilus influenzae typ b 7-10 days Streptococcus pneumoniae 10-14 days Streptococcus agalactiae 14-21 days Staphylococcus aureus 14 days Listeria monocytogenes, Pseudomonas aeruginosa, Gram minus intestinal bacilli
>21 days
Unknown etiology 10-14days
Viralencephalomeningi*s
• Treatment-infec*onscausedbyvirusesofherpes:acyclovir(Zovirax)10mg/kg/doseevery8hours
• Ininfec*onsCMVganciclovir(Cymevene)5mg/kg/doseevery12hours
• Drugsan*oedematous:• 20%Mannitol200ml(children10ml/kg/day)every8-12hours,Dexamethasone8mg(children0.6-1mg/kg/day)every6-8hours
• An*convulsants(Luminal,Relanium)• An*-inflammatory,an*pyre*c
Supervisionofdiagnosisandtreatmentneuroinfec*ons
• KORUN-Na*onalReferenceCentreforBacterialInfec*onsoftheCentralNervousSystem
• KORLD-Na*onalReferenceCentreforAn*microbialSuscep*bilityTes*ng