Infections of the nervous system

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Infections of the nervous system

• PRM de Bittencourt
• Lusaka 2006
• www.unineuro.com.br

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The zoo in the brainBittencourt, Mazer and
Sander,Handbook of Clinical Neurology, 1999
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Infectious peripheral nervous system diseases

• Mononeuropathies
• Mononeuropathy multiplex
• Leprosy
• Most common polineuropathy in the world
• Sensory loss nerve enlargement skin changes
  due to the sensory loss

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Infectious peripheral nervous system diseases

• Other possibilities in Zambia?
• Myelin involvement by HIV? Unlikely
• Mononeuropathy by HIV, axonal?
• PlexopathyOpen mind, everything is possible
• Get an EMG machine and do a PhD

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Peripheral neuropathy

• Polineuropathy
• None that is infectious in practice

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Peripheral nerve diseases

• Polirradiculoneuropathies
• Chronic autoimmune
• Acute Guillain-Barré syndrome
• Ascending motor or sensory
• Post-infectious
• Self-limited
• Benign

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Infectious diseases of the spinal cord

• Epidural abcess
• Subdural abcess
• Transverse myelitis all MS?
• Other myelopathies
• Tuberculosis
• Syphilis
• Schistosomiasis

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Infectious diseases of the spinal cord

• How do you know
• Tuberculosis, Syphilis, Schistosomiasis
• They are granulomatous, involve the spinal canal
  and roots, and compress the cord, giving a mixed
  picture of lower motor neuron, root compression,
  and a cord sensory level, or motor level

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HIV

• Even when these patients have only HIV, without
  other secondary infections, they are different
  from Guillain-Barré and transverse myelitis cases
  because of their general state of sickness
  active HIV disease is like active Tb gives a bad
  general state

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HIV

• Pure direct neuronal infection in late
  presentations
• Encephalopathy simlar do Alzheimers with
  myoclonus and PLEDs
• Myelopathy poliradiculopathy ascending,
  Guillain-Barré like

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Cranial infections

• Bones
• Meninges
• CSF and circulation
• Parenchyma
• Grey matter
• White matter

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Cortical epilepsy

• By definition a neuron must start each seizure
• Generalized or localized
• Encephalitis herpes simplex, HIV
• Cysticercosis
• Other granulamatous

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Hydrocephalus

• CSF is filtered by the choroid plexii in the
  lateral ventricles
• Re-absorbed by the arachnoid villii in the
  convexity of the brain
• Excess production
• Obstruction to flow
• Reabsorption is defficient

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Hydrocephalus obstrutive

• Acqueduct stenosis
• Mass lesions
• Infections
• Inflammatory

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Problems with shunting

• Frequent infection
• peritonitis
• sepsis

• malfunction
• Mechanical
• Child growth
• various
• cysticercosis

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CNS infections

• Bacterial meningitis, abcess
• Viral encefalitis, meningitis, neuritis,
  neuronitis (HIV)
• Fungal meningitis, parenchymal infection
• Toxoplasmosis
• Viral lymphomas

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Acute bacterial meningitis

• Headache, vomitting, fever, somnolence
• Progress in hours to few days
• Drop in general health
• Contact with large numbers of people
• Specific times of year
• Typical clinical exam
• Typical blood tests
• Typical CT and CSF

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ABM differential diagnosis

• Pneumococcal, haemophilus, meningococcal, viral
  benign, viral herpes simplex
• Collect blood, CSF, start therapy, do CT
• Ceftriaxone 1-2gr daily cristalin penicilin
  amicacin acyclovir
• Isolation contacts norfloxacin

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ABMcomplications

• Death
• Meningococcemia
• Other shock and sepsis
• Infarction due to arteritis
• Deafness, strabismus, other cranial nerve
  problems
• Arthralgia and other immune complex deposition
  signs in meningococcal diseases

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Intracerebral abcess

• Focal sign/symptom seizure
• Intracranial hypertension
• Fever
• Slow progress, subacute
• Source of infection in head

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Intracerebral abcess

• Chest x-ray, FBC, ESR, creatinine, Na, K,
• ECG
• CT, ?CSF
• Antibiotics cover for anaarobics, include Flagyl
• Consider calling neurosurgeons in case no source
  or case does not go well or very large

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Benign Viral Meningitis

• Acute disease, similar to ABM, but patient not
  sick
• CSF typical
• Improves with CSF withdrawal
• No need for therapy

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This is by the far commonest meningitis in
Curitiba, Brasil, and it has been since the
people began to know how to diagnose itCSF ESR
general state
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Encephalitis

• HIV Alzheimer-like myoclonus PLEDs on EEG,
  much faster evolution
• CSF full of cells
• Patient very sick
• Progressive atrophy on imaging
• Progressive slowing on EEG

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Herpes Simplex

• Type A meningo-encephalitis, limbic
• Early fever behavioural memory aphasia
  EEG changes
• CSF EEG CT typical

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Herpes Simplex

• Type B meningitis, more benign than ABM
• General sense of better, relatively, being
• No encephalitis
• CSF typical FBC ESR Chest ECG Na, K,
  Creatinine, blood sugar, normal

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Herpes Simplex

• Acyclovir 10mg/kg/8h for 21 days, otherwise
  recurrance 20
• Not wait PCR

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Other encephalitis/ myelitis

• Stemitis, bulbitis
• These cases have disappeared with good CSF and
  good MR and good EEG, plus definition of all HIV
  complications, like PML, lymphomas and
  toxoplasmosis

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Other viral disorders

• Progressive Multifocal Leucoencephalopathy JC
  virus
• Small lesions like MS
• Primary lymphomas of the CNS
• Onset of focal symptoms/signs over days or weeks
• Large astricytoma/vascular like lesions

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Granulomatous disorders

• In the CNS
• Neurocysticercosis
• Tuberculosis
• Toxoplasmosis
• Sarcoidosis
• Wegener granulamatosis

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Granulomatous disorders

• Neurocysticercosis cysts hydrocephalus
  multiple, calcifications, asymptomatic
• Tuberculosis meningitis miliary
• Toxoplasmosis HIV big solitary
• Sarcoidosis look in the mediastinum
• Wegener granulomatosis in the books

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Granulomas in practice

• Multiple small solid miliary Tb, Ca
• Multiple cysts, calcifications, asymetrical
  hydrocephalus cysticercosis
• Large HIV Toxo