Suwannna setthawatcharawanich MDSuwannna setthawatcharawanich, MD.

Department of Medicine, PSU

OutlineOutline

Basic anatomy relates to CNS infection

Clinical syndrome of CNS infection

Route of CNS infection

CSF in CNS infection

Principle of management

Structures of brain and spinal cordStructures of brain and spinal cord1. Meninges

Dorsal root gg.

2. Venous drainage of the brain2. Venous drainage of the brain

3. Arterial system of the brain

4. Ventricular system

Syndrome of CNS infections1. Meningitis (inflammation of meninges: dura, arachoid, pia)

2. CNS parenchymap y

2.1 Diffuse CNS parenchyma: encephalitis

2.2 Focal or multifocal CNS parenchyma: 2.2 Focal or multifocal CNS parenchyma

abscess, cerebritis, cerebellitis, myelitis

3 Paramenigeal lesions: then propagate to CNS3. Paramenigeal lesions: then propagate to CNS

epidural, subdural, thrombophlebitis, adjacent organ

Terminology: organ-itis, abscess, granulomaVentriculitis meningitis arteritis thrombophlebitisVentriculitis, meningitis, arteritis, thrombophlebitis,Cerebritis,…. etc.Epidural abscess, brain abscess, granuloma of ..

How to approach patient with CNS infection

Does the patient have CNS infection?Does the patient have CNS infection?

What is the location of infection?

What is the nature (organism)?What is the nature (organism)?

How to manage patient with CNS infection?

How to approach patient with CNS infection

Does the patient have CNS infection?

Fever + clinical syndrome + duration

Differential diagnosis?

Cardinal symptoms / signs of CNS infections

ไข + ปวดหว + focal S / S + meningeal signไข ปวดหว focal S / S meningeal sign+

conscious changeconscious change

encephalitis meningitisabscess

ไข + ปวดหลง + para/quadri + back pain/tendernessl i / iplegia/paresis

S i l bSpinal abscess

Differential diagnosis of meningitis (ไข + ปวดหว + คอแขง)

1. Meningism: childhood, adolescence, fever with headache,

LP normal, improved after LP

2. Drug induced meningitis: asso. with systemic sign of allergy

CSF: PMN, protein ,, p ,

NSAIDs (ibuprofen, sulindac), azathioprine, INH, cotrimoxazole, penicillin, IVIGcotrimoxazole, penicillin, IVIG

3. Vasculitis & CNT

4 Chemical meningitis: substance in subarachnoid space4. Chemical meningitis: substance in subarachnoid space

contrast agent, MTX, spinal block, ruptured cyst (dermoid,

id id i h i ) epidermoid, craniopharyngioma) CSF: lymphocytic purulent profile

5 C i i i i l fil5. Carcinomatous meningitis: low sugar profile

Differential diagnosis of encephalitisDifferential diagnosis of encephalitis1. Drug induced encephalitis: asso. with systemic sign of allergy

CSF PMN t i CSF: PMN, protein ,

NSAIDs (ibuprofen, sulindac), azathioprine, INH,

cotrimoxazole, penicillin, IVIG

2. Vasculitis & CNT

3. Chemical induced: substance in subarachnoid space

contrast agent, MTX, spinal block

CSF: lymphocytic purulent profile

4. Dementia

5. Delirium from other causes6. Multiple brain metastasisp

Differential diagnosis of abscess or granuloma1.Stroke

2.Brain tumor

3.Trauma 4.Vasculitis (CNT). ( )

Differential diagnosis of spinal cord infection

1 Myelitis from other causes:1. Myelitis from other causes:radiation, post-infection, substance, multiple sclerosis

2 St k 2. Stroke 3. Tumor 4. Vasculitis 5 T 5. Trauma

How to approach patient with CNS infection

Does the patient have CNS infection?

S d f CNS i f ti

What is the location of infection?

Syndrome of CNS infection

Source/route of infection

Cardinal symptoms / signs of CNS infections

ไข + ปวดหว + focal S / S + meningeal signไข ปวดหว focal S / S meningeal sign+

conscious changeconscious change

encephalitis meningitisabscess

ไข + ปวดหลง + para/quadri + back pain/tendernessl i / iplegia/paresis

S i l bSpinal abscess

Syndrome of CNS infection1. Acute meningitis syndrome

2. Subacute/chronic meningitis syndromeg y

3. Acute encephalitis syndrome

4 Ch i h liti d4. Chronic encephalitic syndrome

5. Space - occupying lesion syndrome

6. Toxic - mediated syndrome

Clinical syndrome + duration

Route of infectionf f1. Hematogenous

1 1 Arterial: septicemia septic emboli ----> meningitis abscess mycotic aneurysm 1.1 Arterial: septicemia, septic emboli ----> meningitis, abscess, mycotic aneurysm

1.2 Venous: face, scalp infection -----> emissary v. ----> cerebral thrombophlebitis

2 Lymphatics intra abdominal pelvic infection > spinal or epidural abscess2. Lymphatics: intra-abdominal, pelvic infection ----> spinal or epidural abscess

3. Direct penetration

3 1 I f i f dj i i di i i i li i 3.1 Infection of adjacent organ: otitis media, sinusitis, osteomyelitis

3.2 Trauma, surgery, LP

3.3 Communication between subarachnoid space and outerpart

e.g. CSF rhinorrhea, otorrhea, Pilonidal sinus

3.4 Olfactory epithelium: Amoeba, Herpes simplex

4. Neurotropic spread: rabies

How to approach patient with CNS infection

Does the patient have CNS infection?

What is the location of infection?

Host?

What is the nature (organism)?Host?

CSF analysis

Host

Immunocompetent ImmunocompromisedImmunocompetent Immunocompromised

NewbornNewborn ElderlyChronic diseases

DM, cirrhosis,SLE, RF, etc.

Ch thChemotherapy Prolong antibiotics

Community vs Hospital acquired

Urgent LP ปลอดภยไหม ตองทา CT สมองกอนไหม

Contraindication for LP

1. Absolute:

1 1 ICP from mass lesion1.1 ICP from mass lesion

( papilledema and/or localizing sign)

1.2 Skin infection at LP area

2 Relative: 2. Relative:

2.1 Bleeding tendency

2.2 Septicemic state

CSF examination :

- Lumbar puncture- Cervical puncture, cisternal punctureCervical puncture, cisternal puncture- Ventricular puncture

1 Opening pressure/ closed pressure1. Opening pressure/ closed pressure2. Physical appearance Mi i b b t b3. Microscopic exam: wbc, rbc, cryptococcus, ameba

4. Protein, sugar/blood sugar5. Gram stain, indian ink, AFB, mod. AFB6. Culture: aerobe, TB, fungusg7. Others: ADA, bacterial Ag, cryptococcal Ag, viral

titer, VDRL, PCRtiter, VDRL, PCR

Normal CSF finding1. Clear, colorless. lear, colorless

2. Pressure 15-20 mmHg

El l 3. Electrolyte: Na 137-145, K 2.7-3.9,

Cl 116-122, CO2 20-24

4. Protein 20-50 mg%

5 S 40 70 % 2/3 BS5. Sugar 40-70 mg%, 2/3 BS

6. Cell < 5 /ml, all monocuclear cell 7. No abnormal cell

f F f dType of CSF findings

1 Purulent profiles: 1. Purulent profiles:

2. Lymphocytic - normal glucose

3. Lymphocytic - low glucose

E i hili4. Eosinophilic

CSF profiles Purulent Lymph-glc(N) Lymph-glc(low) Eop y p g ( ) y p g ( )

Appearance cloudy clear xanthochrom cloudyPressure ++ +/N +++/++++ ++/+++Pressure ++ +/N +++/++++ ++/+++Cell (wbc) +++ + ++ ++/+++

predominantly PMN Lymph Lymph EoProtein ++ + +++ ++Protein ++ + +++ ++Sugar --- N -- -

+; mild increased ++ moderate +++ severe+; mild increased, ++ moderate, +++ severe-; mild decrease, -- moderate, --- severeN; normal

Purulent CSF: PMN, low sugar, high prot, slightly ICP

1. Bacterial meningitis*** :

g g p g y

g

Streptococcal pneumoniae

H hil i flHemophilus influenzae

Neiseria meningitidis etc.

2. Amoebic meningoencephalitis (naegleria fowleri)

3 Chemical meningitis contrast media ruptured 3. Chemical meningitis: contrast media, ruptured

dermoid/epidermoid cyst

4. Drug induced meningitis: NSAID, penicillin,

cotrimoxazole IVIG cotrimoxazole, IVIG

2. Lymphocytic - normal glucose CSF:

1 V l h l

y p y gnormal ICP, normal or slightly increased protein

1. Viral meningitis/encephalitis*** :

Adenovirus, echovirus, herpes virus, etc.p

2. Post-viral/post-vaccinal meningoencephalitis

3 Spir ch t rick ttsi l3. Spirochate/rickettsial

4. Bacterial meningitis: partially treated,

Listeria monocytogenes

5 Parameningeal infection5. Parameningeal infection

6. Vasculitic disease

3. Lymphocytic – low glucose CSF: high prot, high ICP

1. TB meningitis***2. Fungal meningitis***: cryptococcus neoforman etc.3. Carcinomatous meningitis: CA, lymphoma, leukemia3. Carcinomatous meningitis CA, lymphoma, leukemia4. Viral: mumps, Herpes Simplex, Lymp choriomeningitis

4 Eosinophilic CSF:4. Eosinophilic CSF: high ICP, N/slightly high prot, sometime low sugar

1. Angiostrongylus catonensis & Gnathostoma spinigerum**

usually more than 20%

2 Other parasitic infection: usually no more than 20%2. Other parasitic infection: usually no more than 20%

NB. CSF eosinophilia: present Eo in the CSF

(trauma, blood, gas)

3. Tumor

Diagnosis of meningitisg g

1. Clinical syndrome of meningitis

Clinical: fever + headache + neck stiffnessAcute vs chronic

2. Source of infection

Clinical: history, physical exam

3. Laboratory

CSF exam, CT/MRI head, other fluid stain/culture, other

lab chem: hemoculture CBC antibody titer etclab chem: hemoculture, CBC, antibody titer, etc.

How to approach patient with CNS infection

Does the patient have CNS infection?Does the patient have CNS infection?

What is the location of infection?

What is the nature (organism)?What is the nature (organism)?

How to manage patient with CNS infection?

M t f CNS i f tiManagement of CNS infection

Prompt treatment is neededp

1. Specific treatment: depend on organismconsider surgical role if neededconsider surgical role if needed

2. Symptomatic treatment3. Be careful of complicationp

1. Acute meningitis syndrome1. Acute meningitis syndrome

ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน

+/- photophobia, CN palsy, other focal S&S, consciousness

Systemic exam. May reveal cluses: herpetic ruption, parotitis,

orchitis, eschar, purpura + shock

urgent LPurgent LP

CCauses:1. Bacteria*** 2. Virus***3. Spirochate/ ricketsia 4. Amoeba3. Spirochate/ ricketsia 4. Amoeba5. Parasite: Angio, Gnatho 6. Chemical/drug induced7. Immunological 8. Miscellaneous9. Meningism

Treatment1. Antibiotics: พจารณา host, clinical, community or hospital acquired

ceftriaxone 2 gm iv q 12 hr, 7-14 d รอผล culturef g q ,

และ sense

กรณ gram positive: ให AB 7-10 d gram negative ให AB 14-21 d กรณ gram positive: ให AB 7 10 d, gram negative ให AB 14 21 d

และตอง LP ซากอนหยด AB โดยม CSF: cell < 50, all mononuclear

Bacterial meningitis: ตองหา source/route of intectionBacterial meningitis: ตองหา source/route of intection

2. กรณ virus: symptomatic : analgesic: paracet, NSAID

ใ 1 ป อาการจะคอยๆดขนใน 1 สปดาห

3. กรณ eosinophilic meningitis: symptomatic: analgesic

ถาม s/s of increased intracraial pressure: LP for release

pressure + corticosteroid oral form, ใหคาแนะนาในการปองกนการตด

ซา เชนการกนอาหาร

2. Subacute/chronic meningitis syndrome2. Subacute/chronic meningitis syndromeไข + ปวดหว + คอแขง ในเวลาเปนสปดาห - เดอน

+/- photophobia, CN palsy, other focal S&S, consciousness

papilledema

Systemic exam. May reveal clues: PPE, Hairy leukoplakia,

umbilicated papule, cachexia p p ,

Diagnosis: Hx + PE +/- CT + CSF exam

CausesCauses1. TB meningitis***2. Cryptococcal meningitis***3. Carcinomatous meningitis: CA, hematologic malignancy4. Neurosyphilis5 V liti di5.Vasculitic diseases6. Sarcoidosis

T tm tTreatment1. กรณ TB meningitis: ให 2IRZE ตามดวย 10IR ตดตามอาการในระหวางใหยา บาง

รายอาจมอาการแยลงไดเลกนอย พจารณาให steroid 1 mg/kg/d 2-4 wk เมอ

1. ม neurological deficit: hemiparesis, paraparesis, etc.

2. decreased consciousness

3. S/S of increased intracranial pressure

4. prominent encephalitic component

5. CSF protein > 500 mg%, or other evidence of spinal blockp g p6. visual failure secondary to chiasmatic arachnoiditis

2. กรณ cryptococcal meningitis:ให amphopericin B 0.25-1mg/kg/dyp g p p g g

total course 1-1.5 gm หลงจากนน ถา normal host หยดยาได ถา AIDS ให

fluconazole 200 mg/d life longfluconazole 200 mg/d life long

3. Acute encephalitis syndrome3. Acute encephalitis syndromeไข + สบสน/อาละวาด/ซม +/- ปวดหว +/- คอแขง

Diagnosis: Hx + PE + CSF exam +/- CT scanCauses:

1. Viral encephalitis***

2. Post viral/post vaccinal encephalitisp p

3. Spirochate, ricketsia

4 Mycoplasma pneumoniae4. Mycoplasma pneumoniae

5. Amoeba

6 Cerebral malaria6. Cerebral malaria

7. Rabies

T tm tTreatment1. Symptomatic : analgesic, anticonvulsant, etc.

2. In case of Herpes simplex encephalitis: positive temporal

lobe lesion in imaging and/or suggestive CSF ( slightly low sugar, lymphocyte, red blood cell) ให acyclovir 10 mg/kg iv

q 8 hr 7-10 d

3. Cerebral malaria:

quinine IVq

plasma exchange in case of hyerparasitemia + impairedconsciousness (parasitemia > 10%) (p )

4. Chronic encephalitis syndrome4. Chronic encephalitis syndrome1. Virus: HIV, SSPE(subacute sclerosing panecphalitis, etc.

2. Spirochate: neurosyphilis

3. Prion: CJD(crufeldt Jacob disease), Kuru( ),

5. Toxic - mediated syndrome1. Tetanus

2. Botulism

3. Pertussis

6. Space - occupying lesion syndrome6. Space occupying lesion syndrome ปวดหว (abscess, cerebritis, granuloma)

ไข + + neurological deficit + papilledema

ปวดหลง (spinal abscess, myelitis, epidural abscess)( p , y , p )

C / CSDiagnosis: Hx + PE + CT/MRI + CSF examCauses:

1. Brain abscess, spinal abscess

2. Brain granuloma

3. Brain cyst

4. Subdural empyemapy

5. Epidural abscess

TreatmentTreatment1. Brain abscess: antibiotics, surgery

2 Spinal abscess: in case of epidural abscess emergency2. Spinal abscess: in case of epidural abscess emergency

surgery, in case of intra-spinal abscess antibioticsand/or surgeryand/or surgery

3. Myelitis:ขนกบวาเปนจากอะไร ถาเปนจาก TB ใหการรกษาแบบTB + steroid,

li i i i i i l ll ถาเปน myelitis จาก virus, post vaccination, post viral, allergy to

contrast media ใหการารกษาตามอาการ, ถาไมพบสาเหตทเกยวของ อาจเปน multiple

sclerosis ให methylprednisolone 250 mg iv q 6 hr 3 d ตามดวย oral

prednisolone 60 mg/d 11 d then tape off

suggestion: refer if no neurologist, neurosurgeon,

MRI in the hospital,กอน refer ตองดผปวย เตรยมเครองชวยเหลอใหด,พรอม

เพราะผปวย myelitis อาจ progress ในระหวาง refer ได

Complication of CNS infection1. Edema: ---> ICP2. Hydrocephalus: obstructive or communicating3. Cortical thrombophlebitis: focal S&S,

consciousness, seizure,4. Cerebral vasculitis: focal S&S, seizure,

behavior change etcbehavior change, etc.5. Syndrome of inappropriate secretion of

nti diuretic h rm neanti-diuretic hormaone6. Cranial neuropathy7. Seizure8, Other: subdural effusion, abscess, ventriculitis,

syringomyelia, pituitary insufficiency

Case1ป 25 ป ผปวยหญง อาย 25 ป รบราชการ บานอย จ. ตรง

CC. ไข ซม 1 วนPI. 2 วนกอนมารพ. ไขสง บนปวดศรษะ กนอาหารไดนอย นอนเกอบตลอดเวลา

อาเจยนบางครง

1 วน ซม ปสสาวะราด อาเจยน ญาตจงพามารพ.PH. SLE 1 ป รกษามาตลอด ลาสดไดยา prednisolone 30 mg/dPE. T 39 C BP 100/70 mmHg P100 /min RR 26/minSystemic exam: unremarkableN l i l E V MNeurological exam: E2V2M5

Sensation, cerebellar : can’t evaluateMotor: move all four limbs (localize pain)Motor: move all four limbs (localize pain)CN : doll’s eye ---> positive, normal fundiReflex : 1+ allStiffness of neck : positive

คาถามคาถาม

1. พยาธสภาพอยทใด

2. พยาธสภาพนาจะเปนอะไร

3. แนวทางตรวจทางหองปฎบตการคออะไร

4. เชอททาใหเกดโรคคออะไร

Meninges, acute meningitis

LP : turbid open pressure 22 mmHgLP : turbid, open pressure 22 mmHg

cell 21,000/mm3 PMN 98%

sugar 15 mg% BS 80 mg% protein 98 mg%sugar 15 mg% BS 80 mg% protein 98 mg%

Gram -ve rod

Case4.ผปวยหญง อาย 20 ป นกศกษา บานอยจ สงขลาผปวยหญง อาย 20 ป นกศกษา บานอยจ. สงขลา

CC. พฤตกรรมเปลยนแปลง 1 วนPI 3 วนกอนมารพ มไข ไมไอ ไมมนามก บนปวดศรษะ ดซมๆ แตยงชวยตวเองไดPI. 3 วนกอนมารพ. มไข ไมไอ ไมมนามก บนปวดศรษะ ดซมๆ แตยงชวยตวเองได

1 วนกอนมารพ. พดจาสบสนไมคอยรเรอง ตอนเยนชกทงตว 1 ครง และซมลง ญาตจงพามารพ ญาตจงพามารพ.

PH. แขงแรงดPE T 38 5 C PR 100/ i BP 130/70 H RR 24/ iPE. T 38.5 C PR 100/min BP 130/70 mmHg RR 24/min

Systemic exam: unremarkable

Neurological exam: E3V4M6

Motor: move all four limbs actively

CN: normal, normal fundi

Other: unremarkable

Reflex: 2+ all, stiffness of neck- negative

คาถามคาถาม

1. พยาธสภาพอยทไหน2. พยาธสภาพนาจะเปนอะไร3. แผนการตรวจทางหองปฎบตการคออะไรฎ

4. เชอททาใหเกดโรคนาจะเปนอะไร

Brain parenchyma, acute encephalitisp y , p

LP: slightly turbid, open pressure 22 mmHg closed pressure 20 mmHg

cell 100/mm3 mono 100%cell 100/mm mono 100%

protein 80 mg% sugar 60 mg% BS 80 mg%

Gram stain - no organismGram stain - no organism

The Solution Focus Making thing p itive d e n’t mean a nny tl k it mean Making things positive doesn t mean a sunny outlook; it means making the choice to see problems as opportunities. Every problem and difficult situation is embedded with a solution the adventure and difficult situation is embedded with a solution - the adventure lies in finding the solution.

ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน

Acute meningitis

อาการอนทพบได คอ

g

อาการอนทพบได คอ

+/- photophobia, CN palsy, other focal S&S,

consciousness

Systemic exam may reveal clues:Systemic exam. may reveal clues:

herpetic eruption, parotitis, orchitis, eschar,

purpura + shock

H d h d?Headache caused?

Meningitis

1 A t i iti1. Acute meningitis

2. Subacute/chronic meningitis2. Subacute/chronic meningitis

ไข + ปวดหว + คอแขง ในเวลาเปน สปดาห - เดอน

Subacute/chronic meningitis

Causes1. TB meningitis***2. Cryptococcal meningitis***3. Carcinomatous meningitis: CA4. Neurosyphilisyp5.Vasculitic diseases6. Sarcoidosis

Type of CSF findings

Purulent profiles1. Purulent profiles

2. Lymphocytic - normal glucosey p y g

3. Lymphocytic - low glucose

4. Eosinophilic

Syndrome of CNS infectionA t i iti d1. Acute meningitis syndrome

2. Subacute/chronic meningitis syndrome

3. Acute encephalitis syndrome

4 Chronic encephalitic syndrome4. Chronic encephalitic syndrome

5. Space - occupying lesion syndrome

6. Toxic - mediated syndrome

Case 2 ผปวยชาย อาย 30 ป อาชพคร บานอย จ.พทลง ผปวยชาย อาย 30 ป อาชพคร บานอย จ.พทลงCC. ไข ซม 1 วนPI. 4 สปดาหกอนมารพ. มไขตาๆ บนปวดศรษะทวไป กนอาหารไดนอยลงPI. 4 สปดาหกอนมารพ. มไขตาๆ บนปวดศรษะทวไป กนอาหารไดนอยลง

กนยาแกปวด อาการดขนแตไมหายขาด ยงคงทางานได1 สปดาหกอนมารพ บนปวดศรษะมากขน อาเจยนบางครง ทางานไมไหว 1 สปดาหกอนมารพ. บนปวดศรษะมากขน อาเจยนบางครง ทางานไมไหว

นอนทงวน

1 วนกอนมารพ ซมลง 1 วนกอนมารพ. ซมลงPH. แขงแรงดPE T 37 C BP 150/100 H PR 80/ i RR20/ iPE. T 37 C BP 150/100 mmHg PR 80/min RR20/minSystemic exam: unremarkableNeurological exam: E V M ตอบคาถามไดแตชาNeurological exam: E3V4M5 ตอบคาถามไดแตชา

CN: normal, normal fundiMotor: grade III at leastgSensation, cerebellar : can’t evaluateReflex: 1+ all, BBK-absent, Stiffneck- positive

คาถามคาถาม

1 พยาธสภาพอยทไหน

2. พยาธสภาพนาจะเปนอะไร

3 แผนการตรวจทางหองปฎบตการคออะไร

4. เชอททาใหเกดโรคนาจะเปนอะไร

Meninges, chronic meningitis

CT scan of the brain: normal

LP: open pressure 40 closed pressure 25 mmHg

cell 200 /mm3 mono 100%cell 200 /mm mono 100%

protein 450 mg% sugar 30 mg% BS 100 mg%

India ink - positiveIndia ink - positive

Case 3 ผปวยชายอาย 40 ป อาชพกอสราง บานอยจ นครศรธรรมราช ผปวยชายอาย 40 ป อาชพกอสราง บานอยจ. นครศรธรรมราชCC. ปวดศรษะ ซมลง 2 สปดาหPI. 2 สปดาหกอนมารพ. ปวดศรษะดานขวาตอๆตลอดเวลา กนยาแกปวดดขนๆ

แตไมหายขาด อาการปวดคอยๆรนแรงมากขน มไขรวมดวย1 สปดาห กอนมารพ. แขนขาดานซายออนแรง เดนไมถนด ยงคงปวด

ศรษะบอยๆ และมไข 1 วนกอนมารพ. นอนเกอบตลอดเวลา อาเจยน และบนปวดศรษะ ซมลงPH. หนาหนวกเรอรง มหนองไหลจากหทง 2 ขางเปนๆหายๆ มา 2 เดอนPE. T 38 C BP 140/80 mmHg PR 90/min RR 22/min

Systemic exam: bilaterally chronic otitis media with discharge

Neurological exam:Neurological exam:

Neurological exam: E3V5M6

Motor: left hemiparesis grade IV

Sensation : intact

CN: left facial palsy UMN, bilateral papilledema

C ’Cerebellar: can’t evaluate

Reflex: hyper-reflexia 3+ on the left

BBK: present - left

Stiffness of the neck: negativeStiffness of the neck: negative

คาถามคาถาม

1. พยาธสภาพนาจะอยทไหน

2. พยาธสภาพนาจะเปนอะไร3 ป ไ3. แผนการตรวจทาง หองปฎบตการคออะไร

Brain, supratentorial lesion

Mass ----> infection: cerebritis or abscess

CT scan of the brain: brain abscess

Classification of CNS infection base on anatomyy

1. Meningitis

2. Parameningeal infection

2.1 Abscess

2.2 Thrombophlebitis

Str ct re adjacent to meninges2.3 Structure adjacent to meninges

3. Encephalitis

4. Cerebritis

5 Cerebellitis5. Cerebellitis

6. Myelitis

Figure 18c. Tuberculosis basilar meningitis in a 30-year-old woman with HIV infection.

Smith A B et al. Radiographics 2008;28:2033-2058

©2008 by Radiological Society of North America

Structures of brain and spinal cordStructures of brain and spinal cordMeninges

She woke up this morning complaint of severe Acute severe headacheShe woke up this morning complaint of severe headache diffuse or localize?

High grade fever 1 day priorHigh grade fever 1 day priorVery severe chills

Neck stiff sore, painful when she tilts her neck forward Stiffness of neck

B i ht li ht h t h Ph t h biBright light hurts her eyes Photophobia

No skin rash, no recent contactsNo trauma, no sinus infectionN i d fi i

No source of infectionI t t h tNo immunodeficiency

No immunosuppressive drugImmunocompetent host

Pertinent subjective data

1. Female 25 years old

2 Acute high fever with chills for 1 day2. Acute high fever with chills for 1 day

3. Severe headache, neck stiffness with pain,

photophobia

4 No source of infection from history4. No source of infection from history

Pertinent objective data

1. Vital sign SIR (systemic inflammatory response):

T39, PR115, RR24

2. Photophobia but normal fundi

3. No focal neurological deficit

4. Positive Kernig and Brudzinski signs

5. Neck – stiff and painful w flexion = stiffness of neck

6. No source of infection by physical examination

- Meningeal irritation

Stiffness of neck

g- Cervicomedulla lesion- Cervical vertebra

N k l- Neck muscle- Menigism

Duration:1 2 days

Meningeal irritation

Duration:1-2 days

Severe diffuse headacheFever

- Meningeal irritation(blood or air or pus?)- Meningismg

Photophobia Meningeal irritation= meningitis

ไข ปวดหว คอแขง Meningitis syndromeไข ปวดหว คอแขง Meningitis syndrome

Duration?

Hours to few days Weeks to months

Acute meningitis Subacute/chronici itiAcute meningitis meningitis

Pain-sensitive cranial structures1 Intracranial structure: sinus afferent v a of dura mater1. Intracranial structure: sinus, afferent v.,a. of dura mater,

circle of Willis &its branches, dura mater adjacent to large

arteriesarteries.

2. Extracranial structure: scalp, fascia, muscle, mucosa arteries.

3 CN 5 7 9 10 i l 2 33. CN 5,7,9,10, cervical nerve 2,3

Pain-insensitive cranial structures Brain parenchyma, ependyma, choroid plexus, pia, arachnoid Brain parenchyma, ependyma, choroid plexus, pia, arachnoid

membrane, dura, skull (except stretched periosteum)

Acute meningitis syndrome

ไข + ปวดหว + คอแขง ภายใน ชม. - ไมกวน

Causes:1. Bacteria*** 2. Virus***3. Spirochate/ ricketsia 4. Amoeba5. Parasite: Angio, Gnatho 6. Chemical/drug induced7. Immunological 8. Miscellaneous9. Meningism

CBC: leukocytosis with neutrophilia

Urgent LP

y p

Urgent LP

Treatment

Pyogenic bacterial meningitisy g gSpecific antibiotics = urgent

Gram +: ceftriaxone (resistant strep)( p)cloxacillin (skin infection)10-14 daysy

Gram -: up to host & sourceceftazidime – melioidosis3 weeks with LP (mono <50, normal

sugar, decreased protein level, culture - )g p )Be careful complications