Infectious Disease of the CNS

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Infectious Disease of the CNS

• Presented By
• Joseph S. Ferezy, D.C.

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Lumbar Puncture

• Common Diagnostic Test
• Diagnostic (Spinal Tap)
• Subarachnoid space
• Examine
• Pressure
• Microorganisms (and culture)
• Proteins (myelin basic)
• Blood

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Lumbar Puncture

• Therapeutic
• Epidural Steroid
• Proceedure
• at L3-4 Interspace
• at L4-5 Interspace (_at_ Iliac Crests)

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Lumbar Puncture Contraindications

• Intracranial Mass Increase Intracranial
  Pressure (ICP)\
• Through Infected Area

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Lumbar Puncture

• Normal
• Clear, Colorless, No Clot
• 70-200 Mm H2O Pressure
• Cells 0-5/mm3 (Mononuclear)
• Na, K, Cl, - PH 7.35 - 7.40
• Glucose 45-80 Mg
• Protein 5-15 Mg (Ventricles), 10-25 Mg
  (Cisternal), 15-45 (Lumbar)
• Gamma Globulins 5-12 of Total Protein
• BUN 5-25 Mg
• Bilirubin 0
• Amino Acids 20 of Blood Level

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Lumbar Puncture Complications

• Headache - Still Fairly Common - Decrease in ICP
  Traction on Meninges
• Backache - Usually Due to Bad Technique and Many
  Attempts Causing Muscle Spasms
• Intracranial Subdural Hematoma Traction and
  Rupture of Veins
• Infection - Non Sterile Procedure
• Uncal Herniation - From Rapid Decrease in
  Pressure
• Traumatic Tap Lacerated Vessels Bleeding

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Acquired Immunodeficiency Syndrome

• AKA AIDS
• The result of an infection with the human
  immunodeficiency virus (also called HIV).
• Virus attacks cells of the immune system, nervous
  system, and other body systems.

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Acquired Immunodeficiency Syndrome

• AIDS can cause some serious nervous system
  problems. These problems can be one of the most
  challenging aspects of the disease.
• HIV infects the nervous system directly.
• Other viruses, fungi, bacteria, or parasites take
  advantage of your weakened immune system and
  infect the nervous system.

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Acquired Immunodeficiency Syndrome

• AIDS-related cancers develop.
• AIDS drugs cause side effects that affect or
  damage nerves.
• Dementia is a common type of mental change caused
  by the AIDS virus.
• Early symptoms include slowed thinking, and poor
  short-term memory and concentration.
• May have changes in behavior and physical
  coordination.

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Acquired Immunodeficiency Syndrome

• Lymphoma - cancer of the lymph tissue that can
  occur in the brain.
• Toxoplasma - parasite found in cat feces and raw
  meat. It causes patches of tissue death in the
  brain.
• Symptoms include headaches and seizures.
  Typically diagnosed with imaging and blood tests.
  
• Sometimes a brain biopsy is needed.
• New imaging techniques may revolutionize.

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Acquired Immunodeficiency Syndrome

• The AIDS virus may also damage the spinal cord.
• With cord damage symptoms include leg weakness
  and lose control of bladder or occasionally
  bowel.
• Other nerves may be damaged, causing symptoms of
  weakness, numbness, tingling, and burning pain in
  the limbs.

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Acquired Immunodeficiency Syndrome

• CNS damaged nerve cells do not repair themselves.
  
• Even if the AIDS virus is brought under control,
  the damage may be permanent.

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• Focal central nervous system lesions in AIDS.
  Left. Brain computed tomographic scan in a
  patient with toxoplasmosis shows a ring-enhancing
  lesion with surrounding edema in the right basal
  ganglia that compresses the frontal horn of the
  lateral ventricle, with midline shift. Right.
  Brain computed tomographic scan in a patient with
  a primary central nervous system lymphoma shows a
  homogeneously contrast-enhancing lesion (arrow)
  with edema adjacent to the frontal horn of the
  right lateral ventricle.

Focal central nervous system lesions in AIDS
Simpson, D. M. et. al. Ann Intern Med
1994121769-785
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Acquired Immunodeficiency Syndrome

• The antiviral drugs used to treat HIV infection
  may help slow the development of dementia.
• Antidementia drugs may be used with memory loss
  and confusion.
• Infection with toxoplasmosis may be prevented by
  taking a combination of trimethoprim and
  sulfamethoxazole.

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Acquired Immunodeficiency Syndrome

• Infection with HIV predisposes to the development
  of neoplasms.
• There are currently four AIDS-defining
  malignancies
• Kaposi's sarcoma (formerly most common)
• Non-Hodgkin lymphoma (NHL)
• Primary CNS lymphoma (PCNSL)
• Invasive cervical carcinoma. patients.

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Acquired Immunodeficiency Syndrome

• AIDS-related lymphoma is generally divided into
  three types.
• Systemic NHL, PCNSL, and the primary effusion
  ("body cavity") lymphomas.
• These disorders are primarily encountered in
  patients with more advanced HIV infection, with a
  CD4 count that is usually below 100/µL

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Acquired Immunodeficiency Syndrome

• PCNSL accounts for up to 15 percent of NHLs in
  HIV-infected patients compared to only 1 percent
  of NHLs in the general population.
• The reported incidence of PCNSL in HIV-infected
  patients is 2 to 6 percent (at least 1000 times
  higher than in the general population) and has
  been as high as 10 percent in autopsy series.

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Acquired Immunodeficiency Syndrome

• The most common histology was diffuse large B
  cell lymphoma (immunoblastic variant).
• Although CNS involvement also occurs in
  AIDS-related systemic lymphoma in the form of
  secondary spread of the tumor to the meninges,
  the disease is limited to the CNS in PCNSL.

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Acquired Immunodeficiency Syndrome

• PATHOGENESIS  A small number of circulating B
  cells enter the central nervous system, and may
  do so in increased numbers as HIV infection
  advances.
• Epstein-Barr virus (EBV) establishes latent,
  life-long infection in over 95 percent of adults.

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Acquired Immunodeficiency Syndrome

• During the course of HIV infection, EBV-specific
  T cells progressively lose the capacity to
  produce Interferon-gamma in response to EBV
  peptides.
• In addition, EBV-positive B lymphocytes occur
  more frequently in the CNS of HIV-infected
  individuals than in normal brains.

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Lyme Disease

• Lyme disease, or borreliosis, is an emerging
  infectious disease caused by at least three
  species of bacteria belonging to the genus
  Borrelia.
• Borrelia burgdorferi is the predominant cause of
  Lyme disease in the United States, whereas
  Borrelia afzelii and Borrelia garinii are
  implicated in most European cases.

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Borrelia bacteria, the causative agent of Lyme
disease. Magnified 400 times.
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Lyme Disease

• Lyme disease is the most common tick-borne
  disease in the Northern Hemisphere.
• Borrelia is transmitted to humans by the bite of
  infected ticks belonging to certain species of
  the genus Ixodes (the hard-bodied 'hard ticks').
• Early manifestations of infection may include
  fever, headache, fatigue, depression, and a
  characteristic skin rash called erythema migrans.

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Ixodes ('hard ticks')
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Erythema Chronicum Migrans (ECM)
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Lyme Disease

• Left untreated, late manifestations involving the
  joints, heart, and nervous system can occur.
• In most cases, the infection and its symptoms are
  eliminated with antibiotics, especially if
  diagnosis and treatment occur early in the course
  of illness.
• Late, delayed, or inadequate treatment can lead
  to late manifestations of Lyme disease which can
  be disabling and difficult to treat.

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Lyme Disease

• Some Lyme disease patients who have completed a
  course of antibiotic treatment continue to have
  symptoms such as severe fatigue, sleep
  disturbance, and cognitive difficulties.
• Some groups have argued that "chronic" Lyme
  disease is responsible for a range of medically
  unexplained symptoms beyond the objectively
  recognized manifestations of late Lyme disease,
  and that additional, long-term antibiotic
  treatment is warranted in such cases.

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Lyme Disease

• Of four randomized controlled trials of long-term
  ceftriaxone and doxycycline treatment courses in
  patients with ongoing symptoms, two found no
  benefit, and two found inconsistent benefits and
  significant side effects and risks from further
  antibiotic treatment.
• Most expert groups including the Infectious
  Diseases Society of America and the American
  Academy of Neurology have found that existing
  scientific evidence does not support a role for
  Borrelia nor ongoing antibiotic treatment in such
  cases.

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Lyme Disease

• Symptoms
• Lyme disease can affect multiple body systems,
  producing a range of potential symptoms.
• Not all patients with Lyme disease will have all
  symptoms, and many of the symptoms are not
  specific to Lyme disease but can occur in other
  diseases as well.

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Lyme Disease

• The incubation period from infection to the onset
  of symptoms is usually 12 weeks, but can be much
  shorter (days), or much longer (months to years).
  
• Symptoms most often occur from May through
  September because the nymphal stage of the tick
  is responsible for most cases.

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Lyme Disease

• Asymptomatic infection exists but is found in
  less than 7 of infected individuals in the
  United States.
• Asymptomatic infection may be much more common
  among those infected in Europe.

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Stage 1 Early localized infection

• ECM occurs at the site of the tick bite 3 to 32
  days after being bitten.
• The rash is red, and may be warm, but is
  generally painless.
• Classically the bullseye is seen, however, the
  partial clearing is uncommon, and thus a true
  bullseye occurs in as few as 9 of cases.

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Lyme Disease

• Erythema migrans is thought to occur in about 80
  of infected patients.
• Patients can also experience flu-like symptoms
  such as headache, muscle soreness, fever, and
  malaise.
• Lyme disease can progress to later stages even in
  patients who do not develop a rash.

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Stage 2 Early disseminated infection

• Within days to weeks after the onset of local
  infection, the borrelia bacteria may begin to
  spread through the bloodstream.
• Erythema migrans may develop at sites across the
  body that bear no relation to the original tick
  bite.

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Stage 2 Early disseminated infection

• Another skin condition, which is apparently
  absent in North American patients, is borrelial
  lymphocytoma, a purplish lump that develops on
  the ear lobe, nipple, or scrotum.
• Other discrete symptoms include migrating pain in
  muscles, joint, and tendons, and heart
  palpitations and dizziness caused by changes in
  heartbeat.

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Stage 2 Early disseminated infection

• Acute neurological problems, which appear in 15
  of untreated patients, encompasses a spectrum of
  disorders.
• Facial or Bell's palsy
• Meningitis, characterized by severe headaches,
  neck stiffness, and sensitivity to light.

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Stage 2 Early disseminated infection

• Radiculoneuritis causes shooting pains that may
  interfere with sleep and abnormal skin
  sensations.
• Mild encephalitis may lead to memory loss, sleep
  disturbances, or changes in mood or affect.
• In addition, simple altered mental status as the
  sole presenting symptom has been reported in
  early neuroborreliosis.

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Stage 3 Late persistent infection

• After several months, untreated or inadequately
  treated patients may go on to develop severe and
  chronic symptoms affecting many organs of the
  body including the brain, nerves, eyes, joints
  and heart. A myriad of disabling symptoms can
  occur.
• Chronic neurologic symptoms occur in up to 5 of
  untreated patients.

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Stage 3 Late persistent infection

• A polyneuropathy manifested primarily as
  shooting pains, numbness, and tingling in the
  hands or feet may develop.
• A neurologic syndrome (Lyme encephalopathy) is
  associated with subtle cognitive problems such as
  difficulties with concentration and short term
  memory.
• Such patients may also experience profound
  fatigue.

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Stage 3 Late persistent infection

• Other problems such as depression and
  fibromyalgia are no more common in people who
  have been infected with Lyme than in the general
  population.
• Chronic encephalomyelitis, which may be
  progressive, may involve cognitive impairment,
  weakness in the legs, awkward gait, facial palsy,
  bladder problems, vertigo, and back pain.

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Stage 3 Late persistent infection

• In rare cases, frank psychosis has been
  attributed to chronic Lyme disease effects,
  including misdiagnoses of schizophrenia and
  bipolar disorder.
• Panic attack and anxiety can occur.
• Delusional behavior accompanied by a
  depersonalization or derealization syndrome
  previously associated with early stages of
  general paresis.

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Stage 3 Late persistent infection

• Lyme arthritis usually affects the knees.
• In a minority of patients arthritis can occur in
  other joints, including the ankles, elbows,
  wrist, hips, and shoulders. Pain is often mild or
  moderate, usually with swelling at the involved
  joint. Baker's cysts may form and rupture. In
  some cases joint erosion occurs.

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Transmission

• Hard-bodied ticks of the genus Ixodes are the
  primary vectors of Lyme disease.
• Transmission is relatively rare, with only about
  1 of recognized tick bites resulting in Lyme
  disease this may be due to the fact that an
  infected tick has to be attached for at least a
  day for transmission to occur.

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Transmission

• In North America, the black-legged tick or deer
  tick (Ixodes scapularis) has been identified as
  the key to the disease's spread on the east
  coast.
• Only about 20 of people who become infected with
  Lyme disease by the deer tick can remember having
  been bitten, making early detection difficult in
  the absence of a rash.

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Transmission

• Tick bites are unnoticed because of the small
  size in the nymphal stage, as well as tick
  secretions that prevent the host from feeling any
  itch or pain from the bite.
• The lone star tick (Amblyomma americanum), found
  throughout the Southeastern United States as far
  west as Texas, is unlikely to transmit the
  disease, though it may be implicated in southern
  tick-associated rash illness, which resembles a
  mild form of Lyme disease.

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Transmission

• On the West Coast, the primary vector is the
  western black-legged tick (Ixodes pacificus).
• The tendency of this tick species to feed
  predominantly on host species that are resistant
  to Borrelia infection appears to diminish
  transmission of Lyme disease in the West.

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Transmission

• While Lyme spirochetes have been found in insects
  other than ticks, reports of actual infectious
  transmission appear to be rare.
• Sexual transmission has been anecdotally
  reported Lyme spirochetes have been found in
  semen and breast milk, however transmission of
  the spirochete by these routes is not known to
  occur.

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Transmission

• Congenital transmission of Lyme disease can occur
  from an infected mother to fetus through the
  placenta during pregnancy, however prompt
  antibiotic treatment appears to prevent fetal
  harm.

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Diagnosis

• Diagnosed clinically based on symptoms, objective
  physical findings (such as erythema migrans,
  facial palsy, or arthritis), a history of
  possible exposure to infected ticks, as well as
  serological tests.
• When making a diagnosis of Lyme disease, health
  care providers should consider other diseases
  that may cause similar illness.

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Diagnosis

• Most but not all patients with Lyme disease will
  develop the characteristic bulls-eye rash, and
  many may not recall a tick bite.
• The EM rash, which does not occur in all cases,
  is considered sufficient to establish a diagnosis
  of Lyme disease even when serologies are negative.

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Diagnosis

• Serological testing can be used to support a
  clinically suspected case but is not diagnostic.
• Diagnosis of late-stage Lyme disease is often
  difficult because of the multi-faceted appearance
  which can mimic symptoms of many other diseases
  the new "great imitator.

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Diagnosis

• Lyme disease may be misdiagnosed as multiple
  sclerosis, rheumatoid arthritis, fibromyalgia,
  chronic fatigue syndrome (CFS), lupus, or other
  autoimmune and neurodegenerative diseases.

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Laboratory testing

• Several forms of laboratory testing for Lyme
  disease are available, some of which have not
  been adequately validated. Most recommended tests
  are blood tests that measure antibodies made in
  response to the infection.
• These tests may be falsely negative in patients
  with early disease, but they are quite reliable
  for diagnosing later stages of disease.

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Laboratory testing

• The serological laboratory tests most widely
  available and employed are the Western blot and
  ELISA.
• CDC the more sensitive ELISA is performed first,
  if it is positive or equivocal, the more specific
  Western blot is run.
• The reliability of testing in diagnosis remains
  controversial, however studies show the Western
  blot IgM has a specificity of 9496 for patients
  with clinical symptoms of early Lyme disease.

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Laboratory testing

• Western blot, ELISA and PCR can be performed by
  either blood test via venipuncture or
  cerebrospinal fluid (CSF) via lumbar puncture.
• Though lumbar puncture is more definitive of
  diagnosis, antigen capture in the CSF is much
  more elusive reportedly CSF yields positive
  results in only 1030 of patients cultured.

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Laboratory testing

• Single photon emission computed tomography
  (SPECT) imaging has been used to look for
  cerebral hypoperfusion indicative of Lyme
  encephalitis in the patient.
• In Lyme disease patients, cerebral hypoperfusion
  of frontal subcortical and cortical structures
  has been reported.

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Laboratory testing

• In about 70 of chronic Lyme disease patients
  with cognitive symptoms, brain SPECT scans
  typically reveal a pattern of global
  hypoperfusion in a heterogeneous distribution
  through the white matter.
• This pattern is not specific for Lyme disease,
  and is also seen in (CNS) syndromes such as HIV
  encephalopathy, viral encephalopathy, chronic
  cocaine use, and vasculitides.

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Laboratory testing

• Abnormal MRI findings are seen in both early and
  late Lyme disease.
• MRI scans may demonstrate white matter lesions on
  T2-weighted images, similar to those seen in
  demyelinating or inflammatory disorders such as
  multiple sclerosis, systemic lupus erythematosus
  (SLE), or cerebrovascular disease.
• Cerebral atrophy and brainstem neoplasm has been
  indicated with Lyme infection as well.

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Prevention

• Attached ticks should be removed promptly.
• Protective clothing includes a hat and
  long-sleeved shirts and long pants that are
  tucked into socks or boots.
• Light-colored clothing makes the tick more easily
  visible before it attaches itself.
• People should use special care in handling and
  allowing outdoor pets inside homes because they
  can bring ticks into the house.

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Prevention

• A more effective, community wide method of
  preventing Lyme disease is to reduce the numbers
  of primary hosts on which the deer tick depends
  such as rodents, other small mammals, and deer.
• Reduction of the deer population may over time
  help break the reproductive cycle of the deer
  ticks and their ability to flourish in suburban
  and rural areas.

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Vaccination

• A recombinant vaccine against Lyme disease was
  developed by GlaxoSmithKline was approved by the
  FDA on December 21, 1998.
• Subsequently, hundreds of vaccine recipients
  reported that they had developed autoimmune side
  effects.
• Supported by some patient advocacy groups, a
  number of class-action lawsuits were filed
  against GlaxoSmithKline alleging that the vaccine
  had caused these health problems.

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Vaccination

• These claims were investigated by the FDA and the
  CDC, who found no connection between the vaccine
  and the autoimmune complaints.
• Despite the lack of evidence that the complaints
  were caused by the vaccine, sales plummeted and
  LYMErix was withdrawn from the U.S. market by
  GlaxoSmithKline in February 2002 in the setting
  of negative media coverage and fears of vaccine
  side effects.

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Tick removal

• It is generally agreed that the most effective
  method is to pull it straight out with tweezers.
• Data have demonstrated that prompt removal of an
  infected tick, within approximately 36 hours,
  reduces the risk of transmission to nearly zero
  however the small size of the tick, especially in
  the nymph stage, may make detection difficult.

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Treatment

• Antibiotics are the primary treatment for Lyme
  disease the most appropriate antibiotic
  treatment depends upon the patient and the stage
  of the disease.
• The antibiotics of choice are doxycycline (in
  adults), amoxicillin (in children), and
  ceftriaxone.
• In later stages, the bacteria disseminate
  throughout the body and may cross the blood-brain
  barrier, making the infection more difficult to
  treat.

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Treatment

• Late diagnosed Lyme is treated with oral or IV
  antibiotics.
• A very small minority of Lyme disease patients
  who have completed a course of antibiotic
  treatment, in the early stages of infection,
  continue to have symptoms such as severe fatigue,
  sleep disturbance, and cognitive difficulties.

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Treatment

• While it is undisputed that these patients can
  have severe symptoms, the cause of these symptoms
  and treatment of such patients is disputed.
• Some attribute to persistent infection or
  coinfections.
• Chronic" Lyme disease has been cited as
  responsible for a range of medically unexplained
  symptoms beyond the objectively recognized
  manifestations of late Lyme disease, with or
  without any evidence of past or present infection.

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Treatment

• Studies have shown little to no benefit from 30
  days of IV antibiotics and 60 days of oral
  antibiotics with high placebo rates.
• Debate rages regarding long term antibiotic
  treatment, but complications of the treatment are
  well documented.

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Treatment

• The Infectious Diseases Society of America and
  the American Academy of Neurology, have concluded
  that there is no convincing evidence that
  Borrelia is implicated in the various syndromes
  of "chronic Lyme disease", and recommend against
  long-term antibiotic treatment as ineffective and
  possibly harmful.

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Treatment

• It is well established that there are significant
  side effects and risks of prolonged antibiotic
  therapy, and at least one death has been reported
  from complications of a 27-month course of
  intravenous antibiotics for an unsubstantiated
  diagnosis of "chronic Lyme disease".

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Treatment

• A number of other alternative therapies have been
  suggested, though clinical trials have not been
  conducted.
• Hyperbaric oxygen therapy (which is used
  conventionally to treat a number of other
  conditions), as an adjunct to antibiotics for
  Lyme has been discussed.

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Alternative Medicine

• Approaches include bee venom because it contains
  the peptide melittin, which has been shown to
  exert inhibitory effects on Lyme bacteria in
  vitro.

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Prognosis

• For early cases, prompt treatment is usually
  curative.
• The severity and treatment of Lyme disease may be
  complicated due to late diagnosis, failure of
  antibiotic treatment, and simultaneous infection
  with other tick-borne diseases (co-infections)
  and immune suppression in the patient.

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Prognosis

• Many patients with Lyme disease have fatigue,
  joint or muscle pain, and neurocognitive symptoms
  persisting for years despite any treatment.
• Patients with late stage Lyme disease have been
  shown to experience a level of physical
  disability
• In rare cases, Lyme disease can be fatal.

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Bacterial Infections

• Acute Pyogenic (Bacterial) Meningitis
• Organisms
• Diplococcus Pneumoniae
• Neisseria Meningitidis
• Haemophilus Influenzae
• Metastasis
• Hematogenous Route
• Extension - Otitis Media, Scalp, Sinusitis
• Trauma Open
• After Neurosurgery or Lumbar Puncture Rarely

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Acute Pyogenic (Bacterial) Meningitis

• Clinical
• Children (6 Months - 1 Yr Greatest Risk) Under 15
  Yr 75 of All Cases - Usually in Winter Months
• Usually Post Infection - Lungs, Ear, Sinus, Skull
  Bones, Throat, Nasopharynx, Mastoids, Exposure to
  Meningococcus, Head Trauma, Neurosurgery, Spinal
  Anesthesia, Chronic Debilitation,
  Immunosuppression
• Signs
• Stiff Painful Neck
• Positive Kernig Brudzinski Tests
• High Fever
• Clouded Consciousness Sensorium

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Acute Pyogenic (Bacterial) Meningitis

• Course
• May Be Quick (Poor Prognosis) or Insidious Days
  to Weeks (Better Prognosis)
• Management - M.D. Referral
• Complete Bed Rest
• Fluid Electrolyte Maintenance
• Antibiotics
• 10 - 20 Die (Especially the Very Young Old)

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Brain Abscess

• In Brain Parenchyma
• Usually Hematogenous Spread (Otitis Media,
  Sinusitis, Ect.)
• Clinical
• 21 Malefemale
• Fever, Chills, H.A., Focal Neurological Signs
• Symptoms of Intracranial Mass
• Papilledema, Decreased Pulse Respiration
• M.D. Referral

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Spinal Epidural Abscess (Acute)

• Usually Diabetic With Other Area of Infection or
  Minor Back Trauma or IV Drug Abuse
• Usually After Other Infection
• Usually Begins As Osteomyelitis
• Clinical
• Spinal Pain
• Radicular Pattern Cord Compression
• Paraparesis Paraplegia
• Loss of Bladder /or Bowel Function
• Increased Msr's UMN Signs With Sensory Loss
  Below Level of Lesion

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Tetanus

• Neurotoxin of Clostridium Tetani
• Periodic, Severe Muscle Spasms
• Clinical
• Usually After a Deep Puncture Wound (Obligate
  Anerobe) With Infected Soil
• Can Be After Scratch, Insect Bite, Vaccination,
  or Without a Wound
• Incubation 4 to 10 Days After Infection, Can Be
  Hours to Weeks
• Chills, Fever, Pain Swelling at Site of
  Infection
• Attacks Motor Neurons (Tetano-spasmin) Lock Jaw
  (Trismus) Risus Sardonicus (Sardonic Smile)early

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Tetanus

• More Muscles Become Involved
• Brief Intense Spasm Increasing in Frequency
  More Powerful Muscle Groups Cause Characteristic
  Posture During Contractions
• May Fracture Bones
• Diagnosed by Clinical Picture
• M.D. Referral
• Prognosis
• Quick Symptoms Poor Prognosis
• Death Early - Longer Survive Better Prognosis

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Botulism

• Definition - Acute, Often Fatal Toxemia From
  Ingestion of Neurotoxin Causing a Descending
  Muscle Paresis Paralysis
• Etiology
• Anerobe
• Most Powerful Toxin Known to Man
• Usually Improperly Home Canned Foods (Especially
  Green Beans)
• Interferes With Actylcholine Peripheral Nerves

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Botulism

• Clinical
• Usually Home Canned Green Beans (Look for Outward
  Buckling of Can)
• 12 to 36 Hours After Ingestion
• Diplopia, Ptosis, Photophobia, Dysphagia,
  Dysphonia, Dysarthria, Descending Flaccid
  Paralysis May Paralyze Diaphragm
• Patient Is Alert, Afebrile, No Sensory Loss
• Refer to M.D.
• Notify C.D.C. In Georgia (404)-329-3311

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Botulism

• Prognosis
• Residual Paralysis (Ocular)
• 50-70 Die

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Brucellosis (Cerebral)

• Febrile With Associated Features
• Infected Farm Animal Contact or Milk
• Refer to M.D. For Antibiotics Tetracycline)

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Psittacosis

• Infected Wild/domestic Birds
• Meningitis or Encephalitis
• Refer to M.D. For Antibiotics (Tetracycline)

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Granulomatous Inflammations

• Syphilis
• Meningitis - Usually Mild During 1st Stage,
  Severe in 2nd 3rd Stage
• Clinical - Acute Meningitis
• Chronic Basal Meningitis
• Usually With Tertiary Syphilis
• Cranial Nerve Involvement III, VI and Eventually
  II
• Syphilitic Arteritis
• Panarteritis
• TIA or Infarction Symptoms (Usually M.C.A.)
• Syphilitic Gumma
• Mass of Granulation Tissue (Rare in CNS)
• Usually With Tertiary Syphilis

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General Paresis

• Chronic Syphilitic Encephalitis
• Mental Status Deterioration, Tumor Symptoms
  Argyll- Robertson Pupils (Always!)
• Syphilitic Optic Atrophy Progressive
• Restriction of Visual Fields Total Blindness
  Within Ten Years

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Congenital Neurosyphilis

• Fetus Infected _at_ 4th Month of Pregnancy

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Spinal Cord Syphilis

• Acute Transverse Myelitis
• Tabes Dorsalis
• Dorsal Nerve Roots Posterior Columns (Usually
  Tertiary)
• Paroxysmal Lancinating Pains in Lower Limbs for
  Years (Lightening Pains)
• Ataxia - Slapping Gait With Rombergs Sign
• Paresthesias Common
• Argyll-robertson Pupils
• Charcot Joints (Due to Decreased Pain)
• Bilateral Ptosis

96
Tuberculous Meningitis

• Exposure Is Inhalation
• Hematogenous Spread
• Clinical
• Usually Been Overseas (Increased Mortality)
• Hiistory of Contact With TB Patient
• Anorexia, HA, Lethargy, Pain in Muscles, Nuchal
  Rigidity
• Meningitis Increased ICP Signs
• Spread From Cold Abscess of Chronic Spinal
  Epidural Abscess

97
Tuberculoma

• In Brain
• Signs of Intracranial Mass (ICM)

98
Sarcoidosis

• Unknown Etiology
• Clinical
• 20-40 Yrs.
• Any Organ (Cns 5)
• I.C.M. Signs

99
Rickettsial

• Typhus
• Rocky Mountain Spotted Fever (RMSF)
• Clinical
• RMS Fever Cases
• Severe Encephalitis (Seizures, Neurological
  Deficits)
• Vomit, H.A., Fever, Maculopapular Rash on Ankles
  Wrist

100
Fungal Infections

• Enter CNS Via Hematogenous or Directly
• Clinical
• Chronic Illness, Relapsing Fever
• Predisposed
• Antibiotic Therapy
• Immunosuppression
• Malignancy
• Debilitating Illness
• Trauma
• Endemic Area
• Prior History

101
Fungal Infections

• Signs Symptoms
• Headache
• Anorexia
• Vomiting
• Insomnia
• Meningeal Irritation
• Papilledema
• Focal Neurologic Signs
• Hemiparesis
• Other Organs Involved
• Phycomyceles (Mucor Mycosis)

102
Fungal Infections

• (Chronic Sinusitis Sudden Unilateral Blindness,
  Redish Black Nasal Discharge, 3,4,/or 6th
  Cranial Nerve Involvement)
• 100 Fatal If Untreated
• M.D. Refer

103
Protozoan

• Toxoplasmosis
• Asymptomatic
• Brain Damage to Developing Fetus
• Domestic Other Animals
• Ingest Cat Feces With Oocyst or Uncooked Meat
  With Encysted Trophozoites
• Hematogenous
• "Walled Off" by Body
• Granuloma Calcify
• Clinical
• Asymptomatic
• Predisposed
• Meningioencephalitis
• Congenitally
• Hepatosplenomegaly
• Jaundice, Hydrocephalus, Encephalitis
• Fatal or Brain Damaged

104
Amebiasis (CNS)

• Naegleria
• Affects Child Young Adults
• Through Nasal Passages in Infected H2O (Lake or
  Improperly Chlorinated Pools)
• Acute, Fever, Nausea, HA, Stupor, Seizure, Coma
  100 Fatal
• Malaria
• Rare in CNS
• History of Malaria
• Acute, Confusion, Clouded Consciousness, Stupor,
  Coma

105
Cysticerosis

• Definition - Larval Stage of Pork Tapeworm
• Ingested Eggs From Adult Worm
• Stomach to Body to Brain
• Cyst - Encapsulate - Calcify Die
• Endemic in Mexico, SA, Asia, Southern US
• Usually Child Young Adult
• Presents With Muscle Pain, HA, Nausea, Vomiting,
  Seizures, Confusion, Delusion
• Subcutaneous Nodules Muscle Tenderness
• Papilledema

106
Hydatid Disease (Echinococcosis)

• Larvae of Sheep Tapeworm in Body Tissue
• Petting Infected Dogs Food Ingest Entire Body
• Usually a Child
• Ruptured Cyst in Muscle Myositis - in CNS
  Severe ICM

107
Viral

• Enteroviruses Usually Aseptic Meningitis (Summer
  Fall)
• Arthropod - Bore Encephalitis
• Viral Meningitis
• Syndrome of HA, Meningeal Irritation Signs
• Caused by Enterovirus or Mumps Virus (Winter
  Spring)

108
Leptomeninges

• Most Common
• Clinical
• Usually Child in Epidemics
• Enterovirus in Summer Fall, Mumps in Winter
  Spring
• HA, Fever, Vomiting, Meningeal Irritation
• Usual Full Recovery
• Treat Symptoms

109
Viral Encephalitis

• Acute, Febrile, Meningeal Irritation, HA,
  Vomiting
• Blood Sucking Vectors (Mosquito or Tick)
• Herpes Encephalitis
• Type I, Acute, Frequently Fatal Encephalitis
• Clinical
• Child or Adult, Male Female
• Flu Like Symptoms (Fever, HA, Malaise)
• Meningeal Irritation, Disorientation,
  Psychosis, Memory Disturbances

110
Rhabdovirus (Rabies)

• Acute, Often Fatal
• Clinical
• Usually Skunks (50),
• Bats (20?)
• Raccoons
• Can Be Mother Nursing Baby, Infected Aerosol,
  Rabid Donar to Corneal Transplant Recipient
• History of Bite
• Incubation of 1-2 Months
• Pain Paresthesias at Bite Site, With Fever,
  Chills, HA, Myalgia

111
Rhabdovirus (Rabies)

• "Furious" Rabies Cyclic Breathing, Muscles
  Spasms on Attempted Swallowing
• Terror at Thought of H2O Hydrophobia
• Autonomic Disturbances
• Meningeal Irritation, Nerve Palsies
• If Bitten by Vampire (Bat) Dumb or Paralytic
  Rabies Acute Ascending Paralysis

112
Reye Syndrome

• Definition Acute Encephalopathy Occurs
  Predominantly in Child
• Follows Antecedent Viral Illness - Associated
  With Use of Aspirin (ASA)
• Clinical
• Acute Onset, Child Recovering From Flu,
  Varicella, Upper Respiratory Infection

113
Reye Syndrome

• Stages
• Lethargy Protracted Vomiting
• Impaired Consciousness With Hallucinations,
  Combative Behavior Hyperventilation.
• Coma With Intermittent Decerebrate Rigidity
  Brainstem Reflexes Intact
• Coma With Decerebrate Rigidity
• Coma, Respiritory Failure Death
• Liver Function Abnormal
• Low Glucose
• Serum Ammonia Abnormal
• Occasionally Fatal
• Normal Recovery Usual - Rare Reoccurrence

114
Slow Viral Infects

• Subacute Sclerosing Panencephalitis (SSPE)
• Measles Virus?
• Clinical Malesfemales 31
• Onset 5 - 15 Years
• Determined in School Personality, Speech
  Problems, Papilledema
• Myoclonus, Alexia, Spasticity