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Infectious Disease of the CNS

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Title: Infectious Disease of the CNS


1
Infectious Disease of the CNS
  • Presented By
  • Joseph S. Ferezy, D.C.

2
Lumbar Puncture
  • Common Diagnostic Test
  • Diagnostic (Spinal Tap)
  • Subarachnoid space
  • Examine
  • Pressure
  • Microorganisms (and culture)
  • Proteins (myelin basic)
  • Blood

3
Lumbar Puncture
  • Therapeutic
  • Epidural Steroid
  • Proceedure
  • at L3-4 Interspace
  • at L4-5 Interspace (_at_ Iliac Crests)

4
Lumbar Puncture Contraindications
  • Intracranial Mass Increase Intracranial
    Pressure (ICP)\
  • Through Infected Area

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10
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

11
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

12
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.

13
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.

14
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.

15
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.

16
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.

17
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.

18
  • 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
19
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.

20
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.

21
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

22
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.

23
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.

24
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.

25
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.

26
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.

27
Borrelia bacteria, the causative agent of Lyme
disease. Magnified 400 times.
28
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.

29
Ixodes ('hard ticks')
30
Erythema Chronicum Migrans (ECM)
31
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.

32
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.

33
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.

34
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.

35
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.

36
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37
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.

38
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.

39
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.

40
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.

41
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.

42
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.

43
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.

44
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.

45
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.

46
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.

47
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.

48
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.

49
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.

50
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.

51
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.

52
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.

53
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.

54
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.

55
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.

56
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.

57
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.

58
Diagnosis
  • Lyme disease may be misdiagnosed as multiple
    sclerosis, rheumatoid arthritis, fibromyalgia,
    chronic fatigue syndrome (CFS), lupus, or other
    autoimmune and neurodegenerative diseases.

59
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.

60
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.

61
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.

62
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.

63
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.

64
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.

65
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.

66
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.

67
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.

68
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.

69
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.

70
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.

71
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.

72
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.

73
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.

74
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.

75
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".

76
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.

77
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.

78
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.

79
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.

80
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

81
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

82
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)

83
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

84
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

85
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

86
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

87
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

88
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

89
Botulism
  • Prognosis
  • Residual Paralysis (Ocular)
  • 50-70 Die

90
Brucellosis (Cerebral)
  • Febrile With Associated Features
  • Infected Farm Animal Contact or Milk
  • Refer to M.D. For Antibiotics Tetracycline)

91
Psittacosis
  • Infected Wild/domestic Birds
  • Meningitis or Encephalitis
  • Refer to M.D. For Antibiotics (Tetracycline)

92
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

93
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

94
Congenital Neurosyphilis
  • Fetus Infected _at_ 4th Month of Pregnancy

95
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
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