Transcript
LIST OF INFECTIONS OF CNS
Dr. L. Surbala (MPT Neurology)
There are four main causes of infections of CNS Bacterial Viral Fungal Protozoal
Dr. L. Surbala (MPT Neurology)
Fungal infections Cryptococcal meningitis Brain abscess Spinal epidural infection
Dr. L. Surbala (MPT Neurology)
Protozoal infections Toxoplasmosis Malaria Primary amoebic meningoencephalitis
Dr. L. Surbala (MPT Neurology)
Bacterial infections Tuberculosis Leprosy Neurosyphilis Bacterial meningitis Brain abscess Neuroborreliosis
Dr. L. Surbala (MPT Neurology)
Viral infections Viral meningitis Eastern equine encephalitis St Louis encephalitis Japanese encephalitis West nile encephalitis Herpes simplex encephalitis Rabies California encephalitis virus Varicella-zoster encephalitis La crosse encephalitis Measles encephalitis Poliomyelitis
Slow virus infections, which include: Subacute sclerosing
panencephalitis Progressive
multifocal leukoencephalopathy
AIDS
MENINGITIS
Dr. L. Surbala (MPT Neurology)
INTRODUCTION It is an acute inflammation of meninges of brain
& spinal cord present with characteristic combination of pyrexia, headache & meningium (confusion or altered consciousness)
The inflammation may be caused by infection with viruses, bacteria, or other microorganisms, and less commonly by certain drugs
It can be life-threatening because of inflammation's proximity to brain & spinal cord; hence condition is classified as a medical emergency
Dr. L. Surbala (MPT Neurology)
CLINICAL FEATURES Acute onset of illness High grade of fever Severe headache Nuchal rigidity & pain Irritability & drowsiness Photophobia & phonophobia
Dr. L. Surbala (MPT Neurology)
Features of rapid ICP (normally between 6 and 18 cm water) Projectile vomiting, blurring of vision, altered sensorium &
convulsions, loss of pupillary light reflex, & abnormal posturing In infants up to 6 months of age, bulging of fontanelle
Septic shock & septicimia Cranial nerve damage Acute renal failure Meningitis caused by meningococcal bacteria may be
accompanied by a characteristic rash consists of numerous small, irregular purple or red spots
("petechiae") on trunk, LE, mucous membranes, conjuctiva, & (occasionally) palms or soles
Dr. L. Surbala (MPT Neurology)
COMPLICATIONS Meningitis can lead to serious long-term
consequences deafness epilepsy hydrocephalus cognitive deficits
if not treated quickly
Dr. L. Surbala (MPT Neurology)
TYPES Pyogenic / bacterial miningitis Tubercular miningitis Viral meningitis
Dr. L. Surbala (MPT Neurology)
PYOGENIC BACTERIAL MENINGITIS
Dr. L. Surbala (MPT Neurology)
PYOGENIC BACTERIAL MENINGITIS Causative organism
Neonates – E-coli, proteus Children – Haemiphillus influenzae type B,
Neisseria meningitidis (Meningococcus) Adolescent - N meningitidis Adult – streptococcus pneumoniae
Dr. L. Surbala (MPT Neurology)
Route of entry Direct contact of the CSF by Contaminated
lumbar puncture, Sinusitis, Trauma Ottitis media Through the blood stream
Incubation period 4- 24 hours
Dr. L. Surbala (MPT Neurology)
PATHOGENESIS The large-scale inflammation that during
meningitis largely be attributed to response of immune system
Immune cells of brain (astrocytes and microglia), respond by releasing large amounts of cytokines, hormone-like mediators that recruit other cells & stimulate other tissues to participate in an immune response.
Dr. L. Surbala (MPT Neurology)
The blood-brain barrier becomes more permeable, leading to "vasogenic" cerebral edema (swelling of brain due to fluid leakage from blood vessels)
Large numbers of WBC enter CSF, causing inflammation of meninges, & leading to "interstitial" edema (swelling due to fluid between cells).
In addition, walls of blood vessels become inflamed (cerebral vasculitis), which leads to a decreased blood flow and a third type of edema, "cytotoxic" edema
Dr. L. Surbala (MPT Neurology)
The three forms of cerebral edema all lead to an increased ICP together with low BP often encountered in acute infection,
Brain cells are deprived of oxygen & undergo apoptosis (automated cell death)
Dr. L. Surbala (MPT Neurology)
SIGNS Positive kernig’s sign & Positive brudjinski’s
Kernig's sign is assessed with patient lying supine, with hip & knee flexed to 90 degrees.
Positive Kernig's sign - pain limits passive extension of knee Brudzinski's sign – if positive, flexion of neck causes
involuntary flexion of knee & hip. Jolt accentuation maneuver helps determine whether
meningitis is present in patients reporting fever & headache The patient is asked to rapidly rotate his head horizontally;
if this does not make the headache worse, meningitis is unlikely
Papillary oedema
Dr. L. Surbala (MPT Neurology)
INVESTIGATIONS Blood analysis
TC is increased DC- neutrophillia ESR- normal Hb- normal
CSF analysis Glucose decreased Protiens increased (100-200mg/dl) Cells – neutophillia (>90%) CT or MRI scan is recommended prior to lumbar
puncture in suspects of risk
Dr. L. Surbala (MPT Neurology)
Gram stain to identify the organism Culture & sensitivity test Postmortem
The findings are widespread inflammation of pia mater and arachnoid layers
Cranial nerves & spinal cord, may be surrounded with pus
Dr. L. Surbala (MPT Neurology)
PREVENTION For some causes of meningitis, prophylaxis can be
provided in long term with vaccine against Haemophilus influenzae type B Meningococcus vaccines against Streptococcus pneumoniae with pneumococcal
conjugate vaccine (PCV) Childhood vaccination with Bacillus Calmette-Guérin (BCG)
Short-term antibiotic prophylaxis is also a method of prevention, particularly of meningococcal meningitis rifampicin, ciprofloxacin or ceftriaxone can reduce their risk
of infection , but does not protect against future infections
Dr. L. Surbala (MPT Neurology)
MANAGEMENT High dose intravenous antibiotic
Penicillin, Cephalosporin Rifampicin, norfloxacin, erythromycin
Mannitol to decrease the raised ICP Corticosteroids can also be used to prevent
complications from overactive inflammation IV fluids should be administered if hypotension or
shock are present Mechanical ventilation may be needed if level of
consciousness is low, or if evidence of respiratory failure
Dr. L. Surbala (MPT Neurology)
Seizures are treated with anticonvulsants Hydrocephalus may require insertion of a
temporary or long-term drainage device (cerebral shunt)
Dr. L. Surbala (MPT Neurology)
TUBERCULAR MENINGITIS It can be seen as a part of primary TB in
children & a part of secondary TB in adults The primary focus being in the lung
Dr. L. Surbala (MPT Neurology)
PATHOGENESIS TB bacilli reached all parts of body & remains
dormant in meninges When immunity is less the foci or bacilli will
rupture in CSF Produce TB meningitis & lots of exudates Obstruction of CSF circulation Damage to lower cranial nerves
Dr. L. Surbala (MPT Neurology)
CLINICAL FEATURES Gradually progressive disease Gradual onset of fever associated with
headache, general weight loss & weakness Loss of appetite Raised ICP Feature of lower cranial nerve paralysis (IX,
X, XI, XII) Difficulty in speaking, swallowing etc
Dr. L. Surbala (MPT Neurology)
INVESTIGATIONS Blood analysis
TC nearly normal DC – lymphocytosis ESR elevated
CSF analysis Turbid & cloudy High protien (500mg/ dl) Boderline increase in glucose Cell are increased (lymphocytosis)
Gram stain: gram positive ZN stain: AF bacilli CT scan with contrast: exudates can be seen
Dr. L. Surbala (MPT Neurology)
TREATMENT Anti – tubercular drugs Corticosteroids Mannitol
Dr. L. Surbala (MPT Neurology)
VIRAL MENINGITIS It is also known as aseptic meningitis Clinical presentation is similar to that of
acute pyogenic meningitis
Dr. L. Surbala (MPT Neurology)
INVESTIGATION Microbiological findings shows no microorganisms CSF glucose is normal Boderline increase in CSF cells (lymphocytes) &
protiens Gram stain is of no importance Polymerase chain reaction (PCR) amplify small traces of
DNA & detect presence of bacterial or viral DNA in CSF Assist in distinguishing various causes of viral meningitis
(enterovirus, herpes simplex virus 2 and mumps in those not vaccinated for this)
Serology (identification of antibodies to viruses) may be useful in viral meningitis
Dr. L. Surbala (MPT Neurology)
TREATMENT Viral meningitis typically requires supportive
therapy only Most viruses responsible for causing
meningitis are not amenable to specific treatment
Herpes simplex virus & varicella zoster virus may respond to treatment with antiviral drugs such as aciclovir
Dr. L. Surbala (MPT Neurology)
Mild cases of viral meningitis can be treated at home with conservative measures such as fluid, bed-rest, & analgesics.
Prognosis is good Gradually recovers without any treatment
Dr. L. Surbala (MPT Neurology)
PT ASSESSMENT History of presenting illness: acute or gradual onset of
illness, high grade fever Past history
Infectious history, trauma, spinal anaesthesia, lumbar puncture, sinusitis, ottitis media
Vital signs: temperature, BP, HR, RR Observation:
abnormal posturing may be seen Abnormal respiration Attitude of limb
Examination Level of conciousness, orientation, memory, speech Cranial nerve examination: signs of damage of lower cranial
nerves
Dr. L. Surbala (MPT Neurology)
Sensory screening: sensations may be intact Motor assessment
ROM, tonicity, reflexes, muscle power Chest examination: important in TB meningitis Respiratory assessment Gustatory examination: swallowing Bladder & bowel involvement Functional assessment Special test: kernig, brudjinski Investigations: blood & CSF examination, CT or MRI,
gram stain, serology
Dr. L. Surbala (MPT Neurology)
Problem list
Dr. L. Surbala (MPT Neurology)
PT MANAGEMENT (GOALS) Psychological support Positioning strategies & prevent bed sores Prevent chest complications Promote vital function Prevent DVT Promote integration of sensory input Postural correction General fitness exercise
Dr. L. Surbala (MPT Neurology)
PSYCHOLOGICAL SUPPORT Maintain a non threatening positive attitude Good support Gain confidence of the patient Counseling of family members & patient Give information as necessary only
Dr. L. Surbala (MPT Neurology)
POSITIONING STRATEGIES & PREVENT BED SORES Proper positioning with pads & cushions Use of water bed or foam mattress Regular inspection of the skin Use cotton clothing to absorb sweat Avoid dragging during transfer Regular turning & changing position
Dr. L. Surbala (MPT Neurology)
PREVENT CHEST COMPLICATIONS Breathing exercise, postural drainage &
suctioning as required Cervical & thoraxic mobility exercise Thoraxic expansion exercise Strengthening of respiratory muscles
Dr. L. Surbala (MPT Neurology)
PROMOTE VITAL FUNCTION Improve respiratory capacity with positioning &
tech s/a glossopharyngeal breathing exercise in respiratory paralysis
Keeping the neck in slight flexion improves respiratory capacity
Specific positioning increase air entry in targeted lobes
Dr. L. Surbala (MPT Neurology)
Massage & mechanical pressure provides reflex stimulus to improve peristalsis (kneading/ stroking)
Facilitate swallowing with positioning, right selection of food texture, oromotor stimulation
Maintaining cardio respiratory endurance with active exercise of possible muscle work
Dr. L. Surbala (MPT Neurology)
PREVENT DVT Active & passive ankle & toe exercise Active limb exercise Limb elevation Early mobilization as soon as possible Propped up position in bed & bed mobility
exercise
Dr. L. Surbala (MPT Neurology)
PROMOTE INTEGRATION OF SENSORY INPUT Stimulation by combined proprioceptive,
visual & auditory input Cues & commands Demonstration of activity Sensory re education if necessary Training in different environment
Dr. L. Surbala (MPT Neurology)
POSTURAL CORRECTION Proper positioning in the lying, sitting & all
functional position Use of braces, sitting & standing frames can
be helpful in children Stretching & strengthening of key postural
muscles Endurance training
Dr. L. Surbala (MPT Neurology)
GENERAL FITNESS EXERCISE Early mobilization & early propped up
position Moving around the bed Regular exercise with bouts of 15-20 min
session for 3-4 times a day Then progress to 30-45 min of exercise Maintenance can be done by 45- 60 min
session of exercise 3-5 times/wk
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