CASE 1

• A 32 yrs old gentleman is brought to ER with history of fever for 3 days, headache & vomiting for 2 days and drowsiness since morning.

O/E• BP = 110/70 mm Hg• Pulse= 112/min• Temp= 103F• CNS : Neck stiffness +ve• SOMI +ve• GCS 11/ 15• Plantars downgoing

CSF• Colour whitish• Appearance turbid• Proteins 213 mg/dl• Glucose 36 mg/dl• Cells 1056/cmm N = 97% L = 3%

• What is your diagnosis?

• How will you manage?

• What can be the complications in this case?

• A 23 yrs old lady is brought to ED with c/o sudden unconsciousness.

• h/o low grade fever and mild headache for last 1 day. No history of vomiting or fits.

O/E• A young lady lying

unconscios• BP = 80 Systolic

pulse = 90bpm• Temp = 100oF• A macular purpuric rash

over legs & abdomen• CNS• GCS 7/15 Plantars

upgoing• SOMI +ve fundi

intact

CSF R.E.• Appearance turbid• Proteins 250 mg/dl• Cells 612 /cmm N = 90 % L = 10 %• Glucose 28 mg/dl

• What is your impression?

• What other investigations will you plan?

• How will you manage her?

• A young girl of age 14 yrs is brought to ED with c/o severe headache for 1 day, fever for 1 day and irritable behaviour for 3 hrs.

• What is your diagnosis?

• What is its treatment?

• A 32 yr old gentleman is brought to ED with c/o low grade fever & easy fatiguability for 1 month, headache for 2 weeks and LOC for 1 day.

O/E• BP = 170/100 mmHg• Pulse = 60bpm• Temp = 99.5oF• CNS:• pupils RRR • SOMI -ve• plantars downgoing• GCS 10/ 15• REST OF EXAM NORMAL

Urgent CT brain shows meningeal enhancement with mild hyrocephalus.

CSF R.E shows:proteins =210mg/dl glucose

=34mg/dlCells = 230/cmm with 88% lymphos

• Same patient presents to ED after 1month with c/o persistant vomiting. O/E

• pt is fully conscious ,oriented• Mildly jaundiced• Labs: Bilirubin = 4-5 mg/dl ALT = 60U/L

• WHAT WILL YOU DO?

• Same patient comes to OPD after 3months with c/o vertgo and instability for 3 days. Clinically there are features of left cerebellar lesion.

• What can be the cause?• What will be your management plan?

• What is your diagnosis?

• How will you manage?

Tuberculomata

• Same patient again brought to ED in an unconscious state. O/E

• VITALS stable• GCS 3/15• Plantars upgoing• Fundi early papilloedema• CT brain Obstuctive hydrocephalus

what to do now?

• A young lady is brought to ED with c/o fever for 5 days, headache for 3 days , irrelevant talk f0r last 2 days & one episode of GTCF.

O/E• A young lady talking irrelevantly• Temp = 100oF• CNS = • Pt conscious, not oriented• No SOMI• No other +ve finding

• A Vesicular rash is seen over area of RHC

CSF R.E.• Appearance clear• Proteins 60mg/dl• Glucose 60mg/dl• Cells 100/cmm L = 88% N = 12%

• What is your diagnosis?

• How will you manage?

• A 24 yrs old gentleman is brought to ED with c/o high grade fever associated with rigors & chills for last 2 weeks, headache for 6 days and 1 episode of GTC fits followed by drowsiness.

O/E• A young man lying unconscious in bed.• BP = 100/60mmHg• Pulse = 120bpm• Temp = 102oF• CNS: GCS 5/I5 Tone decreased on right right plantar upgoing fundi bilateral papilloedema

CT BRAIN Low density

lesion in left frontoparietal region with ring enhancement

• What is your diagnosis?

• How will you manage?

A young boy of age 20 is brought to OPD with c/o low grade fever for 1 month, restlessness and depressive mood for 1month and vomiting with severe frontal headache for 7 days.

O/E• BP 120/80 mm/Hg• PULSE 72bpm• TEMPERATURE 102F• CNS no positive finding

• During hospital stay, pt continued to deteriorate. Headache & fever did not settle despite good antibiotics & analgesics.

• 5 days later he got rt 6th nerve palsy.

• MRI brain advised.

• He became incontinent.• His mental state also deteriorated and

he became disoriented in time, place and person.

• 5 days later he got rt 6th nerve palsy.• No h/o fits• MRI brain advised.

MRI brain• Meningeal enhancement• Focal tuberculomas in right frontal

and parietal region.• So diagnosis is TBM with

tuberculomata

CNS INFECTIONS

• Bacterial infections• Viral infections• Prion diseases• Protozoal infections• Helminthic infections• Fungal infections

Bacterial infections• Meningitis• Suppurative encephalitis• Brain abscess• Tuberculosis• Neurosyphilis• Diphtheria• Tetanus

Viral infections• Meningitis• Encephalitis• Tranverse myelitis• Poliomyelitis• SSPE• Rabies• HIV infection

PRION DISEASES• Creutzfeldt-jakob

disease• Kuru FUNGAL INF. Meningitis i.e• Cryptococcal or• Candida

PROTOZOAL INF:• Malaria• Toxoplasmosis• TrypanosomiasisHELMINTHIC INF:• Cysticercosis• Hydatid disease• Schistosomiasis

• Acute infection of meninges• Pt presents with fever,headache,

vomiting and altered mental status.• O/E there is neck stiffness & signs of

meningeal irritation.• It may be bacterial, viral ,fungal,

protozoal or due to non-infective causes..

VIRAL MENINGITIS• The most common cause of

meningitis• Usually benign & self-limiting• Common viruses causing meningitis

are enteroviruses, herpes simplex, EBV or varicella zoster.

• Mostly occurs in children & young adults.

CLINICAL FEATURES• Sudden severe headache• Pyrexia• irritability• Meningism• Focal neurological signs occur

rarely.

Bacterial Causes of Meningitis

In Neonates:• E-coli• Proteus• Group B Streptococci• Listeria monocytogenes In Pre-school Child:• H-Influenza• N-Meningitidis• Streptococcus

Pneumoniae• Mycobacterium

Tuberculosis

In Older Children and Adults:

• N-Meningitidis • S Pneumoniae• Listeria • M tuberculosis• S aureus• H-Influenza

• Bacterial meningitis is less common but associated with significant morbidity & mortality.

• Most common causes are S pneumoniae, N meningitidis and H influenzae.

• Pt presents with fever, headache, dowsiness & neck stiffness. Rash may be seen in meningococcemia.

TBM SYMPTOMS:• Headache • Vomiting• Low-grade Fever• Lassitude• Depression• Confusion• Behaviour changes

SIGNS:• Meningism ( may be absent)• Nerve palsies• Focal hemisphere

signs• Papilloedema• Deterioration of

conscious level

• It presents with acute onset of headache, fever, focal neurological signs and seizures.

• There may be drowsiness or coma.• Meningism occurs in many cases.• Most imp cause is Herpes simplex.

Bacteria may enter the brain via penetrating injury. There may be direct spread from paranasal sinuses or middle ear. There may be hematogenous spread from septicemia in which case multiple abscesses may form.

Clinical features

• It may present acutely with fever, headache, meningism & drowsiness.

• Commonly it presents over days or weeks with fever, features of raised ICP , seizures and focal signs.

• CT scan brain• Lumbar puncture• Blood cultures• PCR of CSF• Baseline labs

CSF R.ECondition

Cell type Cell count glucose

protein

Normal Lymphocyts

0-4*106/l <60% of BSR

Upto 0.45g/l

Viral lymphocyte 10-2000 Normal

N

bacterial polymorphs 1000-5000

Low N/ incr.

TB P/L/Mixed 50-5000 Low Increased

Fungal lymphocyte 50-500 Low Increas

malignant

lymphocyte 0-100 low N /incr.

• Viral meningitis is usually self-limiting.

• Symptomatic treatment is done.

Treatment of pyogenic meningitis

General T/M:• Bed Rest • IV Fluids • Airway Patency

Specific Antimicrobial T/M

Antibiotic Regimen is modified

according to age & suspected organism.

Mainstay of T/M is IV Antibiotics.

T/M When Cause Of Bacterial Meningitis is KnownPathogen Regime of

choice Alternative

N-Meningitidis

Benzyl Penicillin2.4g IV 4hourlyFor 5-7 days

Cefuroxime Ampicillin Chloramphenicol

Strep Pneumoniae

Cefotaxime2g IV 6hourly orCeftriaxone2g IV 12hourlyFor 10-14 days

Chloramphenicol

H-Influenza CefotaximeOr Ceftriaxone

Chloramphenicol

Listeria Monocytogenes

Ampicillin2g IV 4 hourly +Gentamicin5mg/kg IV daily

Ampicilin + Co-trimoxazol

T/M of Pyogenic Meningitis of Unknown Cause

Pt. with typical Meningococcal Rash:Benzyl Penicillil 2.4g IV 6 hourly.

Adults (18-50 Yr) without typical rash:Cefotaxime 2g IV 6 hourly orCeftriaxone 2g IV 12 hourly Pt. with penicillin resistant Pneumococcal

Infection: Vancomycin 1g IV 12 hourly or Rifampicin 600mg IV 12 hourly

Pt. with suspicion of Listeria Infection:Ampicillin or Co-trimoxazole

Pt. with H/O Anaphylaxis to B-Lactams: Chloramphenicol + Vancomycin

T/M according to age of Pt.

Neonates and infants: Ampicillin with Cefotaxime

Older Children and Young Adults Penicillin G + Ceftriaxone

Older Pt. (>50 Yrs): Ampicillin + Ceftriaxone

Adjuvant Therapy

1. Mannitol: 250ml IV bolus over 10-20 minutes

2. Glucocorticoids: Dexamethasone 0.15mg/kg IV 6hourly 3. Antiepileptics: Diazepam/Phenytoin/Barbiturates

Prevention Of Meningococcal

Infection• Oral Rifampicin 600mg 12 hourly in

adults • Oral Rifampicin 5-10mg/kg 12 hourly in

children• Ciprofloxacin 500mg in adults

(Alternative) Vaccines:For prevention of diseases caused by

Meningococci of Gp. A & C.

Treatment of TBM• General measures• ATT• Steroids• Surgical treatment may be

required if hydrocephalus develops.

Viral encephalitis

• Inf Acyclovir 10mg/kg body weight IV 8hrly for 2-3 weeks.

• symptomatic

Brain abscess• Antibiotics according to site of

abscess like cefuroxime & metronidazole for frontal lobe lesion

• Anticonvulsants may be required• Surgical treatment