CNS Infections Siddiqui

CNS InfectionsCNS Infections

Tahseen J Siddiqui MDTahseen J Siddiqui MDInfectious Disease ConsultantInfectious Disease Consultant

Medical Director Medical Director HIVSTD Care ProgramHIVSTD Care Program

Jackson Park Hospital amp Medical Center Jackson Park Hospital amp Medical Center ChicagoChicago

PresidentPresidentThe Chicago Society of Internal MedicineThe Chicago Society of Internal Medicine

DefinitionsDefinitionsMeningitisMeningitis

bull 1048707 Inflammation of the leptomeningesbull (the covering of the brain)bull 1048707 Usually caused by bacteriabull Meningitis is the 9th deadliest disease in the modern

worldbull The incidence of bacterial meningitis declined from 19

to 15 cases per 100000 from 1998 to 2003 in part due to the introduction of the conjugate Haemophilus influenzae type b and pneumococcal conjugate vaccines

EncephalitisEncephalitisbull 1048707 Inflammation of the brain itselfbull 1048707 Caused by many types of organisms

but mainly virusesChronic meningitisChronic meningitis is defined as meningeal inflammation that persists for more than 4 weeks whereas acute meningitis lasts for less than 4 weeks

MeningitisMeningitis

MortalityMorbidityMorbidity and mortality depend on pathogen patients age and

condition and severity of acute illness

Among bacterial pathogens pneumococcal meningitis causes the highest rates of mortality (21) and morbidity (15)

Mortality rate is 50-90 and morbidity even higher if severe neurologic impairment is evident at the time of presentation (or with extremely

rapid onset of illness) even with immediate medical treatment

RaceBlacks are at greater risk than other races although race may not be

an independent risk factorSex

In neonates male-to-female ratio is 31 No sex preference exists among adults

AgeAccording to the Centers for Disease Control and Prevention (CDC)4

the median age is 39 years In 1986 it was 15 months

MicroorganismsMicroorganismsThat Can Infect the BrainThat Can Infect the Brain

bull 1048708 Bacteriabull 1048708 Virusesbull 1048708 Fungibull 1048708 Parasitesbull 1048708 Prions

Aseptic meningitis (CSF pleocytosis and normal CSF glucose negative bacteria on Gram stain) is the most common CNS infection Most common microorganisms are enteroviruses (primarily cause infection in the summer and early fall account for up to 80 of all cases) human herpesvirus-2 (HHV-2) lymphocytic choriomeningitis virus (LCM) HIV and other viruses

Aseptic meningitis can also follow infection with Borrelia burgdorferi the causative agent of Lyme disease and neurosyphilis etc plus drug-induced (NSAIDs metronidazole IVIG)

Bacterial Meningitis

bull Streptococcus pneumoniae (50)bull Neisseria meningitis (25)bull Group B Streptococci (15)bull Listeria monocytogenes (10) (malignancy)bull Haemophilus influenzae (lt10)bull M tuberculosis bull T pallidum B burgdorferi bull Leptospira (through exposure to animal fluids or

infected water) bull Brucella (through exposure to cattle or

unpasteurized milk)bull Nocardia asteroides (found in the soil can

cause infection in immunocompromised

Risk andor Predisposing Factor Bacterial Pathogen

Age 0-4 weeks S agalactiae (group B streptococci)E coli K1L monocytogenes

Age 4-12 weeks S agalactiae E coli H influenzae S pneumoniae N meningitidis

Age 3 months to 18 years N meningitidis S pneumoniae H influenzae

Age 18-50 years S pneumoniae N meningitidis H influenzae

Age older than 50 years S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli

Immunocompromised state S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli

Intracranial manipulation including neurosurgery Staphylococcus aureus Coagulase-negative staphylococciAerobic gram-negative bacilli includingPseudomonas aeruginosa

Basilar skull fracture S pneumoniae H influenzae Group A streptococci

CSF shunts Coagulase-negative staphylococciS aureus Aerobic gram-negative bacilliPropionibacterium acnes

Slide 2 Neisseria meningitidis meningitis

This cerebrospinal fluid contains a high concentration of neutrophils and many gram-negative diplococci singly and in pairs Although Neisseria meningitidis is the most likely organism differentiation from N gonorrhoeae which can also cause meningitis is not possible with Gram stain But with the PCR

Slide 1 Streptococcus pneumoniae meningitis

This cerebrospinal fluid from a child with meningitis contains many neutrophils and oval gram-positive cocci singly and in pairs Because the number of organisms in infected cerebrospinal fluid is small most laboratories centrifuge the specimen to increase the concentration and then use the sediment for both stains and cultures The density of microbes per milliliter of fluid cannot be estimated from a specimen that has been

centrifugedNeisseria meningitides and Streptococcus pneumoniae account for 37 to 93 of acute bacterial meningitis

Slide 3 Haemophilus influenzae meningitis

This cerebrospinal fluid contains many neutrophils and gram-negative coccobacilli primarily in the cytoplasm of the white cells

Slide 4 Listeria monocytogenes meningitis

This cerebrospinal fluid contains a few neutrophils and two slender gram-positive bacilli Although Gram stains of cerebrospinal fluid are positive in specimens from about 80 of all patients with bacterial meningitis organisms are detected in the cerebrospinal fluid of only about 40 of patients with Listeria meningitis Even when specimens reveal bacteria only a small number may be visible

Signs amp Symptoms of Meningitisbull 1048708 Headache gt 90bull 1048708 Fever gt 90bull 1048708 Neck Stiffness gt 85bull 1048708 Vomiting 35bull 1048708 Seizures 30bull 1048708 Weakness 15bull Photophobiabull Altered mental status (irritability to somnolence delirium and coma )bull Kernigs and Brudzinskirsquos Signbull Papilledemabull Focal neurologic signs-Isolated cranial nerve abnormalities (principally III IV VI VII) in 10-20 hellip

worse outcome (no LP)

bull Symptoms in infantsbull Feverbull Lethargy andor change in level of alertnessbull Poor feeding andor vomitingbull Respiratory distress apnea cyanosis

bull In partially treated meningitis (40) seizures may be the sole presenting symptom

bull Low-grade ventriculitis associated with VP shunt Patients may have a less dramatic presentation with headache nausea minimal fever and malaise

bull Fungal meningitis mildfluctuating headache low-grade fever and lethargy are the primary symptoms

bull Tuberculous meningitis Fever weight loss night sweats and malaise with or without headache and meningismus

Systemic findings

bull Extracranial infection (eg sinusitis otitis media mastoiditis pneumonia urinary tract infection) may be noted

bull Arthritis is seen with N meningitidis

bull Rash Nonblanching petechiae and cutaneous hemorrhages are seen classically with N meningitidis (can occur with other bacterial and viral infections)

bull Endotoxic shock with vascular collapse is characteristic of severe N meningitidis infection

Laboratory Studiesbull CBC with differentialbull Serum electrolytes and liver profile (dehydration or SIADH to assess

organ functioning and adjust antibiotic dosing)bull Serum glucose as baseline for determining normal CSF glucosebull Coagulation profile and platelets in patients with chronic alcohol use

liver disease or if DIC is suspected (require platelets or FFP prior to LP)

bull Urinary electrolytes (SIADH))bull Serum cryptococcal antigen especially if baseline is known (less

diagnostic than India ink and CSF cryptococcal antigen)bull Cultures (prior to antibiotics) blood (50 positive in meningitis

caused by H influenzae S pneumoniae N meningitidis) nasopharynx respiratory secretions urine and skin lesions

bull Latex agglutination or counter immunoelectrophoresis (CIE) of blood urine and CSF for specific bacterial antigens (partially treated meningitis)

bull SerumCSF- RPRVDRL if neurosyphilis is in differential diagnosis (CSF VDRL may be negative)

Imaging Studiesbull Head CT scan (contrast) or MRI (gadolinium)bull In patients with evidence of head trauma immunosuppression

altered mental status or focal findings bull Presence of papilledema and inability to fully assess fundi or

neurologic status are indications for CT scan prior to LPbull Obtain blood cultures and initiate treatment before imaging

studies and LP in patients with suspected bacterial meningitisbull Results may be normal or demonstrate small ventricles

effacement of sulci and contrast enhancement over convexities

bull Late findings include venous infarction and communicating hydrocephalus

bull Rule out brain abscess sinus or mastoid infection skull fracture and congenital anomalies

bull Chest radiography- 50 of patients with pneumococcal meningitis also have evidence of pneumonia

Non Contrast CT- mild ventriculomegaly and sulcal effacement

contrast-enhanced axial T1-weighted magnetic resonance image shows leptomeningeal enhancement

Lumbar Puncture Procedure

bull Elevated opening pressure correlates with increased risk of morbidity and mortality in bacterial and fungal meningitisbull Take tube 1 to chemistry lab for glucose and proteinbull Take tube 2 to hematology lab for cell count with differentialbull Take tube 3 to microbiology and immunology lab for Gram stain bacterial culture acid-fast bacillus (AFB) stain and

tuberculosis (TB) cultures India ink stain and fungal cultures CIE VDRL and cryptococcal antigen if indicatedbull Hold tube 4 for repeat cell count with differential if needed (or for other subsequent studies not initially ordered)bull According to Seupaul 3 diagnostic tests have clinically useful likelihood ratios for the diagnosis of bacterial meningitis

in adults CSFblood glucose ratio less or equal to 04 CSF WBC count greater or equal to 500L and CSF lactate level equal or greater than 3153

Diagnosis

CT Head (SOLIncreased ICP)

LP

Blood Cultures

CSF

bull uarr WBC (PMN) darr Glucose (lt22mmolL) darr CSFSerum Glucose (lt04) uarr Protein (gt045gL) uarr Opening Pressure (gt180mm H2O)

bull CSF culture and gram stainbull Latex agglutination test-detects bacterial antigensbull PCR-Can detect small numbers of bacteriabull CIE-(Counter Immunoelectropheresis)

Able to detect small amounts of antigenbull Early detection (~24h)

Open P AIDS patients with crypto meningitis have increased risk of blindness death unless open pressure maintained at lt30 cm In Bact mening-Lymphocytosis with normal CSF chemistries seen in 15-25 especially when cell counts lt1000 or if partially treated In Viral mening Up to 48 hours significant PMN pleocytosis may be indistinguishable from early bacterial meningitis After 8-12 hours reexamine the CSF If initial granulocytosis changes to mononuclear predominance CSF glucose remains normal and patient continues to look well the infection is most likely nonbacterial Nontraumatic RBCs in 80 of HSV meningoencephalitis although 10 have normal CSF results ~90 of patients with VP shunts have CSF WBC count gt100 cellsmm3 are infected CSF glucose usually normal and organisms are less pathogenic (Staph epi Propionibacterium acnes and diphtheroids) and S aureus coliforms India ink 80-90 effective for fungi AFB stain 40 effective for TBPrior antibiotics may cause gram-positive organisms to appear gram negative and decrease culture yield on average 20 lowest levels of CSF glucose are seen in TB primary amebic meningoencephalitis neurocysticercosis An aseptic profile - bacterial (eg Mycoplasma Listeria Leptospira species Borrelia burgdorferi [Lyme] spirochetes) partially treated bacterial HSV and arboviruses TB meningitis and parasites resemble the fungal profile more closely

5-15 cm H2 O

bull In acutely ill patients perform an LP (if appropriate) and administer first dose(s) of antibiotics +- steroids within 30 minutes of presentation to ED

bull Initiate empiric therapy if LP cannot be performed within 30 minutes bull Begin empiric therapy prior to head CT scan if a focal neurologic deficit is present If no mass effect is present

perform LP bull Treat systemic complications hypotension andor shock hypoxemia hyponatremia (SIADH) DICcardiac

arrhythmias and ischemia seizure and CVA bull Seizure precautions in ED Aggressively control seizures if present since seizure activity increases ICP (ie

lorazepam 01 mgkg IV and IV load with phenytoin 15 mgkg or phenobarbital 5-10 mgkg) bull Dexamethasone may be beneficial in bacterial meningitis if given 15-20 mins before or with the first dose of

antibacterial therapy sepecially for HInf Spneumoniae or TB meningitis raised ICPbull Look for signs of hydrocephalus and increasing ICP

bull Manage fever and pain control straining and coughing avoid seizures and avoid systemic hypotension

bull In stable patients elevating head and monitoring neurologic status

bull Diuresis (ie furosemide 20 mg IV mannitol 1 gkg IV) provided circulatory volume is protected

bull Hyperventilation in intubated patients with a goal of PaCO2 25-30 mm Hg may briefly lower ICP hyperventilation with PaCO2 lt25 mm Hg may decrease CBF disproportionately and lead to CNS ischemia

bull Consider placing an ICP monitor in comatose patients or in those with signs of increased ICP

bull With elevated ICP remove CSF until pressure decreases by 50 and maintain at less than 300 mm water bull Meningococal meningitis H flu needs droplet isolation

Prophylaxis For Close Contacts

bull Close contact with patient with suspected N meningitidis for at least 4 hours during the week before onset (eg house mates daycare center cell mates) or were exposed to patients nasopharyngeal secretions (eg kissing mouth-to-mouth resuscitation intubation nasotracheal suctioning)

bull Rifampin (pediatric dose children lt1 mo - 5 mgkg q12h children gt1 mo - 10 mgkg q12h adult dose 600 mg PO bid) for 4 doses

bull Alternative - Ciprofloxacin (adults) 500 mg PO single dose or ceftriaxone (lt15 y 125 mg gt15 y 250 mg) IM single dose

bull Meningococcal vaccine only in established epidemics or in travelers to epidemic countries

bull Prophylaxis for H influenzae type b is controversial Most authorities treat contacts to protect unvaccinated children younger than 4 years

AGE CAUSATIVE ORGANISM TREATMENT

lt1 MONTH

GBS ECOLIGNRs listeria Ampicillin + cefotaxime or gentamicin

1-3 months

Pneumococci meningococci H influenzae

Vancomycin IV + ceftriaxone or cefotaxime

3 months-adulthood

Pneumococci meningococci Vancomycin IV +ceftriaxone or cefotaxime

gt60 yrsalcoholism chronic illness

Pneumococci gram ndash bacilli listeria meningococci

Ampicillin + vancomycin+ cefotaxime or ceftriaxone

Adult doses cefotaxime (2 g IV q4h) or ceftriaxone (2 g IV q12h) vancomycin (15-20 mgkg IV q12h Ampicillin 50-100 mgkg IV q6h Chloramphenicol (PCN allergic) 50-100 mgkgd POIV divided q6h

Bacteria Susceptibility Antibiotic(s)Durati

inDays

S pneumoniae Penicillin MIC lt01 mgL

Penicillin G 10-14

MIC 01-1 mgL Ceftriaxone or cefotaxime

MIC gt2 mgL Ceftriaxone or cefotaxime

Ceftriaxone MIC gt05 mgL

Ceftriaxone or cefotaxime plus vancomycin or rifampin

H influenzae Beta-lactamase-negative

Ampicillin 7

Beta-lactamase-positive

Ceftriaxone or cefotaxime

N meningitidis Penicillin G or ampicillin 7

Listeria monocytogene

Ampicillin or penicillin G plus an aminoglycoside

14-21

S agalactiae Penicillin G plus an aminoglycoside if warranted

14-21

Enterobacteriaceae

Ceftriaxone or cefotaxime plus an aminoglycoside

21

P aeruginosa Ceftazidime plus an aminoglycoside 21

Trauma Surgery

bull Basilar skull Fracture

S pneumoniae H influenzae amp group A beta hemolytic streptococci

bull Treatment-Treatment-Vancomycin and Rocephin

bull Penetrating Trauma and neurosurgeryVPS

S aureus S

epidermidis Pseudomonas

bull Treatment- Treatment- Vancomycin amp Cefepime or ceftazidim or meropenem

Tuberculous Meningitis-TBM bull Most common cause of chronic meningitis is Mycobacterium tuberculosis (40-60) bull Mycobacterium tuberculosis may infect CNS by crossing the BBB or rupture of a Rich focusbull Following active primary pulm TB but may be absent bull Travel Hx HIV- Immunosuppressants alcoholics bull Presentation is nonspecific (headache fever malaise lethargy and confusion-over 1 to 2 weeks ) bull PPD may be negative bull Diagnosis- CSF-AFB smear (higher-grade infection PCR (expensive) amp AFB cultures (weeks)bull CSF findings include increased opening pressure lymphocytosis increased protein levels decreased

glucose levelsbull Treatment longer than that for pulmonary TB (6m) extended to 1 to 2 years in neurologically

compromised or immunosuppressed bull Tx rifampin 10 mgkgday orally isoniazid 5 mgkgday orally (with pyridoxine) pyrazinamide 15

to 30 mgkgday orally and either ethambutol 15 to 20 mgkgday orally or streptomycin 15 mgkgday intramuscularly for 2 months followed by 10 months of rifampin and isoniazid

bull Most common side effects peripheral neuropathy (isoniazid) flulike illness red discolor (rifampin) nauseavomitingmalaisehyperurecemia (pyrazinamide) and optic neuropathy-eye (ethambutol) All of the agents may cause rash and hepatotoxicity

bull Moxifloxacin 400 mgday orally if resistance bull Steroids for the first 6 monthsbull Household contacts should be tested and treated for latent TB

CEREBRAL MALARIA bull Plasmodium falciparum bull mortality between 25-50 If a person is not treated CM is

fatal in 24-72 hours bull risk factors include being a child under 10 years of age and

living in malaria-endemic area bull The histopathological hallmark of this encephalopathy is the

sequestration of cerebral capillaries and venules with parasitized red blood cells (PRBCs)

bull key elements of Dx are (1) unrousable coma--no localizing response to pain persisting for more than six hours if the patient has experienced a generalized convulsion (2) asexual forms of P falciparum found in blood and (3) exclusion of other causes of encephalopathy ie viral or bacterial

bull Tx is supportive IV quinine and Exchange transfusion- when peripheral parasitemia exceeds 10 of circulating erythrocytes

Syphilitic meningitis (Neurosyphilis)

bull Due to Treponema pallidum in the primary or secondary stage of infection

bull both immunocompetent and immunocompromised (especially HIVAIDS) individuals

bull evolves within months of inoculation but frequently is asymptomatic

bull Fever often is absent but headache and confusion may be evident

bull Typical CSF findings include (Aseptic profile) lymphocytosis increased protein levels normal glucose levels and positive serologic tests for syphilis (CSF) VDRL amp FTA-Abs

bull Treatment- Penicillin G Aggressive dosing (24 million unitsday IV) x 14 days

bull allergy to penicillin desensitization bull With initiation of penicillin G a release of endotoxin may

occur resulting in skin rash and an inflammatory response known as the Jarisch-Herxheimer reaction

Lyme Meningitis (neuroborreliosis )

bull Due to Borrelia burgdorferi in stage 2bull exposure to an ixodid tickbull presents after the characteristic Lyme disease rash

disappearsbull main symptoms are peripheral and cranial

neuropathies (71) bull CSF findings include (Aseptic profile) lymphocytosis

increased protein levels normal glucose levels and positive serologic tests for B burgdorferi

bull treatment is ceftriaxone 2 gday IV or penicillin G 20 million unitsday IV for 10 to 14 days

bull Doxycycline 100 mgday IV may be used in patients who are allergic to penicillins or cephalosporins

bull Symptoms usually resolve slowly over weeks to months

Differentiating Lyme meningitis from enteroviral meningitis (Aseptic meningitis)

The duration of symptoms before evaluation was longer for patients with Lyme meningitis (12 days) than with enteroviral meningitis (1 day) Cranial neuropathy erythema migrans rash or papilledema occurred mostly in patients with Lyme meningitis no patients with enteroviral meningitis

Lyme meningitis was unlikely when cerebrospinal fluid neutrophils exceeded 10

Meningitis Complications

1048708 Death1048708 Hearing loss1048708 Seizures1048708 Learning disorders

Brain Abscess

bull The most common organisms are streptocooci staphylococci and anaerobes

bull May develop frombull Spread from a cranial infection bull Sinusitisbull Dental infection- anaerobes frontal lobe bull Otitis media (temporal lobe and cerebellum-Strep

pseudomonas haemophilus)bull Head traumabull Neurosurgerybull Hematogenous spread- MCAPosterior frontal and parietal lobes- multiple abscess that

are poorly encapsulated and located at the gray-white junction

Brain Abscess

bull Symptomsbull Headache fever focalgeneral neuro

deficitsbull Mass effect Cerebral edema

bull Frontal lobe-hemiparesisbull Temporal lobe-dysphasiabull Cerebellum-ataxia

bull Diagnosisbull MRI CTbull Gram stain and culture by needle aspirationbull NO LP

Brain Abscess

bull Treatment-Parenteral antibiotics-6-8wks

bull Rocephin and Metronidazole

bull Trauma-Use cefepime or ceftazidime for pseudomonas and vancomycin for staphylococci

bull Neurosurgical Drainage

Subdural Empyema amp Epidural Abscess

bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment

bull Emergency surgical evacuation of empyema

bull 3rd generation cephalosporin vancomycin amp metronidazole (Parenteral)

bull Fluid gram stain and culture

Viral Meningitis

bull Enteroviruses (PoliovirusEchovirus Coxsackievirus AB)

bull Paramyxovirus (MumpsMeasles virus)

bull Herpesvirus (HSV-1 and HSV 2Varicella-zoster virusEBVCMVHHV-6 HHV-7

bull Rabies virus

bull HIV

bull LCM virus (Lymphocytic choriomeningitis)

Morbilliform rash with pharyngitis and adenopathy may suggest a viral etiology (eg Epstein-Barr virus [EBV] cytomegalovirus [CMV] adenovirus HIV)

Varicella zoster virus (VZV) or HHV-3 and CMV are causes of meningitis in immunocompromised hosts especially patients with AIDS and transplant recipients

HIV encephalitisHIV encephalitisPlain CT scan Bilateral and symmetric diffuse hypodensity in the periventricular white matter without any mass effect

Lymphocytic Choriomeningitis (LCM)Rodent-borne (common house mouse) viral (Arenaviridae-LCMV ) meningoencephalitisInfections from pet rodents(mice hamsters or guinea pig) fresh urine droppings saliva or nesting

materials Vertical transmission (Pregnancy)-congenital hydrocephalus chorioretinitis and mental

retardation Transmission -directly introduced into broken skin the nose the eyes or the mouth or presumably

via the bite of an infected rodent organ transplantation

Onset of symptoms usually occurs 8-13 days after exposure

bull A characteristic biphasic febrile illness then follows bull The initial phase which may last as long as a week typically begins with any or all of the

following symptoms fever malaise lack of appetite muscle aches headache nausea and vomiting Other symptoms that appear less frequently include sore throat cough joint pain chest pain testicular pain and parotid (salivary gland) pain

bull Following a few days of recovery the second phase of the disease occurs consisting of symptoms of meningitis (for example fever headache and a stiff neck) or characteristics of encephalitis (for example drowsiness confusion sensory disturbances andor motor abnormalities such as paralysis)

bull LCMV has also been known to cause acute hydrocephalus which often requires surgical shunting to relieve increased intracranial pressure

bull Rarely myelitis (muscle weakness paralysis or changes in body sensation)bull An association between LCMV infection and myocarditis

Lymphocytic Choriomeningitis (LCM) Diagnosis

bull During the first phase (leukopeniathrombocytopenia) Liver enzymes in the serum may also be mildly elevated

bull After the onset of neurological disease during the second phase CSF- (aseptic profile) uarr WBC (lymphocytes) normal or ~uarr protein normal glucose normal or ~uarr opening pressure

bull Serologybull Viral Culturesbull PCR bull CSF

bull Supportive tx bull Analgesicsbull Antipyreticsbull Antiemeticsbull mortality is less than 1bull Exposure to rodents suggests infection with lymphocytic

choriomeningitis (LCM) virus and LeptospiraLeptospira infection infection

Fungal Meningitis

bull Most common fungal cause of chronic meningitis is Cryptococcus neoformans (an encapsulated yeast) most often in patients with HIVAIDS

bull Other are Coccidioides immitis Histoplasma capsulatum Blastomyces dermatitidis Aspergillus fumigatus Candida albicans and Sporothrix schenckii

bull Immunocompromised individuals and presentation depends on the fungus involved

bull Cryptococcal meningitis usually presents as headache fever and lethargy Other symptoms are visual impairment cranial neuropathies ataxia seizures and altered cognition

bull Diagnosis-CSF (Aseptic profile) lymphocytosis decreased glucose levels increased protein levels positive culture tests and a greatly elevated opening pressure upon lumbar puncture

bull Cultures and serologyC neoformans-India ink stainCrypto antigen (may be neg in capsule-deficient C neoformans)

bull Amphotericin B AMB deoxycholate (AMBD) 07 to 1 mgkgday with flucytosine 100 mgkgday for 2 weeks followed by fluconazole 400 mgday orally for at least 10 weeks Long-term fluconazole (usually 400 mgday orally) may be used for secondary prophylaxis

Cryptococcus neoformans amp HIV

Cryptococcal meningitis is the most common opportunistic infection of the CNS affecting 5-7 of patients with AIDS The second most common type of meningitis is aseptic meningitis which may be caused by HIV-1 itself HIV-associated meningitis develops within days to weeks after HIV infection It appears as a mononucleosis-like illness and is rarely associated with encephalitis Tx with HAART

Parasitic Meningitis

bull Amoebabull primary amebic meningoencephalitis (PAM)

bull Naegleria fowleribull southern tier states (AR AZ CA FL

GA LA MO MS NC NM NV OK SC TX and VA)

bull Bodies of warm freshwater such as lakes rivers

bull Geothermal (naturally hot) water such as hot springs

bull Geothermal (naturally hot) drinking water sources

bull Warm water discharge from industrial plants

bull Poorly maintained and minimally-chlorinated or unchlorinated swimming pools

bull Soil bull Diagnosis

bull CSF wet prepbull Treatment

bull Amp B and miconazole

bull Helminths

bull Angiostrongylus cantonensis

bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive

1048707 Chronic meningitis include Taenia solium (pork tapeworm-Neurocycticercosis the most common parasitic infection of the CNS ) Angiostrongylus cantonensis (Rat lungworm) Toxoplasma gondii and Acanthamoeba species Echinococcus granulosus (Hydated Disease)

Neurocycticercosisbull most common in Latin America Asia Africa and parts

of Europe

bull can affect subcutaneous muscle or CNS ( ~ 50 meningitis)

bull can be asymptomatic but sometimes symptoms such as severe headache seizures vision changes and ischemic cerebrovascular disease

bull CSF findings usually include elevated protein levels normal glucose levels and eosinophilia

bull albendazole 400 mg twice daily orally for 15 days then 400 mgday orally for 15 days and prednisone 60 mgday orally for 3 days

TOXOPLASMOSISTOXOPLASMOSIS bulleating undercooked meat of animals harboring tissue cysts bullconsuming food or water contaminated with cat feces or by contaminated environmental samples (such as fecal-contaminated soil or changing the litter box of a pet cat)

bullblood transfusion or organ transplantation

bulltransplacentally from mother to fetus

Laboratory Studies

SerologyAnti-Toxoplasma immunoglobulin detection Rising serum (IgG) titers (IgM) antibody response in newly acquired toxoplasmosis or Toxoplasma encephalitis

may be unreliable in immunodeficient individuals especially in AIDS

Serologic testing can be falsely negative or noncontributory if levels do not rise from a baseline

In one study 16 of patients with a clinical diagnosis and 22 of patients with a histologic diagnosis of toxoplasmosis had undetectable anti-T gondii IgG levels

Causes of false-negative results include recent infection and insensitive assays

The detection of Toxoplasma gondii by PCR may facilitate the diagnosis and follow-up of toxoplasmosis in patients with AIDS (sensitivity of 833 and specificity of 957)

Toxoplasma gondii abscesses

TOXOPLASMOSISTOXOPLASMOSIS

bull CT scan or MRIbull Single or multiple hypodense or hypointense lesions in white

matter and basal ganglia with mass effects may be observedbull Lesions may enhance in a homogeneous or ring pattern with

contrastbull Imaging studies may be normal in diffuse toxoplasmosisbull MRI is more sensitive than CT scan in detecting multiple lesionsbull Single lesions favor the diagnosis of lymphoma over that of

toxoplasmosis However while multiple lesions are more common than single lesions in toxoplasmosis in one study 27 of patients had a single lesion on CT scan In the same study 14 had a single lesion on MRI

bull Thallium Th 201 brain single-photon emission computed tomography (SPECT) may be useful in distinguishing between lymphoma and toxoplasmosis Lymphoma shows an increased uptake compared with toxoplasmosis False-positive and false-negative results may occur if the lesion is smaller than 2 cm

bull Proceduresbull Indications for brain biopsy include the following

bull Single mass lesion and negative serologic resultsbull No response to 14 days of empiric therapy

tissue cyst and tachyzoites in the brain parenchyma

Ring-enhanced lesions in the right basal ganglia and the left frontal lobe with a large mass effect and peripheral oedema

ring-enhanced parieto-occipital lesion with a large mass effect and peripheral oedema

TOXOPLASMOSISTOXOPLASMOSISPrevention amp TreatmentPrevention amp Treatment

bull Reduce Risk of Toxo from the Environmentbull Avoid drinking untreated drinking water particularly when traveling in less developed

countriesbull Wear gloves when gardening and during any contact with soil or sand because it might be

contaminated with cat feces that contain Toxoplasma Wash hands thoroughly after gardening or contact with soil or sand

bull Keep outdoor sandboxes covered bull Feed cats only canned or dried commercial food or well-cooked table food not raw or

undercooked meats bull Change the litter box daily if you own a cat The Toxoplasma parasite does not become

infectious until 1 to 5 days after it is shed in a cats feces bull Avoid changing cat litter if possible If no one else can perform the task wear

disposable gloves and wash your hands thoroughly with soap and water afterwards bull Keep cats indoors bull Do not adopt or handle stray cats especially kittens Do not get a new cat while you

are pregnant

bull Reduce Risk of Toxo from Food bull Reduce the risk of acquiring toxoplasmosis and other infections from food by following these

guidelines bull Cook food to safe temperatures A food thermometer should be used to measure the

internal temperature of cooked meat Do not sample meat until it is cooked bull Lamb beef pork or venison should be cooked to an internal temperature of 165degF-

170degF throughout bull Whole poultry should be cooked to 180degF in the thigh

bull Peel or wash fruits and vegetables thoroughly before eating bull Wash cutting boards dishes counters utensils and hands with hot soapy water after

contact with raw meat poultry seafood or unwashed fruits or vegetables bull Freeze meat for several days before cooking to greatly reduce chance of infection

Most healthy people recover from toxoplasmosis without treatmentPersons who are ill can be treated with a combination of drugs such as pyrimethamine and sulfadiazine plus folinic acid

Viral Encephalitidis

Arboviruses are the most common causes of episodic encephalitis with

The 2 most common arboviruses

(1) St Louis encephalitis found throughout the United States but principally in urban areas around the Mississippi River

(2) Geographically misnamed California virus (in particular the strain that causes LaCross encephalitis [LAC]) which affects children in rural areas in states of the northern Midwest and East Among the other arboviruses causing encephalitis the deadliest and fortunately most uncommon eastern equine encephalitis (EEE) is encountered in New England and surrounding areas the milder western equine encephalitis (WEE) is most common in rural communities west of the Mississippi River

Domestic Arboviral Encephalitidisbull Eastern equine encephalitisEastern equine encephalitis also infects birds that live in freshwater swamps of the

eastern US seaboard and along the Gulf Coast In humans symptoms are seen 4-10 days following transmission and include sudden fever general flu-like muscle pains and headache of increasing severity followed by coma and death in severe cases About half of infected patients die from the disorder Fewer than 10 human cases are seen annually in the United States

bull Western equine encephalitisWestern equine encephalitis is seen in farming areas in the western and central plains states Symptoms begin 5-10 days following infection Children particularly those under 12 months of age are affected more severely than adults and may have permanent neurologic damage Death occurs in about 3 percent of cases

bull LaCrosse encephalitisLaCrosse encephalitis occurs most often in the upper midwestern states (Illinois Wisconsin Indiana Ohio Minnesota and Iowa) but also has been reported in the southeastern and mid-Atlantic regions of the country Most cases are seen in children under age 16 Symptoms such as vomiting headache fever and lethargy appear 5-10 days following infection Severe complications include seizure coma and permanent neurologic damage About 100 cases of LaCrosse encephalitis are reported each year

bull St Louis encephalitisSt Louis encephalitis is most prevalent in temperate regions of the United States but can occur throughout most of the country The disease is generally milder in children than in adults with elderly adults at highest risk of severe disease or death Symptoms typically appear 7-10 days following infection and include headache and fever In more severe cases confusion and disorientation tremors convulsions (especially in the very young) and coma may occur

bull Among less common causes of viral encephalitis bull Varicella-zoster encephalitis has an incidence of 1 in 2000 infected

persons bull Measles produces 2 devastating forms of encephalitis postinfectious

which occurs in about 1 in 1000 infected persons and SSPE occurring in about 1 in 100000 infected patients

bull Typically 0-3 unrelated cases of rabies encephalitis are identified yearly

Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4

Cumulative Total Entire Country 547

West Nile VirusWest Nile VirusCumulative 2010 Data as of 3 am Sep 28 2010

Domestic Arboviral DiseasesWest Nile VirusWest Nile Virus

bull Clinical descriptionbull may be asymptomatic bull meningitis fever headache stiff neck and

pleocytosis in CSFbull Myelitis fever and acute bulbar or limb paresis or

flaccid paralysis bull Encephalitis fever headache and AMS-confusion

to coma bull cranial and peripheral neuritis or other

neuropathies including Guillain-Barreacute syndrome bull West Nile fever [WNF] febrile illnesses (non-

localized self-limited illnesses with headache myalgias arthralgias skin rash or lymphadenopathy

WNV between the months of July and September incubation period ranges from three to 14 days

Clinical criteria for diagnosis

bull Neuroinvasive disease requires the presence of fever and at least one of the following

bull Acutely altered mental status (eg disorientation obtundation stupor or coma) or

bull Other acute signs of central or peripheral neurologic dysfunction (eg paresis or paralysis nerve palsies sensory deficits abnormal reflexes generalized convulsions or abnormal movements) or

bull Pleocytosis (increased white blood cell concentration in cerebrospinal fluid [CSF]) associated with illness clinically compatible with meningitis (eg headache or stiff neck)

bull Non-neuroinvasive disease requires at minimum the presence of documented fever as measured by the patient or clinician the absence of neuroinvasive disease (above) and the absence of a more likely clinical explanation for the illness Involvement of non-neurological organs (eg heart pancreas liver) should be documented using standard clinical and laboratory criteria

West Nile VirusWest Nile Virus

Laboratory criteria for diagnosisFour-fold or greater virus-specific serum antibody titer OR Isolation of virus from or demonstration of specific viral antigen or genomic sequences in tissue blood cerebrospinal fluid (CSF) or other body fluid OR Elevated virus-specific immunoglobulin (IgG) antibodies in the acute or convalescent serum specimen as measured by VN or HI or IgG enzyme immunoassay (EIA) OR Virus-specific immunoglobulin M (IgM) antibodies demonstrated in serum by IgM antibody-capture enzyme immunoassay (EIA)

Case classification A case must meet one or more of the above clinical criteria and one or more of the above laboratory criteria

Confirmed case Four-fold or greater change in virus-specific serum antibody titer OR Isolation of virus from or demonstration of specific viral antigen or genomic sequences in tissue blood CSF or other body fluid OR Virus-specific immunoglobulin M (IgM) antibodies demonstrated in CSF by antibody capture enzyme immunoassay (EIA) OR Virus-specific IgM antibodies demonstrated in serum by antibody-capture EIA and confirmed by demonstration of virus-specific serum immunoglobulin G (IgG) antibodies in the same or a later specimen by another serologic assay (eg neutralization or hemagglutination inhibition)

Probable case Stable (less than or equal to a two-fold change) but elevated titer of virus-specific serum antibodies OR Virus-specific serum IgM antibodies detected by antibody-capture EIA but with no available results of a confirmatory test for virus-specific serum IgG antibodies in the same or a later specimen


Caveat in DiagnosisCaveat in Diagnosisbull In some persons West Nile virus-specific serum IgM

antibody can wane slowly and be detectable for more than one year following infection Therefore in areas where West Nile virus has circulated in the recent past the co-existence of West Nile virus-specific IgM antibody and illness in a given case may be coincidental and unrelated

bull In those areas the testing of serially collected serum specimens assumes added importance

bull Dengue fever and West Nile fever can be clinically indistinguishable the importance of a recent travel history and appropriate serologic testing

bull No specific treatment is available bull In severe cases treatment consists of supportive care


CMV Encephlitisbull Cytomegaloviral (CMV) infection usually

presents as an encephaloventriculitis with possible meningeal involvement

Proton density-weighted (SE 270030) axial and coronal images disclose hyperintensity surrounding the frontal horns and trigones of the lateral ventricles and also involving the splenium of the corpus callosum (arrows)

Herpes simplex encephalitis (HSE) bull 10 percent of all cases the overall incidence is 02 per

100000 bull More than half of untreated cases are fatal bull 30 percent of cases due to primary infection majority due to

reactication of virus lying dormant in the trigeminal ganglia bull The mortality rate of herpes simplex encephalitis in

untreated patients is 70 Among treated patients the mortality rate is 19 and more than 50 of survivors are left with moderate or severe neurological deficits

bull HSV-1 most often seen in persons under age 20 or over age 40 single most important cause of fatal sporadic encephalitis in the US

bull transmitted through contact with an infected person bull Symptoms include headache and fever for up to 5 days

followed by personality and behavioral changes seizures partial paralysis hallucinations and altered levels of consciousness Brain damage in adults and in children beyond the neonatal period is usually seen in the frontal and temporal lobes and can be severe

Herpes simplex encephalitis

bull Type 2 virus (genital herpes) is most often transmitted through sexual contact An infected mother can transmit the disease to her child at birth through contact with genital secretions but this is uncommon In newborns symptoms such as lethargy irritability tremors seizures and poor feeding generally develop between 4 and 11 days after delivery


bull Typical symptoms include the following

bull Fever (90)bull Headache (81)bull Psychiatric

symptoms (71)bull Seizures (67)bull Vomiting (46)bull Focal weakness

(33)bull Memory loss

(24)

Typical findings on presentation include the following

Alteration of consciousness

(97)Fever (92)

Dysphasia (76)Ataxia (40)

Seizures (38)Focal (28)Generalized

(10)Hemiparesis

(38)Cranial nerve defects (32)

Visual field loss (14)

Papilledema (14)


Laboratory StudiesSerologic analysis

Serologic evaluation of blood or CSF may be useful for retrospective diagnosis but it has no role in the acute diagnosis and treatment of patients

Strategies based on increases in antibody levels and on the ratio of antibody levels in serum and CSF have not proven to be clinically useful

CSF analysisPatients with herpes simplex encephalitis (HSE) typically have mononuclear pleocytosis of 10-500

WBCsmicroL (average 100 WBCsmicroL)As a result of the hemorrhagic nature of the underlying pathologic process the RBC count may be

elevated (10-500 RBCsmicroL)Protein levels are elevated to the range 60-700 mgdL (average 100 mgdL)

Glucose values may be normal or mildly decreased (30-40 mgdL)In about 5-10 of patients especially children initial CSF results may be normal However on serial

examinations the cell counts and protein values increaseViral cultures of CSF are rarely positive and should not be relied on to confirm the diagnosis

Polymerase chain reactionPCR analysis of CSF for the detection of HSV DNA has virtually replaced brain biopsy as the criterion

standard for diagnosisPCR is highly sensitive (94-98) and specific (98-100)

Results become positive within 24 hours of the onset of symptoms and remain positive for at least 5-7 days after the start of antiviral therapy

Clinical severity and outcome appear to correlate with viral load as assessed by quantitative PCR techniques16 but not all investigators have confirmed this

False-negative findings may occur early in the course of the disease when viral DNA levels are low (within 72 h of the onset of symptoms) or when blood is present in the CSF as hemoglobin may

interfere with PCR18 Pretest probability should be considered in interpretation of results A negative result obtained less than 72 hours after the onset of symptoms in a patient with a high pretest probability (fever focal

neurological abnormalities CSF pleocytosis) should be repeatedFalse-positive test results are rare and usually reflect accidental contamination of the specimen in

the laboratory

Herpes simplex encephalitis)

Imaging StudiesMRI of the brain is the preferred imaging study Abnormalities are found in 90 of patients with HSE MRI may be normal early in the course of illness Findings of localized temporal abnormalities are highly suggestive of HSE but confirmation of the diagnosis depends on the identification of HSV by means of PCR or brain biopsy Head CT may show changes in the temporal andor frontal lobe but CT is less sensitive than MRIApproximately one third of patients with HSE have normal CT findings on presentation

ElectroencephalographyElectroencephalography (EEG) shows focal abnormalities such as spike and slow- or periodic sharp-wave patterns over the involved temporal lobesEEG is 84 sensitive to abnormal patterns in HSE but lacks specificity (32)

Axial gadolinium-enhanced T1-weighted image reveals enhancement of the right anterior temporal lobe and parahippocampal gyrus At the right anterior temporal tip is a hypointense crescentic region surrounded by enhancement consistent with a small epidural abscess

Herpes simplex encephalitis (HSE)

bull The diagnosis of HSE should be considered in any patient with a progressively deteriorating level of consciousness fever abnormal CSF findings and focal neurological abnormalities in the absence of any other causes

bull Rapid initiation of acyclovir therapy is crucial to reduce mortality and morbidity risks

bull Since most relapses occur within 3 months of completing an initial course of intravenous acyclovir a prolonged course of an oral antiviral agent (eg valacyclovir) has been suggested following initial treatment

bull Steroids have been used to reduce cerebral edema in patients with severe HSE

RABIESRABIES

Patients with rabies could present atypically with aseptic meningitis and rabies should be suspected in a patient with a history of animal bite (eg skunk raccoon dog fox bat)

Rabies Major Vector Species in the US

RABIES CONTROL IN ANIMALS

bull 1048708 Stray animal controlbull 1048708 Vaccinationbull 1048708 Humansbull 1048708 Those at riskbull 1048708 Dogs and cats (horses cattle sheep)bull 1048708 Given by veterinarian every 3 yearsbull 1048708 Ferrets (approved vaccine only)

RABIES -IF A PERSON IS BITTEN

bull 1 Wash with soap and waterbull 2 Rabies immunoglobulin (RIG)bull 1048708 Given immediately into the woundbull 3 Rabies vaccinationbull 1048708 Given at day 0 3 7 14 and 28

Diagnosis

bull Signs and Symptomsbull Similar to meningitis-Correspond with

area of infectionbull hallucinations seizures personality

changes aphasia ataxia CN deficits DI SIADH

bull CSF-Similar to viral meningitisbull uarruarr Opening pressure

Progressive Multifocal Leukoencephalopathy (PML)

bull Due to JC virusbull Most patients are immunocompromised

bull Diagnosisbull MRI-Periventricular white matter

lesionsbull CSF typically normal

bull PCR for JVC DNAbull Treatment-No effective treatment

bull Neither cytarabine and cidofovir showed any benefits

bullslow virus infections such as those implicated in the measles-related subacute sclerosing panencephalitis (SSPE) and progressive multifocal leukoencephalopathy (PML)

Prions

Examples of Prion DiseaseThat Affects the Brain

bull 1048708 Kurubull 1048708 Variant Creutzfield-Jacob Diseasebull (Mad Cow Disease)bull 1048708 Chronic Wasting Disease (CWD)bull in deer and elk

Noninfectious Causesbull Neurosarcoidosis- noncaseating granulomas in the lungs skin

joints eyes andmdashrarely CNS- acute aseptic meningitis or chronic meningitis meningeal mass lesions meningitis is usually is caused by opportunistic organisms (cryptococc)

bull CSF lymphocytosis or monocytosis decreased or normal glucose levels and increased protein levels

bull oral corticosteroids Methotrexate may be added to shorten the time

bull Aseptic meningitis can occur in people with SLE as a result of the lupus from the medications (ie nonsteroidal anti-inflammatory drugs [NSAIDs] azathioprine) used for specific symptoms or from opportunistic infections that develop in individuals receiving chronic immunosuppressive therapy CSF findings typically include lymphocytosis increased protein levels and variable glucose levels

bull WG is a severe necrotizing granulomatous systemic vasculitis associated with the ANCA antibody It mostly involves the respiratory tract and kidneys but may also affect the eyes and CNS Chronic meningitis a rare complication of WG is treated with high-dose corticosteroids and cyclophosphamide

CNS Infections

Definitions

Meningitis

Microorganisms That Can Infect the Brain


Slide 6

Slide 7

Slide 8

Signs amp Symptoms of Meningitis

Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery

Tuberculous Meningitis-TBM

CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis

Lymphocytic Choriomeningitis (LCM)


Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS

TOXOPLASMOSIS Prevention amp Treatment


Domestic Arboviral Encephalitidis

Slide 44

Domestic Arboviral Diseases West Nile Virus


Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57


RABIES - IF A PERSON IS BITTEN

Slide 60


Prions

Examples of Prion Disease That Affects the Brain

Noninfectious Causes

DefinitionsDefinitionsMeningitisMeningitis

bull 1048707 Inflammation of the leptomeningesbull (the covering of the brain)bull 1048707 Usually caused by bacteriabull Meningitis is the 9th deadliest disease in the modern

worldbull The incidence of bacterial meningitis declined from 19

to 15 cases per 100000 from 1998 to 2003 in part due to the introduction of the conjugate Haemophilus influenzae type b and pneumococcal conjugate vaccines

EncephalitisEncephalitisbull 1048707 Inflammation of the brain itselfbull 1048707 Caused by many types of organisms

but mainly virusesChronic meningitisChronic meningitis is defined as meningeal inflammation that persists for more than 4 weeks whereas acute meningitis lasts for less than 4 weeks















































Systemic findings



























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions

















































Systemic findings



























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Neisseria meningitidis meningitis
















Systemic findings



























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Haemophilus influenzae meningitis











Systemic findings



























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions










Systemic findings



























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions

























Diagnosis


LP

Blood Cultures

CSF





5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions




5-15 cm H2 O




















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions






















lt1 MONTH


1-3 months



3 months-adulthood







inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions




inDays


Penicillin G 10-14






Ampicillin 7






14-21


14-21

Enterobacteriaceae


21


Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Trauma Surgery





S aureus S





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions





































Brain Abscess





Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Brain Abscess





Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Brain Abscess






bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions




bull Diagnosis

bull MRI CT

bull NO LP

bull Treatment




Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



Viral Meningitis




bull Rabies virus

bull HIV





















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



















Fungal Meningitis






















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions

















bull Helminths


bull Rat lungworm

bull G spinigerum

bull GI parasite

bull Treatment

bull Supportive



of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions




of Europe








Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions






Laboratory Studies



























are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions






















are pregnant






















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions

















Alabama 3

Arizona 101

Arkansas 3

California 50

Colorado 38

Connecticut 7

Florida 7

Georgia 10

Idaho 1

Illinois 18

Indiana 5

Iowa 3

Kansas 6

Kentucky 1

Louisiana18

Maryland 9

Massachusetts 3

Michigan16

Minnesota 3

Mississippi 5

Missouri 4

Nebraska36

Nevada 2

New Jersey17

New Mexico11

New York89

North Dakota 8

Ohio 2

Pennsylvania 12

South Dakota 20

Tennessee 1

Texas 31

Virginia 2

Wisconsin 1

Wyoming 4














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions














































(24)



(97)Fever (92)



(10)Hemiparesis



Papilledema (14)

















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions



















the laboratory










RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions












RABIESRABIES







Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions








Diagnosis












Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions










Prions









CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

Slide 16

Slide 17


Slide 19

Slide 20

Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

Slide 29

Slide 30


Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



Slide 47

Caveat in Diagnosis

CMV Encephlitis




Slide 53



Slide 56

Slide 57



Slide 60


Prions











CNS Infections

Definitions

Meningitis



Slide 6

Slide 7

Slide 8


Systemic findings

Slide 11

Laboratory Studies

Imaging Studies


Diagnosis

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Trauma Surgery


CEREBRAL MALARIA





Brain Abscess

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Viral Meningitis



Fungal Meningitis



Neurocycticercosis

Slide 39

TOXOPLASMOSIS




Slide 44



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Caveat in Diagnosis

CMV Encephlitis




Slide 53



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Slide 57



Slide 60


Prions



CNS Infections Siddiqui

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Transcript of CNS Infections Siddiqui