CENTRAL NERVOUS

SYSTEM INFECTIONS

Dr. Khalid Mohammed Ali

Associate Professor
Consultant Neurologist
OBJECTIVES
 To be aware about the types of CNS
infections
 To know the different clinical and pathological

pattern of CNS infections

 To be able to deal with emergency situations

of CNS infections
Infections of the central nervous system (CNS)
can be divided into 2 broad categories:
1. Primarily involving the meninges
(meningitis).
2. Primarily confined to the parenchyma
(encephalitis).
 MENINGITIS
A clinical syndrome characterized by
inflammation of the meninges.
Anatomically, meningitis can be divided into:
1. Inflammation of the dura (pachymeningitis).
2. Inflammation of the arachnoid tissue and
subarachnoid space (leptomeningitis): more
common.
 RISK FACTORS
Extremes of age (< 5 or >60 years).
Immunosuppression: diabetes mellitus, renal
failure, HIV (encapsulated organisms mainly
Streptococcus pneumoniae).
Crowding: meningococcal meningitis.
Recent exposure to others with meningitis.
Splenectomy and sickle cell disease:
encapsulated organisms.
Alcohol consumption, intravenous drug abuse.
Bacterial endocarditis.
 CAUSES
Bacterial meningitis:
Middle-age:
 Meningococcal meningitis.
 Haemophilus influenzae meningitis.
 Pneumococcal meningitis.
Streptococcus agalactiae (group B streptococci),
E.coli: neonates.
Elderly: Listeria monocytogenes.
Staphylococcal meningitis: intracranial manipulation
e.g. neurosurgery.
Tuberculous meningitis.
Nonbacterial meningitis:
 Viral: herpes simplex virus, cytomegalovirus,
HIV.
 Fungal: cryptococcal meningitis.
 Parasitic: amoebic meningoencephalitis.
Autoimmune diseases: systemic lupus
erythematosus.
Carcinoma.
Aseptic meningitis: the cause is not apparent after
initial evaluation, acute onset of meningeal
symptoms and prominent lymphocytes on CSF.
 CLINICAL FEATURES
Onset: acute (bacterial), subacute, chronic.
The classic triad of bacterial meningitis:
 Fever.
 Headache.
 Neck stiffness.
Nausea, vomiting, photophobia.
Convulsions, irritability, confusion, coma.
Patients with viral meningitis: preceding
systemic symptoms/ respiratory tract infections
(e.g., myalgia, fatigue, anorexia).
Elderly individuals/co-morbidities: lethargy and
absence of meningeal symptoms.
A history of exposure to a patient with a similar
illness, travel to endemic area, recent antibiotic
use.
Examination:
Glasgow coma scale, vital signs.
Focal neurological signs: cranial nerves III, IV, VI,
and VIII; papilloedema.
Signs of meningeal irritation: (neck stiffness,
Kernig’s and Brudzinski signs).
Systemic findings:
 Petechiae/purpura (meningococcal meningitis).
 Chest examination (tuberculosis).
 Hepatosplenomegaly and lymphadenopathy
(viral/ HIV).
 Heart murmurs (infective endocarditis).
 DIFFERENTIAL DIAGNOSES
Encephalitis.
Cerebral malaria.
Noninfectious meningitis: SLE, carcinoma.
Central nervous system (CNS) vasculitis.
Stroke.
Subarachnoid haemorrhage.
Subdural empyema.
 INVESTIGATIONS
Complete blood count (CBC).
Serum glucose.
Renal and liver function tests.
Blood, nasopharynx, respiratory secretion
cultures.
Lumbar puncture and CSF analysis: opening
pressure, cell count (and differential), chemistry
and microbiology.
Neuroimaging (computed tomography, magnetic
resonance imaging).
 Agent Opening WBC Glucose Protein
Pressure count
Bacterial ↑ ↑↑ ↓ ↑
meningitis >80% CSF glucose
neutophils to blood
glucose ratio
of <½

Tuberculous ↑ ↑ ↓ ↑
meningitis lymphocytes

Viral Normal ↑ Normal Normal but

meningitis lymphocytes may be
slightly
elevated
Aseptic Normal ↑ Normal Normal but
meningitis lymphocytes may be
slightly
elevated
 TREATMENT
Airway protection, oxygen, correct hypovolaemia.
Antipyretics.
Anticonvulsants if needed.
Empirical treatment: third generation cephalosporin
(ceftriaxone, cefotaxime) ± vancomycin.
 >55yrs: add ampicillin.
Tuberculous meningitis: isoniazid, rifampicin,
pyrazinamide, ethambutol, streptomycin for 9-12
months.
Steroids (as adjuvant treatment): e.g. H.influenzae,
tuberculosis, and pneumococcal meningitis.
 COMPLICATIONS
Hypotension or shock including disseminated
intravascular coagulation (DIC).
Hypoxemia.
Hydrocephalus.
Cranial nerve dysfunction: mainly II, VIII…
Brain abscess.
Subdural empyema
Mental retardation, brain atrophy.
Waterhouse-Friderichsen syndrome.
 PREVENTION
Vaccination is recommended in susceptible
individuals
Meningococcal vaccine: patients with immune
deficiencies, travelers to epidemic areas and
laboratory workers with routine exposure to
N.meningitidis.
Pneumococcal vaccine(S.pneumoniae): >65 years
and individuals with chronic cardiopulmonary
illnesses.
Both vaccines+H.influnzae): Splenectomized
patients: encapsulated bacterial organisms
(S.pneumoniae, N.meningitidis. H.influnzae).
 CHEMOPROPHYLAXIS
It is given to contacts of infected persons:
Meningococcal meningitis:
Rifampicin, ceftriaxone, ciprofloxacin.
Haemophilus influenzae:
Rifampicin.
 ENCEPHALITIS
Causes:
Viral (most common): herpes simplex type 1 and
2, Varicella-zoster, HIV, measles…
Mycoplasma species, Toxoplasma gondii.
Non-infectious causes include the demyelinating
process in acute disseminated encephalitis.
 CLINICAL FEATURES
The viral prodrome: fever, headache, nausea,
vomiting and myalgia.
Upper respiratory tract infections.
Varicella-zoster virus (VZV), measles: rash.
Epstein-Barr virus (EBV) or cytomegalovirus
(CMV): lymphadenopathy, hepatosplenomegaly.
Mumps: parotid enlargement.
The classic presentation is encephalopathy with
diffuse or focal neurological symptoms:
 Behavioral and personality changes.
 Acute confusion, decreased level of
consciousness.
 Photophobia.
 Generalized or focal seizures.
The signs of encephalitis may be diffuse or
focal:
 Altered mental status/ coma.
 Personality changes (very common).
 Focal findings (e.g. hemiparesis, focal
seizures).
 Cranial nerve defects.
 DIFFERENTIAL DIAGNOSES
Autoimmune encephalitis
Meningitis.
Cerebral malaria.
Acute confusional states secondary to metabolic
causes, drugs, toxins, psychosis.
Subarachnoid haemorrhage.
 INVESTIGATIONS
Complete blood count (CBC).
Serum glucose.
Renal function test.
Lumbar puncture: normal opening pressure and
glucose, normal or slightly increased protein,
increases lymphocytes.
Electroencephalogram (EEG).
Neuroimaging.
Viral serology.
 TREATMENT
General stabilization of the patient.
Antipyretics, anticonvulsants.
Aciclovir: as early as possible (within 30
minutes).
Management of and increased intracranial
pressure.
Treatment of complications (e.g. hypotension
shock, hypoxemia or hydrocephalus).
 COMPLICATIONS
Recurrent seizures.
Increased intracranial
pressure/ hydrocephalus.
Cranial nerves dysfunction.
Coma.
 BRAIN ABSCESS
Brain abscess is a focal intracranial infection
that may present as a life-threatening emergency.
Immunocompromised patients: higher incidence
of brain abscess.
 PATHOPHYSIOLOGY
Direct extension: from a primary focus of
infection outside the central nervous system that
extends into the brain e.g. chronic otitis media,
sinusitis and mastoiditis.
Hematogenous: e.g. chronic pulmonary
infections such as lung abscess and
bronchiectasis, endocarditis, abdominal or pelvic
infections.
Intracranial trauma or neurosurgical
intervention.
 CAUSATIVE AGENTS
Polymicrobial infections:
Streptococci.
Gram-negative bacilli: Pseudomonas.
Bacteroides(Anaerobes).
Staphylococci.
T.gondi, fungi (Immunocompromised
patients)
 CLINICAL FEATURES
Fever, headache, and focal neurological deficit.
The headache is often nonspecific, range from
mild to severe, focal or generalized.
Seizures.
Confusion>> coma.
Focal neurological deficit: hemiparesis
Third or sixth cranial nerve palsies, papilledema.
Neck stiffness and meningeal irritation signs.
DIFFERENTIAL DIAGNOSES
Meningitis.
Encephalitis.
Epidural and subdural empyema.
Epidural hematoma.
Intracerebral haemorrhage.
 INVESTIGATIONS
Complete blood count.
Inflammatory markers.
Blood cultures or cultures from the suspected
primary infection.
Serology.
Images: CT scans with and without contrast,
MRI is more sensitive than CT imaging.
Abscess aspiration and culture can be
performed.
 TREATMENT
General stabilization of the patient/ ABC.
Antipyretics.
Emergency: neurosurgical consultation.
Seizures control if present.
Broad spectrum antibiotics: third or fourth
generation cephalosporin + metronidazole;
vancomycin.
Serial neuroimaging: to follow the resolution of
the abscess.
 COMPLICATIONS
Persistent weakness, aphasia, or
cognitive impairment.
Increased intracranial pressure.
Intraventricular abscess rupture.