Acute Meningitis

1. Acute meningitis is an infection in the meninges that cover the brain and spinal cord.
2. Causative organisms
a. Mycoses - Cryptococcus neoformans, coccidioides, candida, actinomyces, histoplasma,
aspergillus
b. M tuberculosis, Lyme disease, HIV, Syphilis
3. Manifestations - flu-like syndrome, fever, and headache, less marked meningeal signs
4. Treatment - symptomatic and cause-directed
Acute Transverse Myelitis
1. Acute transverse myelitis is the acute inflammation of gray and white matter in one or more
adjacent spinal cord segments, usually thoracic.
2. Causative organisms mycoplasma, Lyme disease, syphilis, TB, viral meningoencephalitides
3. Manifestations
a. Pain in the neck, back, or head
b. Bandlike tightness around the chest or abdomen, weakness, tingling numbness of the
feet and legs, and difficulty voiding
c. Completè transverse sensorimotor myelopathy, paraplegia, loss of sensation below the
lesion, urinary retention, and fecal incontinence
4. Treatment - directed at the cause or associated disorder but is otherwise supportive
Aseptic Meningitis
1. Aseptic meningitis is the inflammation of the meninges with CSF lymphocytic pleocytosis and no
cause is apparent after routine CSF stains and cultures.
2. Causative organisms
a. Echovirus, coxsackievirus, enteroviruses 68 through 71, and other Enterovirus spp.
b. Herpes simplex virus type 2 (HISV-2), HIV, arthropod-borne viruses, mumps virus
c. Spirochetes (syphilis, Lyme disease, or leptospirosis) and rickettsiae (typhus, Rocky
Mountain spotted fever, or ehrlichiosis)
3. Manifestations - flu-like syndrome, fever, and headache, less marked meningeal signs
4. Treatment
a. Hydration, analgesics, and antipyretics
b. If listerial, partially treated, and early bacterial meningitis cannot be excluded,
antibiotics effective against bacterial meningitis are given pending results of cultures or
repeated CSF tests.
Bacterial Meningitis
1. Bacterial meningitis is the inflammation of the meninges of the brain or spinal cord. It is also
known as “septic meningitis”.
2. Causative organisms
a. Group B streptococci (during the first 2 months of life)
b. Neisseria meningitidis (meningococci)
c. Streptococcus pneumonia (pneumococci)
d. Gram-negative organisms – E coli, Klebsiella spp, Enterobacter spp, Pseudomonas spp, H
influenza type B
e. Staphylococci, Listeria
 3. Manifestations - fever, headache, nuchal rigidity, Brudzinski's sign, Kernig's sign, neck stiffness,
lethargy, confusion, seizures, focal deficits, death
4. Treatment
a. Unknown organisms
i. Ampicillin and cefotaxime or gentamicin with tobramycin for infants less than 1-
month-old
ii. Ampicillin and cefotaxime or ceftriaxone with vancomycin for children older
than 1-month-old
iii. Ampicillin and ceftriaxone or cefotaxime and vancomycin for adults
b. For Gram-positive organisms – vancomycin and ceftriaxone or cefotaxime and ampicillin
c. For Gram-negative bacilli – meropenem or ceftazidime, ceftriaxone or cefotaxime
d. For HiB - ceftriaxone or cefotaxime
e. For meningococci – penicillin G or ampicillin and ceftriaxone or cefotaxime
f. For streptococci and pneumococci – vancomycin and ceftriaxone or cefotaxime with or
without rifampin
g. Dexamethasone 0.15 mg/ kg IV q6h in children and 10 mg IV q6h in adults given with
the first dose of antibiotics for 4 days
h. Vancomycin 15-20 mg/ kg q8h for immunocompromised patients
i. For pseudomonas – meropenem, 4th generation cephalosporin or vancomycin with or
without rifampin
j. For listeria – ampicillin
k. For patients recent neurosurgical procedure or with an intraventricular shunt –
vancomycin, meropenem plus metronidazole
l. For herpes encephalitis – acyclovir and doxycycline
5. Common antibiotic dosages
a. Ceftriaxone 50 mg/kg q12h for children and 2g q12h for adults
b. Cefotaxime 50 mg/kg q6h for children and 2g q4-6h for adults
c. Ceftazidime 50 mg/kg q8h for children and 2g q8h for adults
d. Cefepime 2g q12h for children and 2g q8-12h for adults
e. Ampicillin 75 mg/kg q6h for children and 2-3 g q4h for adults
f. Penicillin G 4 million units q4h for children and adults
g. Nafcillin and oxacillin 50 mg/kg q6h for children and 2 g q4h for adults
h. Vancomycin 15 mg/kg q6h for children and 10-15 mg/kg q8h for adults
i. Meropenem 40 mg/kg q8h for children and 2 g q8h for adults k. 1
j. Gentamicin and tobramycin 2.5 mg/kg q8h for children and adults
k. Amikacin 10 mg/kg q8h for children and 7.5 mg/kg q12h for adults 6
l. Rifampin 6.7 mg/kg q8h for children and 600 mg q24h for adults m.
m. Chloramphenicol 25 mg/kg q6h for children and 1 g q6h for adults
6. Supportive therapy includes treatment of fever, dehydration, electrolyte disorders, seizures, and
shock
7. If Waterhouse-Friderichsen syndrome is suspected, high-dose hydrocortisone 100-200 mg IV q4-
6h or as continuous infusion
8. If brain herniation is suspected, hyperventilation (Paco 2, 25 to 30 mm Hg acutely), mannitol 0.25
to 1.0 g/kg IV, and additional dexamethasone 4 mg IV q4h
9. Patients with severe meningococcal meningitis - drotrecogin alfa (activated protein C)
Brain Abscess
 1. Brain abscess is an intracerebral collection of pus.
2. Causative organisms – anaerobic streptococci, Bacteroides Sp, staphylococci,
Enterobacteriaceae, aspergillus, and other deep mycoses, Toxoplasma gondii and other tissue
protozoa
3. Manifestations - headache, nausea, vomiting, lethargy, seizures, personality changes,
papilledema, focal neurologic deficits, fever, chills, and leukocytosis
4. Treatment - antibiotics for at least 4-8 weeks
a. For streptococci, Enterobacteriaceae, and most anaerobes - cefotaxime 2g IV q4h or
ceftriaxone 2g IV q12h
b. For B fragilis - metronidazole 15 mg/kg loading dose then 7.5 mg/kg IV q6h
c. For staphylococcus - vancomycin 1g q12h or nafcillin 2g q4h
d. Surgical drainage
e. Patients with increased intracranial pressure – high-dose corticosteroids
(dexamethasone) 10 mg IV once then 4 mg IV q6h × 3-4 days
f. Anticonvulsants to prevent seizures
Encephalitis
1. Encephalitis is the inflammation of the parenchyma of the brain, resulting from direct viral
invasion.
2. Causative organisms
a. Epidemic viruses - arboviruses, polioviruses, echoviruses, coxsackiviruses
b. Sporadic viruses - herpes simplex, rabies, varicella-zoster, mumps
c. Secondary immunologic complications - influenza and B, enteroviruses, Epstein-Barr
virus, hepatitis A and B, HIV
3. Manifestations - fever, headache, altered mental status, seizures, and focal neurologic deficits
4. Treatment
a. Supportive care - treatment ot fever, dehydration, electrolyte disorders, and seizures
b. For HSV encephalitis - acyclovir 10 mg/kg IV q8h x14 days
Leprosy
1. Leprosy is also known as Hansen's disease.
2. Causative organism - Mycobacterium leprae mi
3. Manifestationsons
a. Affects peripheral nerves, skin, and mucous membranes
b. Skin lesions, areas of anesthesia, and enlarged nerves - principal signs
c. Lepromatous leprosy –
i. Diffuseuse or nodular lesions (lepromas) containing many acid-fast M leprae
bacilli cells (multibacillary lesions)
ii. Found predominantly on the cooler surfaces of the body, such as the nasal
mucosa and the peripheral nerve trunks at the elbow, wrist, knee, and ankle
iii. Sensory loss results from damage to nerve fibers
d. Tuberculoid leprosy
i. Few well-defined anesthetized lesions containing only a few acid-fast bacilli
(paucibacillary lesions)
ii. Borderline forms of the disease are unstable conditions, presenting with
intermediate signs and symptoms
4. Treatment
 a. MDT (multidrug therapy) - dapsone, rifampin, clofazimine, and either ethionamide or
prothionamide à
b. Paucibacillary (tuberculoid and borderline tuberculoid) -> treated in 6 months, although
dapsone alone is usually given tor up to 3 years after disease inactivity
c. Lepromatous or borderline lepromatous leprosy - primary treatment for 3 years, with
dapsone alone continued for the rest of the patient's life d.
d. Anti-inflammatory therapy - to alleviate the immunologic sequelae
e. Wound prevention techniques and proper wound care
Neurocysticercosis
1. Neurocysticercosis is a neurologic disorder from a helminth.
2. Causative organisms - Tania solium
3. Manifestations - local inflammation, gliosis, edema, seizures, cognitive or focal neurologic
deficits, personality changes, obstructive hydrocephalus, subacute eosinophilic meningitis
4. Treatment
a. Albendazole 7.5 mg/kg po q12h x 8-30 days but not to exceed 800 mg per day
b. Praziquantel 20-33 mg/kg pot id × 30 days
c. Dexamethasone 8 mg IV od for first 2-4 days
Parasitic Neurologic Infestations
1. Schistosomiasis - necrotizing eosinophilic granulomas develop in the brain, causing seizures,
increased intracranial pressure, and diffuse and focal neurologic deficits.
2. Echinococcosis - focal deficits and seizures
3. Coenurosis - tapeworm larvae, obstruct SF outflow in the 4th ventricle
4. Gnathostomiasis - necrotic tracts surrounded by inflammation along with the nerve roots spinal
cord, and brain or in subarachnoid hemorrhage, causing low-grade fever, stit neck, photophobia,
headache, migratory neurologic deficits (occasionally affecting the 6th or 7th cranial nerve), and
paralysis
Prion Diseases
Prion diseases are progressive, fatal, and untreatable degenerative brain disorders. These include the
following: N Un
1. Creutzfeldt-Jakob disease (CD) - degenerative neurologic disorder tr at is classified as
transmissible spongiform encephalopathy transmitted by contaminated harvested human
growth hormone products, immunoglobulins, corn ai grafts, dural grafts, or electrode implants.
2. Gerstmann-Sträussler-Scheinker disease (GSS) is a very rare, usu 'V familial, fatal
neurodegenerative disease that affects patients from 20-60 years of age and is transmitted as an
autosomal dominant trait.
3. Fatal insomnia (FI) - a very rare autosomal dominant inherited prion disease of the brain caused
by a mutation to the protein PrPc.
4. Variant CJD (vCJD)
5. Kuru - an incurable neurodegenerative disease characterized by body tremors and pathologic
bursts of laughter.
Progressive Multifocal Leukoencephalopathy
 1. Progressive Multifocal Leukoencephalopathy is a subacute and progressive CNS demyelination,
multifocal neurologic deficits, and death.
2. Causative organisms - reactivation of the JC virus
3. Manifestations - clumsiness, hemiparesis, aphasia, dysarthria, hemianopia, cognitive
impairment, sensory, cerebellar, and brain stein deficits, headaches, convulsive seizures, and
gradual, relentless progression culminates in death
4. Treatment - cidofovir
Rabies
1. Rabies is viral encephalitis transmitted by the saliva of infected bats and certain other infected
mammals.
2. Causative organisms - rabies virus
3. Manifestations
a. Depression and fever, followed by agitation, excessive salivation, hydrophobia, pain, or
paresthesias
b. b. Initial - fever, headache, and malaise
c. Encephalitis (furious rabies) - restlessness, confusion, agitation, bizarre behavior,
hallucinations, insomnia, excessive salivation, and painful spasms of the laryngeal and
pharyngeal muscles (hydrophobia)
d. Paralysis (dumb rabies) - ascending paralysis and quadriplegia
4. Treatment
a. Heavy sedation with ketamine and midazolam
b. Comfort measures
c. Prompt, meticulously executed prophylaxis
d. Wound is cleansed immediately and thoroughly with soap and water or benzalkonium
chloride ITON
e. Deep puncture wounds are flushed with soapy water using moderate pressure
f. Wounds are usually left open
g. Postexposure prophylaxis (PEP) with rabies vaccine and rabies immune globulin (RIG) is
given depending on the biting animal and circumstances
i. RIG 20 IU/kg is infiltrated around the wound for passive immunization
ii. If injection volume is too much for distal areas (fingers, nose), some RIG may be
given IM
iii. Accompanied by Human Diploid Cell Vaccine (HDCV) for active immunization
1. Series of five 1-mL IM injections (deltoid area is preferred), beginning on
the day of exposure (day 0), in a limb other than the one used for RIG
2. Subsequent injections occur on days 3, 7, 14, and 28
3. WHO recommends a 6th injection on day 90
h. PEP for a person previously vaccinated against rabies includes 1-mL. IM injections of
HDCV on days 0 and 3 but no RIG.
Subdural Empyema
1. Subdural empyema is the collection of pus between the dura mater and arachnoid.
2. Causative organisms - anaerobic streptococci, Bacteroides sp, staphylococci,
Enterobacteriaceae, aspergillus and other deep mycoses, Toxoplasma gondii and other tissue
protozoa
3. Manifestations - fever, headache, lethargy, focal neurologic deficits (suggesting widespread
involvement of one cerebral hemisphere), seizures, meningeal signs, vomiting, papilledema,
coma and death
4. Treatment
a. Emergency surgical drainage of the empyema and any underlying sinusitis
b. Antibiotic coverage is the same as that for brain abscess except in young children, who
may require antibiotics for any accompanying meningitis
c. Anticonvulsants and measures to reduce intracranial pressure