Differential Diagnoses

CNS tumor- lymphoma, any space

occupying lesion

Opportunistic infection- bacterial,

viral, fungal

Stroke- either hemorrhagic or

nonhemorrhagic
 Differential Diagnoses
Abscess

Meningitis (most probably TB)

Encephalitis (Enterovirus or Arbovirus [MCC in Ph

is Japanese Encephalitis virus])

Lymphoma

Acute Ischemic Stroke

 Whats the most likely
diagnosis?
Abscess- (+) focal neurologic findings

Meningitis (most probably TB): (+) stiff neck

and photophobia; (+) Kernigs and Brudzinskis

Encephalitis (+) [acute febrile]

confusion/altered consciousness

Lymphoma- (+) lymphadenopathies

 TB Meningitis
PTB completed 6 mos.
treatment but no repeat CXR
done after treatment (2014)
CXR (June 7, 2016): PTB both
upper lobes; consider beginning
of mild pulmonary congestion
Stage II Tuberculous Meningitis
 Diagnostic Exams for TB
Meningitis
CSF analysis: leukocytosis
predominantly lymphocytes, mildly
decreased sugar, and markedly
increased CSF protein
Pellicle formation
CSF gram stain will show acid fast bacilli
PCR
CSF Genexpert test for TB
CSF culture which will grow 3-6weeks
Patients CT CT of TBM
 Treatment
Recommended Treatment of WHO in agreement
with CNSP
Usual dose for TBM are as follows:
INH at 10 mkd (range: 10-15 mg/kg; max dose: 300 mg/day)
Rifampicin at 15 mkd (range: 10-20 mg/kg; max dose: 600
mg/day)
EMB at 20 mkd (range: 15-25 mg/kg; max: 1200 mg/day 2)
PZA at 30 mkd (range: 30-40 mg/kg; max: 2000 mg/day 1)
Two months of quadruple anti-Kochs followed by
double therapy for another 10 months = 12 months
Key recommendations of WHO Rapid Advice
Treatment of TB in Children 2010 and the Draft PPS-
DOH/NTP Joint Statement 2011
 Encephalitis
HSV JEV
Clinical Aseptic meningitis 75% in children 0-14 years old
Manifestatio Focal neurologic (patient is 16 yo)
ns deficits and Patient is unvaccinated against
seizures are Japanese Enceph
common Fever, headache and altered
Predominant sensorium, some GI symptoms
involvement of the seizures
frontal and temporal Appearance of masked like
lobes of the brain facial appearance, paralysis
Clinical types of upper extremities,
Type 1 associated bulboparetic syndrome,
orofacial herpes in psychosis, central hyperpneic
children 6 months or breathing, extrapyradimal
older symptoms
Type 2 associated
In 2-4 days: resolution of
with genital herpes
congenital or perinatally
symptoms or death
 HSV JEV
Diagnosis CSF analysis sterile CSF analysis
CSF, lymphocytosis, viral picture
normal sugar, 4 fold increase in
increased protein antibody
EEG paroxysmal concentration in
lateralized epileptiform CSF/blood
discharges or periodic Identification of
lateral epileptic pathogen by viral
discharges- PLEDS culture
(frontal and temporal) Neuroimaging
Increased antibody bilateral
titers IgG and IgM thalamic,
Identify organism by brainstem and
PCR basal ganglia
Neuroimaging focal lesions
 HSV JEV
Treatme Acyclovir 10-20 None
nt mg/kg q8 h x Steroids no value
10-14 days Vaccine efficacy 56-
Only encephalitis 90%
that has a Vaccine
treatment. Give preventable
ASAP even if not disease
sure caused by
HSV since it could
be fatal
Patient HSV JEV
s CT

 Lymphoma
Presents as intracranial mass lesion
Headache, nausea, vomiting, mental status
changes, fever, focal neurological findings
Head CT scan shows a ring or contrast
enhancing lesion
Will need brain biopsy for definitive
diagnosis
Treated with cranial radiation and corticosteroids
r/o: rare in childhood, risk factor is usually those
with AIDS which the patient does not have
 Acute Ischemic Stroke
Trigger for ischemic stroke: Chronic
hypoxemia to the brain due to CHD:
TOF

r/o: AIS has no fever; CT showed ring

enhancing lesion leaning more
towards brain abscesses or other
tumors