Infection of CNS

- Bacterial meningitis is a fatal infection (Uti cause of death)

- Meningies: dura, arachnoid, pia (DAP), dura  outer periosteal layer and inner meningeal layer,
it contains dural venous sinuses), between arachnoid and pia mater is the subarachnoid space 
csf circulate (it protect the brain, produces mainly by the choroid plexus located in lateral and
fourth ventricle, spinal cord also surrounded by the arachnoid layer)

- Lumbar puncture performed in between fourth and fifth lumbar space. (skdi:2)
- Obstruction of csf causes hydrocephalus.
- The endothelial of BBB is a very tight junction so it prevents pathogen and toxic substances to
enter also the immunoglobulin, complement and antibiotic.
- Meningitis is an inflammation of the arachnoid membrane, pia mater and the underlying CSF.
(around the brain and spinal cord)
- Most common bacteria responsible for meningitis: streptococcus pneumonia, Neisseria
meningitides, listeria monocytogenes and hemophilus influenza.
- Gain entry via nasopharyngeal colonization, direct extension or secondary to bacteremia
(primary: sinuses, middle ear, pulmonary, endocarditis or gastrointestinal)
- This bacteria can multiply happily because there is no immunoglobulin or complement.
- But the PMN cell will eventually get into the subarachnoid space and release cytokines and will
create a purulent exudate in subarachnoid space. This inflammation will damage the BBB itself
so the protein will go into that space easily increasing the protein level in the CSF and lowering
the glucose concentration in the CSF. This result in obstruction through ventricular sstem and
diminish property of arachnoid granulation leads to progressive cerebral edema, increased
intracranial pressure, and decrease cerebral blood flow lead to irreversible ischemic damage.
- Symptoms: fever, headache, nuchal rigidity, nausea, vomiting, photophobia and signs of cerebral
dysfunction, seizure and focal neurologic deficit may be present in 20-30% cases, cranial nerve
palsies, papilledema
- It can manifest as either acute fulminant illness that progress rapidly or subacute infection that
progress several days.
- Neonates: hypo or hyperthermia, lethargy, fretfulness, refusal to feed, irritability, vomiting and
diarhea, bulging fontanella occurs late in the illness.
- In adults physical exam: fever or hypothermia.
- Nuchal rigidity  asking the patient to touch his chin to the chest. Meningeal inflammation limit
flexion due to pain and stiffness.
- Thorough physical exam to asses for primary source: ear, nose, throath (otitis media and
sinusitis), cardiac murmur (endocarditis), lung exam (pneumonia) skin:petechiae and purpura) in
meningococcal meningitis
- Streptococcus pneumonia: ear, sinus, lung
- LP, brain imaging first (if have new-onset seizure, ICP sign, SOL)
- High opening pressure with high white blood cell count range 1000-5000
- Csf glucose concentration usually low less than 60% of serum glucose concentration.
- Pleocytosis, low glucose, high protein  warrant bacterial meningitis.
- DD endocarditis, bacteremia, brain abcsees, drug-induced meningitis, SLE, non-bacterial
meningitis, subdural empyema.
- Treat antimicrobial therapy

- Cephalosporin generasi ketiga ceftriaxone or cefotaxime

- Chemoprophylaxis for close’s friends oral rifampin (48 hours) or single-dose oral
ciprofloxacin, single dose IM ceftriaxone.
- Vaccine!!!--> h.influenza type b, 13-valent pneumococcal conjugate vaccine (<6 years) PCV13
and PPSV23(>65 years)
- Mortality factor systemic compromise, impaired consciousness, low WBC in the CSF,
infection with S.pneumoneia.
- Neurologic sequelle common CN palsies, hydrocephalus, paresis, seizure disorder and hearing
loss (adult), intellectual delay, hearing loss, seizure disorder (children)

Adam and victors:

- Hematogenous spread or cranial structures adjacent to brain (ears, paranasal sinuses,
osteomyelitic foci), or iatrogenic (from surgery)
- Cerebral tissur is resistant to infection.
- Cranial epidural and subdural spaces never the site of blood-borne infections, in contrast to the
spinal epidural space.
- Adult  pneumococcus (streptococcus pneumonia), meningococcus (Neisseria meningitides),
hemohiluz influenza (in unvaccinated children), listeria monocytogenes
- Is a medical emergency
- Sustain blood pressure and treating septic shock (volume replacement, pressor therapy)
- Penicillin?
- In children and adult third generation cephalosporin such as ceftriaxone combined with
vancomycin
- Suspected listeria  added ampicillin

-
- Most cases should be treated for 10-14 ays except if there is sinus origin, in which it need to have
a longer treatment. Ab administered full dose parenterally.
- Repeated lumbar punctures are not necessary to assess the effects of therpy as long as theres is a
clinical improvement.
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