Central Nervous System, Eye, and Urinary Tract Infections

Mary Y. Mancao, M.D. University of South Alabama Dept. of Pediatrics Mobile, AL

CNS Infections
Meningitis Encephalitis Focal infections of the CNS Transverse myelitis, Guillaine-Barre Syndrome Spongiform Encephalopathy

Pathogenesis of CNS infections

Nasopharyngeal Colonization

Local Infection

Bacteremia

Seeding other sites

MENINGITIS

Epidemiology of Bacterial Meningitis in the United States

Meningitis: Microbial Etiology

Neonates: Group B streptococcus, Gram negative enterics, Herpes simplex Older child: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B, Viral Sickle disease: S. pneumoniae Asplenia: S. pneumoniae, N. meningitidis, Salmonella sp. T-cell defects: Listeria monocytogenes

Other Causes of CNS Infections

Chronic granulomatous infection

Mycobacterium tuberculosis Coccidiodes immitis Cryptococcus neoformans Histoplasma capsulatum

Nematodes
Toxocara species Trichinella spiralis Angiostrongylus cantonensis

Cestodes
Taenia solium

Protozoan infection
Toxoplasma gondii Trypanosoma Acanthamoeba species

Others
Leptospira species Treponema pallidum Borrelia burgdorferi

Meningitis: Clinical Manifestations

Infants: Inconsolable crying, irritability, refusal to feed, fever Child: Fever, poor appetite and activity, vomiting, headache, photophobia Physical examination: altered sensorium, stiff neck, poor perfusion, skin rashes

Meningitis: Clinical Signs

Meningitis: Diagnosis
Lumbar puncture (LP) CSF indices: cell count, protein, glucose CSF gram stain and culture Contraindications to LP:

Signs of increased intracranial pressure Patient unstable Clotting/Platelet disorder

Guidelines for Cerebrospinal Fluid Analysis

Clinical WBC % Polys Glucose Situation Cells/mm3 mg/dL Normal 0-5 0 > 60 Protein mg/dL < 30

Viral
Bacterial TB Neonate

2-2000
5-5000 5-2000 0-32

< 50
> 60 < 50 < 60

> 60
< 45 < 45 > 60

30-80
> 60 > 60 20-170

Meningitis: Treatment

Bacterial meningitis
<2weeks of age: Ampicillin and Gentamicin 2 wks-3 mos of age: Ampicillin and Cefotaxime > 3 months of age: Cefotaxime or Ceftriaxone

Meningitis: Empiric Treatment

Viral meningitis: Acyclovir Tuberculous meningitis: INH, RIF, ETH, STM, PZA Fungal menigitis: Amphotericin, 5FC

Encephalitis
Neonate: Acute vs. Congenital Beyond the neonatal period: Virus (Enterovirus, Herpes simplex virus, Epstein Barr virus, and Arbovirus California encephalitis), Bacteria (Bartonella henslae) Postinfectious: Varicella zoster virus, Mycoplasma

Focal infections of the CNS

Etiologic Agents

Brain Abscess Subdural empyema Epidural abscess Cranial Spinal

Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Other Gram negative and positive bacteria Anaerobic bacteria

CT Findings: Subdural Empyema

Eye Infections

Common Clinical Conditions

Blepharitis Dacrocystitis Conjunctivitis Endophthalmitis Uveitis Chorioretinitis

Conjunctivitis: Viral

Adenoviral Conjunctivitis

Conjunctivitis: Bacterial

Gonococcal conjunctivitis

Pneumococcal conjunctivitis

Chorioretinitis: Toxoplasmosis

Major Infectious Causes of Eye Disease

Disease
Blepharitis
Dacrocystitis

Bacteria
Staph aureus

Viruses

Fungi

Parasite

Strep pneumoniae
H. Influenzae GC, Chlamydia* Neisseria meningitidis Herpes simplex Measles Varicella zoster Fusarium AcanthaAspergillus moeba

Conjunctivitis Strep pneum Adenovirus**

*Usually occurs in less than 3 months of age ** Can cause pharyngoconjunctival fever

Major Infectious Causes of Eye Disease

Disease
Ophthalmia Neonatorum

Bacteria

Viruses

Fungi

Parasite

GC HSV C. trachomatis Candida Aspergillus HSV, VZV CMV, HSV Histoplasma Toxoplasma VZV C. Immitis Candida sp. Toxocara

Endophthalmitis S. aureus Pseudomonas Other Gm neg Iridocyclitis Chorioretinitis Treponema pallidum M. tuberculosis

Eye Infections: Diagnosis and Treatment

Diagnostic approach
Gram stain Culture Immunofluorescent stain Serologic tests Blood cultures Ophthalmologic evaluation and slit lamp exam

Management
Topical antimicrobial agents Specialized treatment including systemic therapy

Urinary Tract Infections

Urinary Tract Infections

Infection of the kidneys and its pelvis: Pyelonephritis Infection of the bladder: Cystitis Infection of the urethra: Urethritis

UTI: Pathogenesis

Bacteria ascend from perineal flora Sexual activity can displace bacteria Catheterization increases risk Young women most commonly affected

Clinical Manifestations of UTI

Variable presentation, can be asymptomatic Cystitis

Dysuria Frequency of urination Urgency

Pyelonephritis
Fever Flank Pain

Prostatitis
High Fever and signs of cystitis

Diagnosis of UTI
Collection of sterile urine Clean-voided midstream urine Microscopic examination

Pyuria: >10 WBC/mm3

Chemical Screening tests

Leukocyte esterase

Urine Culture: > 105 bacteria/mL

Management of UTI
Guided by results of culture and antimicrobial susceptibility tests Most common pathogen: Escherichia coli Empiric antibiotic choices include:

Sulfamethoxazole/trimethoprim Ampicillin Fluroquinolone (>18 years of age)