1. Fishing for a Diagnosis - “Nervous” infections
Neurology Grand Rounds
08 January 2009
Antony Thomas
Consultant Neurologist
UHCW & Alexandra hospital Redditch

2. Best Wishes for a Happy, successful, peaceful and prosperous New Year to all.

3. RC 23 years, Right handed, sheep farmer Well until 8/05/08
Occipital headache: severe
Nausea, vomiting
Blurred vision, double vision
Dribbling
“behaves as drunk” slurred speech, dizziness and unsteady
Weak right face with failure to close right eye

4. RC A&E @ WRH 10/05/08 CT Head: ? Normal Sent home
Readmitted at WRH 14/05/08 with deterioration, worsening headache, slurring, decreased swallow, diplopia
MR Brain: abnormal

9. Transferred to Neurosurgery UHCW 16th
Pyrexial
GCS 15, no papilledema
Right V1 sensory impairement
Right eye abduction weakness
Bilateral nystagmus R>L
Right Facial weakness LMN
Bulbar paresis, dysarthria, right sided tongue weakness
Mild right sided weakness and minimal sensory impairement
Right sided cerebellar signs
Rest of the systemic examination unremarkable

10. Investigations Leukocytosis, Neutrophilia, Monocytosis Impaired LFT
Deteriorating Renal functions
CRP normal  85 172
Autoantibodies: negative
HIV: Negative
Serum ACE: normal

11. Microbiology @ Worcester
Telephone call
Blood culture (14/05 sample): grown Listeria
Started on antibiotics after repeating cultures
Amoxicillin 2G Q4H
Gentamicin

12. Progress Respiratory distress Poor cough, inadequate gag
Throat suction: thick yellowish secretions
Hypoxic, hypercapneic
Chest crackles more on right lower base
CXR: Right lower lobe opacity

14. Transfer to ITU Intubated and ventilated ARDS: on oscillator
Hydrocortisone
Co-trimoxazole added
Repeat MR Brain: similar findings

17. BLOOD CULTURE REPORT POSITIVE :Gram positive bacilli Erythromycin S
              
Erythromycin S  
Fusidic Acid R  
Gentamicin S  
Penicillin        R  
Trimethoprim  S  
Vancomycin   S                   
Listeria monocytogenes  isolated 

18. Progress Cardiorespiratory arrest x 2 Succesful CPR Amiodarone
Gradually improved
CXR got better

20. Progress Unfortunately………………… Desaturating
More ventilatory requirements
Worsening respiratory, liver and renal functions
Pupil unequal and dialated
R.I.P

21. Listeria Monocytogenes
Meningo-encephalitis: common
Immunocompromised & debilitated individuals
In new born, well known and often fatal
CSF – pleocytosis (initially polymorphonuclear)
Rarely normal CSF
Rhombencephalitis

23. Listeria Early CT scan normal Multiple abscesses in the brain
Monocytosis

24. CNS Infections
Meninges and subarachnoid space can be infected by viruses, bacteria, spirochaetes and fungi
Virus and bacteria: seasonal variation
Classic case unmistakable
But subtle presentations can lead to fatal delay in diagnosis

25. Typical acute meningitis
Pyrexia
Severe headache
Phtophobia
Rapid development of neck stiffness
Kernig’s sign, Brudzinski sign
If untreated  vomiting, drowsiness and eventually coma

26. Viral causes Meningitis Encephalitis Entero ((Echo,polio, coxsackie)
HSV2
Lymphocytic choriomeningitis VZ
Mumps
HIV
Encephalitis
HSV VZ
CMV
EBV
HIV
Mumps
Measles
Rabies
Arbo

27. Typical Cerebrospinal Fluid Findings in Various Types of Meningitis
Test Bacterial Viral Fungal Tubercular
Opening pressure Elevated Usually normal Variable Variable
WBC ≥1,000 per mm3 <100 per mm3 Variable Variable
Cell differential Predominance of Predominance of Predominance Predominance
PMNs* lymphocytes† of lymphocytes of lymphocytes
Protein Mild to marked Normal to elevated Elevated Elevated
elevation
CSF-to-serum glucose Normal to marked Usually normal Low Low
ratio decrease
CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes.
*—Lymphocytosis present 10 percent of the time.
†—PMNs may predominate early in the course.