Presentation on theme: "Fishing for a Diagnosis - “Nervous” infections"— Presentation transcript:
1Fishing for a Diagnosis - “Nervous” infections Neurology Grand Rounds08 January 2009Antony ThomasConsultant NeurologistUHCW & Alexandra hospital Redditch
2Best Wishes for a Happy, successful, peaceful and prosperous New Year to all.
3RC 23 years, Right handed, sheep farmer Well until 8/05/08 Occipital headache: severeNausea, vomitingBlurred vision, double visionDribbling“behaves as drunk” slurred speech, dizziness and unsteadyWeak right face with failure to close right eye
4RC A&E @ WRH 10/05/08 CT Head: ? Normal Sent home Readmitted at WRH 14/05/08 with deterioration, worsening headache, slurring, decreased swallow, diplopiaMR Brain: abnormal
20Progress Unfortunately………………… Desaturating More ventilatory requirementsWorsening respiratory, liver and renal functionsPupil unequal and dialatedR.I.P
21Listeria Monocytogenes Meningo-encephalitis: commonImmunocompromised & debilitated individualsIn new born, well known and often fatalCSF – pleocytosis (initially polymorphonuclear)Rarely normal CSFRhombencephalitis
23Listeria Early CT scan normal Multiple abscesses in the brain Monocytosis
24CNS InfectionsMeninges and subarachnoid space can be infected by viruses, bacteria, spirochaetes and fungiVirus and bacteria: seasonal variationClassic case unmistakableBut subtle presentations can lead to fatal delay in diagnosis
25Typical acute meningitis PyrexiaSevere headachePhtophobiaRapid development of neck stiffnessKernig’s sign, Brudzinski signIf untreated vomiting, drowsiness and eventually coma
27Typical Cerebrospinal Fluid Findings in Various Types of Meningitis Test Bacterial Viral Fungal TubercularOpening pressure Elevated Usually normal Variable VariableWBC ≥1,000 per mm3 <100 per mm3 Variable VariableCell differential Predominance of Predominance of Predominance PredominancePMNs* lymphocytes† of lymphocytes of lymphocytesProtein Mild to marked Normal to elevated Elevated ElevatedelevationCSF-to-serum glucose Normal to marked Usually normal Low Lowratio decreaseCSF = cerebrospinal fluid; PMNs = polymorphonucleocytes.*—Lymphocytosis present 10 percent of the time.†—PMNs may predominate early in the course.