Emergency Neuroinfection

Introduction
• Infection of the CNS  medical emergency that rapidly progresses to
death in as many as 40% of patients
• Survivors long term deficits of neurological function
• The greatest challenge identifying life-threatening diagnosis in
patients presenting with non-specific symptoms
• The clinical signs and symptoms that should lead emergency
physicians to consider CNS infection

Dorsett & Liang, 2016;

Beaman, 2018
Pruitt, 2012
Bacterial Meningitis
• In the US, between 2003-20074,100 cases of bacterial meningitis
• significant morbidity with mortality rates  13 to 27%
• risk factorsage, community setting, immunosuppression,
individuals working with meningitis- causing pathogens (ie,
microbiologists), and travel to certain regions

Chang, 2017
Bacterial Meningitis- Clinical features
• Fever; headache; and either altered sensorium, neck stiffness, or
another meningeal sign.
• Rashmeningococcal or pneumococcal meningitis should be high on
the DD

Chang, 2017
Bacterial Meningitis- Dx workup
• CSF analysis lumbar pucture unless contraindicated
• Blood cultures
• Computerised tomography (CT) is initially required only for patients
with suspected elevated intracranial pressure (papilloedema, focal
signs,seizure, deteriorating consciousness state) or who are
immunocompromised; CT scanning should not delay initiation of
antibiotic therapy
• Procalcitonin
• Polymerase chain reaction (PCR) testing  if blood cultures are
negative or the patient has already received antibiotic therapy
Dorsett & Liang, 2016
Bacterial Meningitis- Therapy
• Neonates: Ampicillin (150 mg/ kg IV q8 hours) with cefotaxime (100– 150 mg/ kg IV q8– 12
hours) or an aminoglycoside to cover for Streptococcus agalactiae, Escherichia coli, Listeria
monocytogenes, and Klebsiella. Ceftriaxone should be avoided in this population to avoid the risk
of hyperbilirubinemia.
• Ages 1 month to 23 months: Vancomycin 15 mg/ kg IV q6 hours and ceftriaxone 75 to 100 mg/
kg IV q12 to 24 hours
• Ages 2 years to 50 years: Vancomycin 15 to 20 mg/ kg IV q8– 12 hours (up to 2 g) with a third-
generation cephalosporin to cover for organisms such as S. pneumoniae, Neisseria meningitidis,
Haemophilus influenzae, and E. coli.
• Age > 50 years old: Vancomycin (30– 45 mg/ kg IV q8– 12 hours), ampicillin (1– 2 g IV q4 hours),
and a third- generation cephalosporin to cover for S. pneumoniae, N. meningitides, aerobic gram-
negative bacilli, and L. monocytogenes.
• Patients with a recent penetrating head injury or CSF shunt should receive cefepime (2 g IV q12
hours) in addition to vancomycin for added Pseudomonas coverage.
• Pregnant patients: Ampicillin 2 g IV q4 hours (add to therapy for Listeria coverage)
• Immunocompromised patients: Vancomycin 15 mg/ kg q8 hours with ampicillin 2 g IV q4 hours
and ceftriaxone 2 g IV q12 hours.
Chang, 2017
• If pneumococcal meningitis is suspected and antibiotics are to be
given, consider giving dexamethasone (0.15 mg/ kg IV q6 hours for 2–
4 days) 10 minutes before antibiotics
• Beta- lactam allergy: Vancomycin 15 to 20 mg/ kg IV q8 to 12 hours
plus Moxifloxacin— 400 mg IV q24 hours, addition of trimethoprim-
sulfamethoxazole 5 mg/ kg IV q6 to 12 hours if Listeria coverage
is needed
• Multiple drug allergy patients: fluoroquinolones
• Vancomycin- resistant history: linezolid 600 mg IV/ PO q12 hour

Chang, 2017
Bacterial Meningitis- Key Message
• It is important to recognize potential bacterial meningitis early.
• Lumbar puncture will aid in definitive diagnosis, but, if this procedure
is delayed and suspicion is high, antibiotics should be given first.
• Meningitis is a treatable condition, and early intervention will have a
great impact on reducing morbidity and mortality.
Encephalitis
• HSV was classically the most
common cause of encephalitis.
• Morbidity of HSV encephalitis
depends upon the patient’s
neurologic condition at the time
of acyclovir administration
• Untreated HSV encephalitis has
a mortality of 70% to 100%

Pruitt, 2012
Encephalitis- Clinical Features
• Meningitis with focal neurologic findings meningoencephalitis
• New- onset seizures, cognitive deficits, new psychiatric symptoms,
lethargy/ coma, cranial nerve abnormalities, or movement disorders
• Temporal lobe features (micro- or macropsia, olfactory hallucination,
behavioural change)
• Fever is usually present but can be absent up to 30% of the time.

Martinez, 2017
Encephalitis- Clinical Investigation
• Blood cultures and CSF analysis
• PCR assessment
• Chest X Ray
• EEG
• MRI cerebral edema, classic findings for HSV encephalitis, located
in the temporal lobe. West Nile Virusthe basal ganglia, thalamus,
brainstem, cerebellum, and spinal cord

Martinez, 2017
Beaman, 2018
Encephalitis- Therapy
• Empiric treatment for presumed viral encephalitis is the antiviral
acyclovir at 10 mg/ kg every 8 hours for 21 days.
• Empiric broad- spectrum antibiotics are typically also given to cover
for possible bacterial meningitis until CSF studies result.
• Corticosteroids have been suggested for the acute treatment of viral
encephalitis.
• In the setting of increased ICP treatment of elevated intracranial
pressure (ie, hyperventilation, steroids, mannitol, hypertonic saline,
and elevation of the head of the bed) should also be considered

Martinez, 2017
Brain Abscess
• Despite medical advances, brain abscess remains a life- threatening
condition. Mortality rate of 5% to 20%. 30% to 60% of patients suffer
neurological sequelae

Chinai, 2017
Brain Abscess- Clinical Features
• The signs and symptoms of a
brain abscess are influenced by
the location and size of the
infection, the causative
pathogen, and the patient’s
immune status and medical
comorbidities

Chinai, 2017
Brain Abscess- Diagnostic Work up
• Imaging: CT with contrast, MRI with gadolinium
• Blood culture
• CSF analysis
• Aspiration biopsy

Chinai, 2017
Brain abscess - Therapy
• Selected cases may be medically managed with intravenous
antibiotics and steroids, especially if there is a small abscess (less
than 2.5 cm)
• Needle aspiration  lower mortality rate
• Surgical excision  related to foreign bodies, fungal brain abscesses,
multiloculated abscesses, failure to diagnose on previous image-
guided aspiration, or worsening clinical condition or radiological
appearance following 1 to 2 weeks of medical management
• Selected patients may require antiseizure prophylaxis

Chinai, 2017
HIV related CNS Infection
• Human immunodeficiency virus (HIV) infection  impairs cell-
mediated immunity  predisposing patients to viral, fungal, and
parasitic diseases.
• HIV-related CNS infections are frequently opportunistic JC virus,
Epstein-Barr virus, cytomegalovirus, and T. Gondii
• Altered mental status, fever, headache, seizures, or focal neurologic
signs  CNS infection should always be considered

Dorsett & Liang, 2016

• Treatment depends on the most likely cause and should be initially
broad pending the results of this workup.
• In addition to empiric antibiotic therapy  initiating or continuing
antiretroviral therapy (ART).

Dorsett & Liang, 2016

APPROACH TO THE PATIENT WITH FOCAL FINDINGS
SUGGESTIVE OF SPINAL CORD OR
PERIPHERAL PROCESSES

• Emergency neurologic consultations for rapid onset of dysfunction

localizing to the spinal cord
• Myelitis or postinfectious demyelination with an array of etiologies
• Intramedullary enhancing lesions of neuromyelitis optica (NMO) and
sarcoidosis may mimic infection
• Bacterial spinal epidural abscess medical and surgical emergency

Pruitt, 2012
• Spinal epidural abscessunderlying illnesses, such as diabetes,
chronic renal failure, or malignancy
• Back pain and point tenderness with or without fever and sometimes
in the absence of neurologic abnormalities on initial examination
• Lumbar puncture should be avoided  infection dissemination risk.
• Four to 6 weeks of antibiotics after immediate decompressive
laminectomy are required with vancomycin and antibiotics targeting
gram-negative bacilli (piperacillin-tazobactam, cefotaxime, and
meropenem)

Pruitt, 2012
Conclusion
• Neurologic infectious diseases remain a significant cause of morbidity
and mortality, affecting both healthy hosts and those with HIV and
immunosuppression.
• There is a growing spectrum of pathogens and their clinical
presentations.
• Timely diagnosis is essential to ensure good-quality survival.
• As time is of the essence, empiric antibiotic coverage tailored to the
patient’s age and clinical risk factors should be initiated as soon as
possible.