Fishing for a Diagnosis -“Nervous” infections

Neurology Grand Rounds08 January 2009

Antony ThomasConsultant Neurologist

UHCW & Alexandra hospital Redditch

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

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

RC

A&E @ WRH 10/05/08CT Head: ? NormalSent homeReadmitted at WRH 14/05/08 with

deterioration, worsening headache, slurring, decreased swallow, diplopia

MR Brain: abnormal

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

Investigations

• Leukocytosis, Neutrophilia, Monocytosis

• Impaired LFT

• Deteriorating Renal functions

• CRP normal 85 172

• Autoantibodies: negative

• HIV: Negative

• Serum ACE: normal

Microbiology @ Worcester

Telephone call

Blood culture (14/05 sample): grown Listeria

Started on antibiotics after repeating cultures

Amoxicillin 2G Q4HGentamicin

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

Transfer to ITU

Intubated and ventilated

ARDS: on oscillator

Hydrocortisone

Co-trimoxazole added

Repeat MR Brain: similar findings

BLOOD CULTURE REPORT

POSITIVE  :Gram positive  bacilli  

              Erythromycin S  Fusidic Acid R  Gentamicin S  Penicillin        R  Trimethoprim  S  Vancomycin   S                   

Listeria monocytogenes  isolated 

Progress

Cardiorespiratory arrest x 2

Succesful CPR

Amiodarone

Gradually improved

CXR got better

Progress

• Unfortunately…………………

• Desaturating

• More ventilatory requirements

• Worsening respiratory, liver and renal functions

• Pupil unequal and dialated

• R.I.P

Listeria Monocytogenes

• Meningo-encephalitis: common

• Immunocompromised & debilitated individuals

• In new born, well known and often fatal

• CSF – pleocytosis (initially polymorphonuclear)

• Rarely normal CSF

• Rhombencephalitis

Listeria

• Early CT scan normal

• Multiple abscesses in the brain

• Monocytosis

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

Typical acute meningitis

• Pyrexia

• Severe headache

• Phtophobia

• Rapid development of neck stiffness

• Kernig’s sign, Brudzinski sign

• If untreated vomiting, drowsiness and eventually coma

Viral causes

• Meningitis– Entero ((Echo,polio,

coxsackie)– HSV2– Lymphocytic

choriomeningitis– VZ– Mumps– HIV

• Encephalitis– HSV– VZ– CMV– EBV– HIV– Mumps– Measles– Rabies– Arbo

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.