Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Transtheoretical model wikipedia , lookup
Dental emergency wikipedia , lookup
Infection control wikipedia , lookup
Mass drug administration wikipedia , lookup
Herpes simplex research wikipedia , lookup
Canine parvovirus wikipedia , lookup
Focal infection theory wikipedia , lookup
Canine distemper wikipedia , lookup
Hypothermia therapy for neonatal encephalopathy wikipedia , lookup
ENCEPHALITIS,CEREBRAL EDEMA 5/14/2017 Dr. Alka Stoelinga 1 • Encephalitis means inflammation of brain parenchyma • Cause: usually viral • Brain inflammation also develops in bacterial and fungal meningitis • Not an isolated entity • Usually associated with meningeal inflammation together • Also term as “Meningoencephalitis” • Commonest virus is Herpes simplex which reaches brain via the Olfactory nerve • Meningism is the triad of • Nuchal rigidity (neck stiffness) • Photophobia (intolerance of bright light) • Headache. 5/14/2017 Dr. Alka Stoelinga 2 Etiology: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 5/14/2017 Arbo virus Japanese B encephalitis Herpes simplex Coxsackie Epstein-Barr viruses Adenovirus Varicella zoster Influenza Measles Entero virus Mumps (Aseptic meningitis) HIV Rabies Dr. Alka Stoelinga 3 Clinical features: • Acute onset of Fever, Headache, Meningism and Drowsiness in mild cases. • In severe illness: focal signs(e.g Aphasia, hemiplegia or cranial nerve palsies), siezures and coma may develop • Coma: Rapid deterioration in sensorium • Altered consciousness, focal signs and seizure are more common in encephalitis as compared to meningitis • Patient may agitate(while in meningitis patients is usually calm, conscious, drowsy and nonagitated) 5/14/2017 Dr. Alka Stoelinga 4 Examination: 1. 2. 3. 4. 5. Coma/Altered level of consciousness Meningeal signs may be present Focal neurological deficits Hypertonia/Brisk reflexes/Extensor plantar Opthalmoscopic examination: Look for papilloedema 5/14/2017 Dr. Alka Stoelinga 5 Investigation: 1. CT scan head :Shows area of edema 1. In Herpes simplex encephalitis CT scan show low density lesions in the temporal lobes 2. MRI head 3. EEG : Shows slow wave changes 4. CSF analysis • • • • Cell: 10-2000 Mainly Lymphocytes Glucose usually normal Protein normal or Slightly raised 5. Viral serology of blood and CSF 6. PCR: Herpes simplex virus DNA can be detected by PCR 5/14/2017 Dr. Alka Stoelinga 6 Management: • • • • Supportive Fluid balance Control of seizure Treatment of raised ICP:Dexamethasone 4mg QID for raised intracranial pressure • Herpes simplex encephalitis: Acyclovir Dose: 10mg/kg/dose IV 10 hourly Acyclovir should be given to all suspected cases of viral encephalitis • Anticonvulsants if presence of Epilepsy 5/14/2017 Dr. Alka Stoelinga 7 Prognosis: • Mortality is 10-30% when antiviral drugs are used, without antiviral mortality is 70% • Survivors may have cognitive impairment or developed epilepsy Complications: 1. Focal Neurological deficit 2. Loss of cognitive function 3. Seizure 5/14/2017 Dr. Alka Stoelinga 8 CEREBRAL MALARIA • Severe form of falciparum malaria • Common in tropical area • Treatable condition Pathogenesis : • Sequestration of parasitized RBC into blood vessels of internal organs: Brain • Rouleax formation • Cerebral anoxia • Hemolysis 5/14/2017 Dr. Alka Stoelinga 9 Clinical features: • Chills, Persistent high fever, headache, orthostatic hypotension, myalgia • Red blood cell (RBC) sludging that leads to capillary blockage at several sites • The three initial stages of Cerebral Malaria are: 1. Cold Stage: It ranges from chills to extreme shaking for 1-2 hours 2. Hot Stage: It is characterized by a high fever up to 107°F (41.7°C) for 3-4 hours 3. Wet Stage: It is characterized by profuse sweating for 2-4 hours • There are three primary symptoms of cerebral malaria which are common in both adults and children: 1. Impaired consciousness with non-specific fever, 2. Generalized convulsions and neurological abnormalities, and 3. Coma that lasts for 24-72 hours, initially rousable and then unrousable 5/14/2017 Dr. Alka Stoelinga 10 • It also manifests with – signs of increased intracranial pressure – Hemiplegia – Encephalopathy – Delirium – seizures and – Coma • If not treated on time, it can lead to complications like – Jaundice – Hemoglobinuria – a tender and enlarged spleen – acute renal failure – Uremia 5/14/2017 Dr. Alka Stoelinga 11 Examination: • • • • • • Altered consciousness Pallor Icterus Bleeding manifestation No focal neurological deficit Splenomegaly 5/14/2017 Dr. Alka Stoelinga 12 Investigation: Peripheral blood smear: Thick and Thin smear CSF analysis Blood Sugar, electrolytes, ABG, urea, creatinine 5/14/2017 Dr. Alka Stoelinga 13 Treatment of Severe P. falciparum Malaria/ Cerebral Malaria Regimen Regimen 1 First Drug Second Drug Artesunate 2.4 mg/kg bw iv or im on Doxycycline100mgs BID (2.2mg/kg BID for <45kgs[4]) admission; then at 12 h and 24 h, then once a for 7 days OR day for 7 days Mefloquine 15 mg/kg (750 mg) base, then 10 mg/kg (500 mg) base at 6–8 hours and (if >60 kg) followed by 5 mg/kg (250 mg) at 16 hours (Total 1500 mg) OR Clindamycin 20mg base/kg/day divided in three doses for 7 days in pregnancy Regimen 2 Artemether 3.2 mg/kg bw i.m. given on admission then 1.6 mg/kg bw per day for 7 days Same as above Regimen 3 Quinine 20 mg salt/kg bw on admission (iv Doxycycline OR Clindamycin as above infusion or divided im injection), then 10 mg/kg bw every 8 h; infusion rate should not exceed 5 mg salt/kg bw per hour; course for 3 days for malaria acquired in Africa and South America, 7 days for malaria acquired in SE Asia Regimen 4 Quinidine gluconate 10 mg salt/kg (equivalent Doxycycline OR Clindamycin as above to 6.2 mg base/kg) iv infused over 1–2 hours, followed immediately by 0.02 mg/kg/min salt (equivalent to 0.0125 mg/kg/min base) continuous iv infusion; course for 3 days for malaria acquired in Africa and South America, 7 days for malaria acquired in SE Asia 5/14/2017 Dr. Alka Stoelinga 14 INTRACRANIAL SPACE OCCUPYING LESION(ICSOL) 5/14/2017 Dr. Alka Stoelinga 15 TUBERCULOMA (TBM) • Non-neoplastic mass • Tumor like growth of Tuberculous tissue in the central nervous system, characterized by symptoms of an expanding cerebral, Cerebellar, or spinal mass • Presents as ring enhancing lesion • Seizure: Partial seizure • Focal neurological deficit • Headache 5/14/2017 Dr. Alka Stoelinga 16 Investigation: 1. CT scan head: Ring enhancing lesion 2. AFB smear 3. Mantoux 4. CXR Treatment: • Similar to that of tubercular meningitis 5/14/2017 Dr. Alka Stoelinga 17 5/14/2017 Dr. Alka Stoelinga 18 NEUROCYSTICERCOSIS (NCC) • Cysticercosis, is an infection which results from the ingestion of the eggs of the pork tapeworm (uncooked/undercooked pork meat), Taenia solium • Neurocysticercosis, is when the brain or spinal cord (CNS) is affected by the larval stage of T. solium • Neurocysticercosis is the most common helminthic (tapeworm) infestation to affect the CNS worldwide • Is the prime cause of acquired epilepsy. 5/14/2017 Dr. Alka Stoelinga 19 Clinical features: • • • • • Seizures: Partial/ Generalised Hydrocephalus Features of raised ICP Stroke, focal neurological deficits Meningitis 5/14/2017 Dr. Alka Stoelinga 20 Investigations: 1. Neuroimaging: – MRI(early stage)/CT head(late phase) • • • • Ring enhancing lesion Scolex Calcification Perilesional edema 2. Fundoscopy 3. Soft tissue X-ray 4. Serologic test: ELISA 5/14/2017 Dr. Alka Stoelinga 21 Treatment: • Treatment of seizure Antiepileptics • Treatment of Hydrocephalus if present • Cysticidal therapy Indicated for active lesions Albendazole 15mg/kg/d for 8-28 days Praziquantel • In immature cyst stage High dosage of corticosteroids • In the colloid cyst stage Surgical removal of the cyst, along with albendazole is indicated • In calcified dead cysts No treatment 5/14/2017 Dr. Alka Stoelinga 22 • • • • • • TBM Secondary to primary or post primary TB Bigger size than NCC Situated in the midline and margins are thick and irregular More perilesional edema seen Calcification Midline shift and hydrocephalus 5/14/2017 NCC • Due to ingestion of T.solium egg • Small size <10mm and are multiple in number • Usually situated in the periphery with well defined margins • Less perilesional edema • Calcification • Hydrocephalus is uncommon Dr. Alka Stoelinga 23 BRAIN ABSCESS Predisposing factors: • Hematogenous spread: Can occur from any site of primary infection but is commonly associated with: 1. Infection of chest, including lung abscess, bronchiectasis and empyema 2. Infection of heart such as infective endocarditis 3. Infection of bone or dental abscess can be primary site of infection • Direct/Local spread: Penetrating injury of skull, PNS, Middle ear • Mostly involve Frontal and temporal lobes 5/14/2017 Dr. Alka Stoelinga 24 • Causative organisms: – Mixed aerobic and anaerobic organisms are involved Staph aureus Streptococcus milleri Enterobacteriae 5/14/2017 Dr. Alka Stoelinga 25 Clinical feature: • Illness develops more gradually than acute bacterial meningitis. • Fever, headache, drowsiness, altered sensorium • Partial seizure • Focal neurological deficit • Features of meningitis • Septicemia 5/14/2017 Dr. Alka Stoelinga 26 Investigations: • Neuroimaging: CT scan head Single or multiple ring enhancing lesion with perilesional edema(central low density and surrounding edema) • CSF analysis usually not helpful and C/I if there is evidence of raised ICP • Blood : TC,DC,ESR,C/S 5/14/2017 Dr. Alka Stoelinga 27 5/14/2017 Dr. Alka Stoelinga 28 Treatment: • Emperic antibiotic therapy must be started Inj Benzyl penicillin 2 million units IV hourly +Inj Chloramphenicol 1-2 gm IV 6 hourly + Inj Metronidazole 500mg IV 6 hourly • Steroid: Inj Dexamethasone 4-25 mg 6 hourly followed by tappering of dose to reduce cerebral edema • Along with drainage of Pus • 3rd generation Cephalosporin+Metronidazole+Cloxacillin/Vancomycin • Antibiotics should be continued for 6-8 weeks. 5/14/2017 Dr. Alka Stoelinga 29