23. intracranial infection - prof sunartini

7/26/2019 23. Intracranial Infection - Prof Sunartini

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Intracranial Infection

in infant and children

Sunartini

INT Prog. FM UGM22042010

Infections of the CNS

two broad categories- those which involve primarily the meninges,

and- those which are confined primarily to theparenchyma.

Under the heading of meningeal infections, wewill consider general concepts after whichthree basic categories will be discussed:- pyogenic meningitis,- granulomatous meningitis,- lymphocytic meningitis.

Infections of the CNS (2)

Infection of the central nervous system (CNS)can be viral, bacterial, fungal, or parasitic inorigin. Infectious microorganisms most often

enter the CNS by direct penetration aftertrauma or by travelling in the bloodstream

There are three major categories of CNS infectionstreated by a neuro-ICU:

Encephalitis Meningitis Brain Abscess

Infections of the CNS(3)

In contrast to the organization of meningeal infections,parenchymal infections have been organized in termsof the various types of organisms which include

syphilis, parasites, fungi, viruses, and prions(scrapie, kuru & Creutzfeldt-Jakob disease).The definitions of at least two terms should be madeclear for parenchymal infections:

cerebritis and encephalitis.

Both of these terms imply inflammation of parenchymain the cerebrum, and on occasion are usedinterchangeably. However, by convention these termsdo have specific and different meanings among

practicing neuropathologists

Infections of the CNS (4)

Cerebritis means inflammation of all tissues in thebrain substance, and is used to indicate a stagepreliminary to abscess formation. Thus, cerebritis is avery destructive process and implies bacterial infection.

Encephaltitis, on the other hand, meansinflammation of brain tissue secondary to viral infection.Inflammation in encephalitis is not usually as intense asin cerebritis, and the destruction, while still profound, is

not usually as great.

Myelitis is the counterpart of encephalitis in the spinalcord.

Encephalitis

What is encephalitis?

Encephalitis is defined as inflammation of the brain dueto an infection.

This inflammation is commonly the result of a viral

infection. Viruses can gain access to the centralnervous system (CNS) through the blood or by travelingwithin nerve cells (neurons).

The neuro-ICU deals primarily with acute viralencephalitis.There are approximately 20,000 cases of encephalitisin America each year.

In Indonesia no exact data.


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MeningitisWhat is meningitis?Meninges is a membranous covering the innersurface of the skull of the brain

A fluid known as cerebrospinal fluid (CSF) circulatesaround the brain and serves to cushion the brainagainst injury.

Meningitis is an inflammation of the meninges dueto infection.It occurs when a foreign pathogen invades thesubarachnoid space and populates the CSF.The foreign microorganisms can either be bacteria orviruses. meningitis can be classified as eitherbacterialor viral.Since bacterial infection is much more serious, aneuro-ICU is specialized towards the treatment ofthis type of meningitis.

Cont Epidemiology :

1995 : bacterial as the etiology of 2800 cases ofmeningitis in children under 18 years in USA

1986 :cases were children of 1 mo -5 yr old,in1995 meningitis cases in this group 87%decreased and median age of bacterialmeningitis bakterialis meningkat increased to15% in the age of 15 -25 yr old

2001: India, from 54 of children with acutebacterial meningitis 78% were in the age of 1year and 52 % under 6 months old.

What are the causes of bacterial meningitis?Generally, bacterial meningitis is more dangerous than

the viral form and can constitute a medical emergency.

Two of the major forms of bacteria* Streptococcus pneumoniaeand Neisseria meningitidis. ------>Therefore, bacterial meningitis usually occurs in either a

pneumococcal or a meningococcal form.Pneumococcal meningitis is typically observed in adults.

It can arise following brain trauma, and is predisposed bysickle cell anemia, alcoholism, and diabetes.

Meningococcal meningitis most often occurs in children,adolescents, and young adults.

Cont

Etiologi : 1982- 2001 : bacterial the

study in Public HealthLaboratory Service (PHLS)Neisseria meningitidis.

3 type of bacterial cause ofacute bacterial meningitis ,are Streptococcuspneumoniae, Neisseria

meningitidis, andHaemophilus influenzab(Hib).

Organism Identified Most FrequentlyOrganism Identified Most Frequently

as a Cause of Bacterial Meningitisas a Cause of Bacterial Meningitis

Acute BacterialAcute BacterialMeningitisMeningitis

Chronic BacterialChronic BacterialMeningitisMeningitis

StreptococStreptococ.. pneumoniaepneumoniae

HaemophilusHaemophilus influenzaeinfluenzae

NeisseriaNeisseria meningitidismeningitidis

Escherichia coliEscherichia coli

Other gramOther gram--negatifnegatifbacillibacilli

ListeriaListeria monocytogenesmonocytogenes

Salmonella speciesSalmonella species

LeptospiraLeptospira speciesspecies

StaphylococcusStaphylococcus aureusaureus

Group B streptococciGroup B streptococci

MycobactMycobact. tuberculosis. tuberculosis

TreponemaTreponema pallidumpallidum

BorreliaBorrelia burgdorferiburgdorferi

The Age distribution of 4 important types of acute bacterialThe Age distribution of 4 important types of acute bacterialmeningitis in a tropical African Country where meningococcalmeningitis in a tropical African Country where meningococcal

meningitis is prevalent at a later age than in developed countrimeningitis is prevalent at a later age than in developed countrieses

0 1 12 5 10 20 40 60 or >MONTHS YEARS

AGE

E. coli

S. pneumoniae

H. influenzae

N. meningitis


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Patofisiology

Infection(ENT))

Hematogenicspread out

EntrancetpCNS

Multiplicationof bscteria

InflamationEdema

CNS Dysfunction

Severe HeadacgeNeckstiffnessPhotophobiaConvulsion(classic symptom)

What are the clinical features of bacterialmeningitis?Bacterial meningitis presents as an acute disease.It is characterized by three main features:

- headache,- high persistent fever, and- neck stiffness (an inability to bow the head, known as

nuchal rigidity).Bacterial meningitis can also be accompanied by a varietyof other symptoms including- rashes,- nausea,- lethargy, and- general malaise.- In addition, seizures occur in about 20% of patients and- coma occurs in 5-10% of patients.The latter development is associated with a particularlypoor prognosis.

Table 3. Diagnosis and treatment of meningitisDepend on the result of CSF examination

CLINICAL PICTURE

Cardinal Symptom Headache High fever persistent Neck stiffness (an inability to bow the head,

known neckas nuchal rigidity)

other symptoms including

-rashes,

- nausea,- lethargy, and- general malaise.- seizures occur in about 20% of patients- coma occurs in 5-10% of patients.

The first signs : convulsion, irritabel,delirium, somnolent, letargi, & maybecoma

Pathognomonis Sign : Meningeal Sign

Neckstiffness, Brudzinsky I,II Sign, Kernig sign : (+)

CLINICAL SIGN

Specific Symptoms :Petechie & purpura: Meningococcemia

some times H. infl.

Progresive hemorrhage : MeningococcRash Str. PneumonieArthralgie : Meningococcemie & H. influenzae

NeonatesNeonates

High fever, vomiting, irritabel, convulsion,somnolent highpitch cry

Specific : Large Fontanel bulging,tenderness Difficult to find meningeal sign e.gneck stiffness Brudzinsky and Kernig sign

Baby (3Baby (3--1212 bulanbulan))

Very difficult -- various clinical sign

If there is a sign of sepsis --> consider

intracranial infection

Large fontanel : bulging


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..LUMBAR PUNCTURE : indication, contraindications,

LCS: Oppalescent / unclear WBC increase Protein increase

Glucose ratio between LCS : blood decerase

Intracranial pressure on LCS increase

Gram stain : positif bacteria

Culture: Gold standard: positif

Fast Diagnosis : latex partile agglutination

DIAGNOSIS

Laboratory Examination

CSF Normal Baby BacterialMeningitis

ViralMeningitis

Leucocyte < 10 per m3 200-100.000/m3 25-1000/ m3

Neutroph.


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JAMA, 2007

TREATMENT

Fluid and electrolyte management

Antibiotik

Steroid dexametason

Glucose 40%

1.1. Nursing CareNursing Care

2.2.In critical periodIn critical period ------> PICU> PICU

3.3. treatmenttreatment

a. Homeostasis ivfd

b. Convulsion / st. convulsivus

Stop seizure immediatelyStop seizure immediately

Adequate OxygenationAdequate Oxygenation

AirwayAirwayc. Corticosteroids for Bacterial M-is

d. Antibiotics

TREATMENT II. Antibiotic for Bacterial Meningitis

Bacteriae Drugs

N. Influensa

S. Pneumonia

N. Meningitis

Gram Negatif

Staphylococus

-Kloramfenikol, ampisilin

-Seftriakson, Sefotaksim

-Penisilin, Kloramfenikol

-Sefuroksim, Seftriakson

-Vankomisin

-Penisilin, Kloramfenikol

-

Sefuroksim, Seftriakson-Sebutaksim, Septazidin

-Seftriakson, Amikasin

-Gentamysin, netilmisin

-Nafsilin, Vankomisin

-Rifampisin

THE PRINCIPAL OF ANTIBIOTIC

1. Choose the proper AB

2. Maintain the therapeutic level in CSF

3. Use AB which can entrance through BBB

4. The Ratio of AB level in CSF and blood are:

KloramfenikolKloramfenikol 9 : 19 : 1 CefaloridinCefaloridin 1 : 701 : 70

CefalotinCefalotin 1 : 71 : 7AmpisilinAmpisilin 1 : 561 : 56

Influence withInfluence with

Inflamation of meninges

Protein bound

ANTIBIOTIC ARE GIVEN IN 2 FASE

I.vmin 5 DAYS (fever free), continued oral

Culture (+) Drugs

Neonates and babies:

Combination of (1)

or

Neonates

-(1) Ampisilin 200 400 mg/kg BB

- + Kloramfenikol 100 mg/lg BB

-(2) Ampisilin 200 400 mg/kg BB

-+ Sefurokxim 100 200 mg/kg BB

-Ampisilin 200 400 mg/kg BB

-+ Gentamycin 6 mg/kg BB

I. Result of culture : not yet ------> EMPIRICII. Result of culture positif : --> drugs sensitive


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TABEL 4 Pengobatan yang direkomendasikan untukmeningitis aseptik

Etiologi Pengobatan

Cytomegalovirus Ganciclovir (Cytovene) (clinicalresearch trial)

Enterovirus Immune globulin (possiblypleconaril)

Herpes simplex virus Acyclovir (Zovirax)

Hu manimmunodeficiency virus

Multidrug antiretroviralregimens

Lyme disease Ceftriaxone (Rocephin)

Syphilis High -dose penicillin

Toxoplasmosis Pyrimethamine (Daraprim) andsulfadiazine

Tuberculosis Multidrug anti mycobacterialregimens

Tunkelet al 2004

How is bacterial meningitis treated in a neuro-ICU?The first step : to obtain a CSF sample via lumbar puncture and to then initiate antibiotic therapy.The antibiotic regimen should be specific to the type ofbacteria causing the meningitis.- a regimen of ampicillin and a third-generation

cephalosporins such as ceftriaxone- Dehydration and/or shock ---> by blood volume

expansion and the use of pressors to increase bloodpressure.

- Cerebral edema and increased intracranial pressure- depressed level of consciousness,- severe headache, and- projectile vomiting.

- ICP monitoring.- Seizures are treated by the use of rapid acting

anticonvulsants such as diazepam and lorazepam.Lorazepam infusion is commonly followed-up with alonger lasting anticonvulsant known as phenytoin (Dilantin).

Dose Guidelines of Intravenous Antimicrobials in Infantsand Children With Bacterial Meningitis

Antibiotic

Dose (mg/kg/d)

IV

Maximum Daily

DoseDosing Interval

Ampicillin 400 6-12 g q6h

Vancomycin 60 2-4 g q6h

Penicillin G 400,000 U 24 million q6h

Cefotaxime 200-300 8-10 g q6h

Ceftriaxone 100 4 g q12h

Ceftazidime 150 6 g q8h

Cefepime* 150 2-4 g q8h

Imipenem 60 2-4 g q6h

Meropenem 120 4-6 g q8h

Rifampin 20 600 mg q12h

*Minimal experience in pediatrics and not licensed for treatment of meningitis.

Caution in use for treatment of meningitis because of possible seizures.

Manajemen

Admitted to the hospital, Antibioticin the dose of intracranial infectionFor bacterial meningitis : combination ofAmpicillin and Cefotaxime orChloramphenicol

Empiric : acyclovir for neonates and babywith lesion in buccal or ginggiva /stomatitisor vesicle cause by herves virus, suspectedvirus ensefalitis, sepsis, without positifculture, or sepsis with HIV infection of theparent.

Management Aseptic meningitis : symptomatic As general : minimize the symptom such as

analgetics, fluid and treatment for prevention ofsequele

Adequate oxigenation , fluid and electrolite

Specific treatment for bactertial meningitisAntibiotics for Gram (+ and -) + Dexamethasone

For virus used acyclovir or gancyclovir dependon the etiology with or without immunoglobulin


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What is the prognosis for bacterialmeningitis?

Prognosis directly depends on the speed with which therapyis initiated.It is also dependent on the identity of the invading bacteria- the age and- medical status of the patient.

With rapid and effective treatment mortality ratesvary between 5-25%.

Delayed long-term sequelae such as : deafness and intellectual deterioration. death.The earlier a diagnosis is made and treatment instituted, thegreater the chance of survival without neurologicaldisabilities.

What are the complications of bacterialmeningitis?

o) shock, a condition known as the Waterhouse-

Friderichsen syndrome.p) cerebral edema.

This can translate into a dangerous increase inthe pressure within the skull (the intracranial

pressure or ICP). Both of these complicationsare life-threatening and mandate treatment inan intensive care unit.

ENCEPHALITIS

NN

Herpes Simplex Encephalitis

Herpes Simplex encephalitis is one of the mostserious complications of herpes simplex disease.There are two forms:

Neonatal there is global involvement and the brainis almost liquefied. The mortality rate approaches100%.

Focal disease the temporal lobe is most commonlyaffected. This form of the disease appears in childrenand adults. It is possible that many of these cases

arise from reactivation of virus. The mortality rate ishigh (70%) without treatment.

It is of utmost importance to make a diagnosis ofHSE early. It is general practice that IV acyclovir isgiven in all cases of suspected HSE before laboratoryresults are available.

Neonatal Herpes Simplex (1)

Incidence of neonatal HSV infection variesinexplicably from country to country e.g.from 1 in 4000 live births in the U.S. to 1 in10000 live births in the UK

The baby is usually infected perinatallyduring passage through the birth canal.

Premature rupturing of the membranes is awell recognized risk factor.

Neonatal Herpes (2)

The risk of perinatal transmission isgreatest when there is a florid primaryinfection in the mother.

There is an appreciably smaller risk fromrecurrent lesions in the mother, probablybecause of the lower viral load and thepresence of specific antibody

The baby may also be infected from othersources such as oral lesions from themother or a herpetic whitlow in a nurse.


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Neonatal Herpes Simplex (3)

The spectrum of neonatal HSV infection

varies from a mild disease localized to theskin to a fatal disseminated infection.

Infection is particularly dangerous inpremature infants.

Where dissemination occurs, the organsmost commonly involved are the liver,adrenals and the brain.

Where the brain is involved, the prognosisis particularly severe. The encephalitis isglobal and of such severity that the brainmay be liquefied.

Neonatal Herpes (4)

A large proportion of survivors of neonatalHSV infection have residual disabilities.

Acyclovir should be promptly given in allsuspected cases of neonatal HSV infection.

The only means of prevention is to offercaesarean section to mothers with florid

genital HSV lesions.

Other Manifestations..(1)

Disseminated herpes simplex aremuch more likely to occur in immunocompromised individuals.

The widespread vesicular resemblesthat of chickenpox. Many organs otherthan the skin may be involved e.g.

liver, spleen, lungs, and CNS.

Other Manifestation (2)

Other cutaneous manifestations include

eczema herpeticum which is potentially aserious disease that occurs in patients witheczema.

Herpetic whitlow which arise from implantationof the virus into the skin and typically affect thefingers.

zosteriform herpes simplex". This is a rarepresentation of herpes simplex where HSVlesions appear in a dermatomal distributionsimilar to herpes zoster.

Laboratory Diagnosis (1)

Direct Detection

Electron microscopy of vesicle fluid - rapid result

but cannot distinguish between HSV and VZV

Immunofluorescence of skin scrappings - can

distinguish between HSV and VZV

PCR - now used routinely for the diagnosis of

herpes simple encephalitis

Laboratory Diagnosis.(2)

Virus Isolation

HSV-1 and HSV-2 are among the easiest viruses to

cultivate. It usually takes only 1 - 5 days for a result

to be available.

Serology

Not that useful in the acute phase because it takes

1-2 weeks for before antibodies appear afterinfection. Used to document to recent infection.


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Management

At present, there are only a few indications ofantiviral chemo-therapy, with the high cost of

antiviral drugs being a main consideration.Generally, antiviral chemotherapy is indicatedwhere the primary infection is especially severe,where there is dissemination, where sight isthreatened, and herpes simplex encephalitis.

MANAGEMENT.

Acyclovir this the drug of choice for most

situations at present. It is available in a number offormulations:

Intra Vena (HSV infection in normal and immuno

compromised patients)

Oral (treatment and long term suppression of

mucocutaneous herpes and prophylaxis ofHSV in immunocompromised patients)

Cream (HSV infection of the skin and mucousmembranes)

Ophthalmic ointment

Management

Famciclovir and valacyclovir oral only, moreexpensive than acyclovir.

Other older agents e.g. idoxuridine,

trifluorothymidine, Vidarabine (ara-A).

These agents are highly toxic and issuitable for topical use for opthalmic

infection only

Note acyclovir is effective in crrelation with thymidinekinase

babi

babi

Dead-end host

Human

NyamukNyamuk

Vector :Cx. tritaeniorhynchus

Cx.gelidus

Cx. pseudovishnuiCx. fuscocephalus

Cx.wishnuiCx.annulirostris

etc

Nyamuk lainaedes sp.

Bird

Black crowned night heronSpring Fall

Local winter reservoir

Transporarialtransmission i n mosquitos

Snake, birts bats

Temperatur zone

Bird migration

Transmisi berlanjut

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Stadium ini dimulai bila suhu badandan sedimentation rate dari butir-

butir darah merah normal.

Gejala neurologi menunjukanadanya gejala-gejala perbaikanatau tetap tidak ada perubahan.

Diagnosa laboratoium dapat dilakukandengan beberapa cara; secara serologi,biologi, identifikasi virus, pemeriksaandarah dan cairan sumsum.

Secara serologis dapat dilakukanpemeriksaan Haemoglutination InhibitionTest (HI Test), Complement Fication Test(CFT), Neutralizing Antibody Test (NAT)pada anak mencit , ELISA, Agar GelDiffuion (AGD), Single Radial HaemolysisTest.

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).

Gejala Klinik

Nipah virus berhubungan dengan encephalitis(inflammation of the brain) ditandai denganfever dan drowsiness dan lebih serius padaSSP dapat menimbulkan coma, seizures, and

inability to maintain breathing.

Nipah virus terjadi 3-14 hari fever danheadache diikuti drowsiness and disorientationditandai dengan mental confusion.

Tanda dan gejala dengan cepat menjadi komadari 24-48 jam beberapa pasien mengalami

gangguan pernafasan sampai pertengahaninfeksi

Penyakit nervous serius oleh nipah virus

encephalitis telah perlihatkan ditunjukkanoleh beberapa sequelae, jugaconvulsions persistent dan personalitychanges.

Dari tahun 1998-1999 (outbreak) : 40 %pasien terkena penyakit nervous seriusdan banyak menimbulkan kematian

Cairan Serebrospinal tidak normal 75%kasus

EEG menunjukkan diffuse secara pelan

slow dengan abnormalities focal overtemporal regions (75%),

Tomogram computer normal danmagnetic resonance otak sampai phaseakut menunjukkan perluasan sebaranlesi-lesi focal pada subcortical dan deep

white matter.

Diagnosis PENCEGAHAN

Obat ribavirin menunjukkan hasil yangeffektif terhadap virus dalam uji coba invitro


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DAFTAR PUSTAKA

Petrus Nahak, SKM., Mkes, 2001Japanese Encephalitis (JE) BuletinEpidemiologi Propinsi NTT

www.cdc.co.id/travel/ diseases/japence

A Chaudhuri and P G E Kennedy 2002Diagnosis and treatment of viralencephalitis Postgraduate MedicalJournal 78:575-583

REFFERENCES

Shah,SS (editor) 2009 Pediatric Practice Infectious disease

Krugman, 2003 Infectious disease

mmmm

Sunartini

23. intracranial infection - prof sunartini

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