Acute infections of the nervous system include bacterial meningitis, viral meningitis, encephalitis, focal infections such as brain abscess and subdural empyema, and infectious thrombophlebitis. Key goals: emergently distinguish between these conditions, identify the pathogen, and initiate appropriate antimicrobial therapy.
APPROACH TO THE PATIENT: Acute Infection of the Nervous System
First identify whether infection predominantly involves the subarachnoid space (meningitis) or brain tissue (termed encephalitis when viral, cerebritis or abscess if bacterial, fungal, or parasitic) (Fig. 191-1). Nuchal rigidity is the pathognomonic sign of meningeal irritation and is present when the neck resists passive flexion.
Principles of management:
Initiate empirical therapy whenever bacterial meningitis is considered.
All pts with head trauma, immunocompromised states, known malignancies, or focal neurologic findings (including papilledema or stupor/coma) should undergo a neuroimaging study of the brain prior to LP. If bacterial meningitis is suspected, begin empirical antibiotic therapy prior to neuroimaging and LP.
Stupor/coma, seizures, or focal neurologic deficits do not occur in viral meningitis; pts with these symptoms should be hospitalized and treated empirically for bacterial and viral meningoencephalitis.
Immunocompetent pts with a normal level of consciousness, no prior antimicrobial treatment, and a CSF profile consistent with viral meningitis (lymphocytic pleocytosis and a normal glucose concentration) can often be treated as outpatients. Failure of a pt with suspected viral meningitis to improve within 48 h should prompt reevaluation including follow-up examination, repeat imaging, and laboratory studies, often including a second LP.
The management of pts with suspected CNS infection. ADEM, acute disseminated encephalomyelitis; AFB, acid-fast bacillus; Ag, antigen; CTFV, Colorado tick fever virus; DFA, direct fluorescent antibody; HHV, human herpesvirus; LCMV, lymphocytic choriomeningitis virus; MNCs, mononuclear cells; TB, tuberculosis; WNV, West Nile virus.
ACUTE BACTERIAL MENINGITIS
Pathogens most frequently involved in immunocompetent adults are Streptococcus pneumoniae (“pneumococcus,” ~50%) and Neisseria meningitidis (“meningococcus,” ~25%). Predisposing factors for pneumococcal meningitis include infection (pneumonia, otitis, sinusitis), asplenia, hypogammaglobulinemia, complement deficiency, alcoholism, diabetes, and head trauma with CSF leak. Listeria monocytogenes is a consideration in pregnant women, individuals >60 years, alcoholics, and immunocompromised individuals of all ages. Enteric gram-negative bacilli and group B streptococcus are increasingly common causes of meningitis in individuals with chronic medical conditions. Staphylococcus aureus and coagulase-negative staphylococci are causes following neurosurgical procedures, especially shunting procedures for hydrocephalus.
Presents as an acute fulminant illness that progresses rapidly in a few hours or as a subacute infection that progressively worsens over several days. The classic clinical triad of meningitis is fever, headache, and nuchal rigidity (“stiff neck”). Mental status changes occur in >75% of pts and vary from lethargy to coma. Nausea, vomiting, and photophobia are also common. Seizures occur in 20–40% of pts. Raised intracranial ...