3. CASE 1
• A 32 yrs old gentleman is brought to
ER with history of fever for 3 days,
headache & vomiting for 2 days and
drowsiness since morning.

4. •
•
•
•
•
•
•
O/E
BP = 110/70 mm Hg
Pulse= 112/min
Temp= 103F
CNS : Neck stiffness +ve
SOMI
+ve
GCS
11/ 15
Plantars
downgoing

5. CSF
•
•
•
•
•
Colour
Appearance
Proteins
Glucose
Cells
whitish
turbid
213 mg/dl
36 mg/dl
1056/cmm
N = 97%
L = 3%

6. • What is your diagnosis?
• How will you manage?
• What can be the complications in this
case?

8. • A 23 yrs old lady is brought to ED
with c/o sudden unconsciousness.
• h/o low grade fever and mild
headache for last 1 day. No history
of vomiting or fits.

9. O/E
• A young lady lying
unconscios
• BP = 80 Systolic
pulse = 90bpm
• Temp = 100oF
• A macular purpuric
rash over legs &
abdomen
• CNS
• GCS 7/15
Plantars upgoing
• SOMI +ve
fundi
intact

10. CSF R.E.
• Appearance
• Proteins
• Cells
• Glucose
turbid
250 mg/dl
612 /cmm
N = 90 %
L = 10 %
28 mg/dl

11. • What is your impression?
• What other investigations will you
plan?
• How will you manage her?

13. • A young girl of age 14 yrs is brought
to ED with c/o severe headache for 1
day, fever for 1 day and irritable
behaviour for 3 hrs.

14. • What is your diagnosis?
• What is its treatment?

16. • A 32 yr old gentleman is brought to
ED with c/o low grade fever & easy
fatiguability for 1 month, headache
for 2 weeks and LOC for 1 day.

17. O/E
•
•
•
•
•
•
•
•
•
BP = 170/100 mmHg
Pulse = 60bpm
Temp = 99.5oF
CNS:
pupils RRR
SOMI -ve
plantars downgoing
GCS 10/ 15
REST OF EXAM NORMAL

18. Urgent CT brain shows meningeal
enhancement with mild hyrocephalus.
CSF R.E shows:
proteins =210mg/dl glucose =34mg/dl
Cells = 230/cmm with 88% lymphos

19. • Same patient presents to ED after 1month
with c/o persistant vomiting. O/E
• pt is fully conscious ,oriented
• Mildly jaundiced
• Labs:
Bilirubin = 4-5 mg/dl
ALT
= 60U/L
• WHAT WILL YOU DO?

20. • Same patient comes to OPD after
3months with c/o vertgo and
instability for 3 days. Clinically there
are features of left cerebellar lesion.
• What can be the cause?
• What will be your management plan?

21. • What is your diagnosis?
• How will you manage?

22. Tuberculomata

23. • Same patient again brought to ED in
an unconscious state. O/E
• VITALS stable
3/15
• GCS
upgoing
• Plantars
early papilloedema
• Fundi
• CT brain Obstuctive hydrocephalus

24. what to do now?

26. • A young lady is brought to ED with
c/o fever for 5 days, headache for 3
days , irrelevant talk f0r last 2 days
& one episode of GTCF.

27. O/E
•
•
•
•
•
•
A young lady talking irrelevantly
Temp = 100oF
CNS =
Pt conscious, not oriented
No SOMI
No other +ve finding

28. • A Vesicular rash is seen over area of
RHC

29. CSF R.E.
•
•
•
•
Appearance
Proteins
Glucose
Cells
clear
60mg/dl
60mg/dl
100/cmm
L = 88%
N = 12%

30. • What is your diagnosis?
• How will you manage?

32. • A 24 yrs old gentleman is brought to
ED with c/o high grade fever
associated with rigors & chills for
last 2 weeks, headache for 6 days
and 1 episode of GTC fits followed by
drowsiness.

33. O/E
•
•
•
•
•
A young man lying unconscious in bed.
BP
= 100/60mmHg
Pulse = 120bpm
Temp = 102oF
CNS:
GCS
5/I5
Tone decreased on right
right plantar upgoing
fundi bilateral papilloedema

34. CT BRAIN
Low density lesion
in left
frontoparietal
region with ring
enhancement

36. • What is your diagnosis?
• How will you manage?

38. A young boy of age 20 is brought to
OPD with c/o low grade fever for 1
month, restlessness and depressive
mood for 1month and vomiting with
severe frontal headache for 7 days.

39. O/E
•
•
•
•
BP
120/80 mm/Hg
PULSE
72bpm
TEMPERATURE 102F
CNS
no positive finding

40. • During hospital stay, pt continued to
deteriorate. Headache & fever did
not settle despite good antibiotics &
analgesics.
• 5 days later he got rt 6th nerve palsy.
• MRI brain advised.

41. • He became incontinent.
• His mental state also deteriorated and he
became disoriented in time, place and
person.
• 5 days later he got rt 6th nerve palsy.
• No h/o fits
• MRI brain advised.

42. MRI brain
• Meningeal enhancement
• Focal tuberculomas in right frontal
and parietal region.
• So diagnosis is TBM with
tuberculomata

43. CNS INFECTIONS

44. •
•
•
•
•
•
Bacterial infections
Viral infections
Prion diseases
Protozoal infections
Helminthic infections
Fungal infections

45. Bacterial infections
•
•
•
•
•
•
•
Meningitis
Suppurative encephalitis
Brain abscess
Tuberculosis
Neurosyphilis
Diphtheria
Tetanus

46. Viral infections
•
•
•
•
•
•
•
Meningitis
Encephalitis
Tranverse myelitis
Poliomyelitis
SSPE
Rabies
HIV infection

47. •
•
•
•
PRION DISEASES
Creutzfeldt-jakob
disease
Kuru
FUNGAL INF.
Meningitis i.e
Cryptococcal or
Candida
PROTOZOAL INF:
• Malaria
• Toxoplasmosis
• Trypanosomiasis
HELMINTHIC INF:
• Cysticercosis
• Hydatid disease
• Schistosomiasis

48. • Acute infection of meninges
• Pt presents with fever,headache, vomiting
and altered mental status.
• O/E there is neck stiffness & signs of
meningeal irritation.
• It may be bacterial, viral ,fungal, protozoal
or due to non-infective causes..

49. VIRAL MENINGITIS
• The most common cause of meningitis
• Usually benign & self-limiting
• Common viruses causing meningitis
are enteroviruses, herpes simplex,
EBV or varicella zoster.
• Mostly occurs in children & young
adults.

50. CLINICAL FEATURES
•
•
•
•
•
Sudden severe headache
Pyrexia
irritability
Meningism
Focal neurological signs occur rarely.

51. Bacterial Causes of
Meningitis
•
•
•
•
•
•
•
•
In Neonates:
E-coli
Proteus
Group B Streptococci
Listeria monocytogenes
In Pre-school Child:
H-Influenza
N-Meningitidis
Streptococcus Pneumoniae
Mycobacterium
Tuberculosis
In Older Children
and Adults:
•
•
•
•
•
•
N-Meningitidis
S Pneumoniae
Listeria
M tuberculosis
S aureus
H-Influenza

52. • Bacterial meningitis is less common
but associated with significant
morbidity & mortality.
• Most common causes are S
pneumoniae, N meningitidis and H
influenzae.
• Pt presents with fever, headache,
dowsiness & neck stiffness. Rash may
be seen in meningococcemia.

54. TBM
•
•
•
•
•
•
•
SYMPTOMS:
Headache
Vomiting
Low-grade Fever
Lassitude
Depression
Confusion
Behaviour changes
SIGNS:
• Meningism ( may be
absent)
• Nerve palsies
• Focal hemisphere
signs
• Papilloedema
• Deterioration of
conscious level

55. • It presents with acute onset of
headache, fever, focal neurological
signs and seizures.
• There may be drowsiness or coma.
• Meningism occurs in many cases.
• Most imp cause is Herpes simplex.

56. Bacteria may enter the brain via
penetrating injury. There may be
direct spread from paranasal sinuses
or middle ear. There may be
hematogenous spread from
septicemia in which case multiple
abscesses may form.

57. Clinical features
• It may present acutely with fever,
headache, meningism & drowsiness.
• Commonly it presents over days or
weeks with fever, features of raised
ICP , seizures and focal signs.

58. •
•
•
•
•
CT scan brain
Lumbar puncture
Blood cultures
PCR of CSF
Baseline labs

59. CSF R.E
Condition Cell type
Cell count
Normal
0-4*106/l
Lymphocyts
Viral
lymphocyte
bacterial polymorphs
TB
P/L/Mixed
Fungal
lymphocyte
malignant lymphocyte
glucos protein
e
<60% Upto
of BSR 0.45g/l
10-2000
Normal N
1000-5000 Low
N/ incr.
50-5000
Low
Increas
ed
50-500
Low
Increas
0-100
low
N /incr.

60. • Viral meningitis is usually selflimiting.
• Symptomatic treatment is done.

61. Treatment of pyogenic
meningitis
General T/M:
• Bed Rest
• IV Fluids
• Airway Patency

62. Specific Antimicrobial
T/M
Antibiotic Regimen is
modified
according to age &
suspected
organism.
Mainstay of T/M is
IV Antibiotics.

63. T/M When Cause Of
Bacterial Meningitis is Known
Pathogen
NMeningitidis
Strep
Pneumoniae
Regime of
choice
Alternative
2.4g IV
4hourlyFor 5-7
days
Ampicillin
Chloramphenicol
Benzyl Penicillin Cefuroxime
Cefotaxime
2g IV 6hourly or
Ceftriaxone
2g IV 12hourly
Chloramphenicol

64. H-Influenza
Cefotaxime
Chloramphenicol
Or
Ceftriaxone
Listeria
Ampicillin
Monocytogen 2g IV 4 hourly +
es
Gentamicin
5mg/kg IV daily
Ampicilin + Cotrimoxazol

65. T/M of Pyogenic Meningitis
of Unknown Cause
 Pt. with typical Meningococcal Rash:
Benzyl Penicillil 2.4g IV 6 hourly.
 Adults (18-50 Yr) without typical rash:
Cefotaxime 2g IV 6 hourly
or
Ceftriaxone 2g IV 12 hourly
 Pt. with penicillin resistant Pneumococcal Infection:
Vancomycin 1g IV 12 hourly
or
Rifampicin 600mg IV 12 hourly

66.  Pt. with suspicion of Listeria Infection:
Ampicillin
or
Co-trimoxazole
 Pt. with H/O Anaphylaxis to B-Lactams:
Chloramphenicol + Vancomycin

67. T/M according to age of Pt.
 Neonates and infants:
Ampicillin with Cefotaxime
 Older Children and Young Adults
Penicillin G + Ceftriaxone
 Older Pt. (>50 Yrs):
Ampicillin + Ceftriaxone

68. Adjuvant Therapy
1. Mannitol:
250ml IV bolus over 10-20 minutes
2. Glucocorticoids:
Dexamethasone 0.15mg/kg IV 6hourly
3. Antiepileptics:
Diazepam/Phenytoin/Barbiturates

69. Prevention Of
Meningococcal Infection
• Oral Rifampicin 600mg 12 hourly in adults
• Oral Rifampicin 5-10mg/kg 12 hourly in
children
• Ciprofloxacin 500mg in adults
(Alternative)
Vaccines:
For prevention of diseases caused by
Meningococci of Gp. A & C.

70. Treatment of TBM
•
•
•
•
General measures
ATT
Steroids
Surgical treatment may be required
if hydrocephalus develops.

71. Viral encephalitis
• Inf Acyclovir 10mg/kg body weight
IV 8hrly for 2-3 weeks.
• symptomatic

72. Brain abscess
• Antibiotics according to site of
abscess like cefuroxime &
metronidazole for frontal lobe lesion
• Anticonvulsants may be required
• Surgical treatment