Saturday, August 16, 2008

Essentials of Diagnosis

• History: fever, headache, chills, sweats, malaise; focal neurological deficits—acute or subacute; infections in paranasal sinuses, mastoid, or elsewhere; intravenous drug use.

• Signs: Fever, leukocytosis; heart murmur; focal neurological deficits.

• Laboratory studies: MRI imaging; lumbar puncture, if not contraindicated by papilledema or presence of a mass lesion on MRI scanning; blood cultures, where appropriate.

The presence of fever, headache, focal neurological deficits, alterations of mental status, seizures, or some combination of these features suggests both focal disturbance of brain parenchyma and meningeal irritation. The range of conditions that can produce these disorders is large. Among the noninfectious causes, one must consider cerebrovascular disorders and primary or metastatic cancer as leading possibilities. In approaching such problems, it is important to try to determine the precise tempo of progression of the problem (ie, did the symptoms appear and become maximal in seconds to minutes, over a few hours, or over days?). Apoplectic onset or a seizure suggests an embolic process, whereas the development of a deficit over minutes to hours is more consistent with thrombosis or hemorrhage. Slower developing deficits suggest the growth of a mass lesion or sequential vascular insults which become additive.

Bacterial Endocarditis

The neurological complications of bacterial endocarditis are multiple, but the most frequent are those due to multiple emboli with infarction of the brain. Although larger emboli can cause obvious strokelike syndromes (most often in middle cerebral artery distribution), multiple smaller emboli may produce complex confusion states admixed with lesser degrees of focal disturbance. Brain abscesses, although infrequent in endocarditis, are usually associated with S aureus endocarditis and, if present in endocarditis, are usually small. They usually resolve with antimicrobial therapy alone. The formation of mycotic aneurysms at the site of embolism is not uncommon and may occur late in the course of the condition. As noted above, rupture of such aneurysms may be fatal.

One must be alert to the possibility of bacterial endocarditis in any patient with known congenital or acquired alteration of the heart valves, particularly if there has been recent oral or urogenital surgery or intravenous drug use. The traditional signs and symptoms of subacute bacterial endocarditis include asthenia, arthralgias, myalgia, anorexia, heart murmurs, splenomegaly, Roth spots, clubbing, fever, and sweats. Most such cases were caused, in the preantibiotic days, by oral streptococci, which have intrinsically low virulence, infecting heart valves damaged by rheumatic fever and causing small vegetations. However, such cases are now less prevalent and, with increasing intravenous drug use, S aureus, which can infect normal heart valves, is an increasingly prevalent cause of endocarditis. S aureus causes "acute" endocarditis with large vegetations, which embolize to cause metastatic abscesses, Osler's nodes, and, a much more toxic appearance than is typical of subacute endocarditis. The metastatic abscesses in staphylococcal endocarditis often occur in the brain and other parts of the CNS, so that the first presentation of endocarditis is often (20-40%) with stroke or another neurologic problem. The signs of endocarditis may all be easily overlooked, and the cause of the neurologic dysfunction missed if attention is devoted exclusively to the neurological phenomena. Thus, fever in the patient with neurologic findings should prompt a search for signs and symptoms of endocarditis, outlined above. The diagnostic criteria have recently been codified by Durack et al (1994). Once endocarditis is suspected, the most sensitive and specific diagnostic study is the transesophageal echocardiogram (ECHO). Repeated blood cultures may be required to identify the causative organism, but identification of the infecting microorganism and quantitative determination of its susceptibility to antibiotics are of critical importance in determining the nature and duration of treatment with intravenous antibiotics.

Herpes Simplex Virus-Induced Encephalitis

Encephalitides caused by viral infection of the brain frequently result in acutely or subacutely developing syndromes that combine headache, fever, alterations of mental status, seizures, and focal deficits. The most frequent cause of sporadic viral encephalitis is herpes simplex virus (HSV). The process in neonates is most frequently due to HSV type 2 (HSV2) resulting from maternal genital infection that was present at the time of birth. In children or adults, the encephalitic process is almost always caused by type 1 HSV (HSV1). Whether the brain infection results from exogenously acquired virus or from virus resident in cranial sensory ganglia or in the brain has not been determined.

In children or adults, the process usually takes place over a few hours to days. Initially the patient may exhibit behavioral changes or loss of memory or occasionally may complain of unusual olfactory or gustatory sensations. If present, these are valuable hints that herpes encephalitis should be considered. These symptoms may be followed by the development of headache, fever, focal deficits (hemiparesis or aphasia), and progressive disturbance of consciousness. Signs of meningeal irritation (stiff neck or vomiting) are often lacking. The diagnosis is most easily established by an MRI scan combined with typical CSF changes. The MRI scan is more sensitive than a CT scan for detecting HSV1 encephalitis; CT scans often appear normal during the first several days of the illness (when therapy is likely to have the greatest impact). Abnormalities on an MRI scan typically consist of contrast-enhancing lesions (bright on T-2-weighted images) in the medial temporal lobe and inferior frontal lobe, often extending medially and upwards into the putamen. Occasionally a seemingly separate area of disease is present in the cingulate gyrus.

The lesions are often associated with cerebral edema, and they are often bilateral, though rarely symmetrical. In our experience the lesions of HSV may be mimicked by cerebrovascular lesions in the temporal lobe or by the lesions associated with mitochondrial encephalopathies. The CSF is abnormal with a lymphocytic pleocytosis and moderately elevated protein concentration. The presence or absence of erythrocytes in the CSF is not of diagnostic help. Use of the HSV1 PCR to detect the presence of HSV genomes in CSF is generally very sensitive and highly specific, and this method has generally supplanted brain biopsy for diagnosis. The test may be falsely negative on the first day or two of the illness and after the second week. Tests for HSV antibody in the CSF are rarely positive early in the disease; cultures for HSV are almost always negative. The electroencephalogram may point to the presence of a temporal lobe abnormality; however, it is not highly specific for HSV infection. Nonetheless, a normal electroencephalogram weighs against a diagnosis of HSV encephalitis.

Treatment with intravenous acyclovir should be instituted as soon as the diagnosis is suspected, because delay in treatment is associated with a poorer outcome. With early, specific therapy, the mortality and morbidity are substantially reduced, and there is little risk from the drug except in patients with renal failure.

Arbovirus-Induced Encephalitis

A variety of arthropod-borne viruses (togaviruses) cause encephalitis, often in localized outbreaks associated with summertime increases in mosquito populations. The treatment of these encephalitides requires excellent supportive care until the patients improve on their own; there are no currently available specific antiviral compounds that are effective against arboviruses.

Brain Abscesses

A variety of bacterial infections must be considered in producing the brain abscess symptom complex. Brain abscesses commonly cause seizures, focal deficits, and, as they enlarge, progressive obtundation. Although many patients with brain abscesses have no evident primary source of infection, it is imperative to search carefully for a primary focus in the paranasal or mastoid sinuses with contiguous spread to the brain. These sites may yield the organism(s) causing the brain abscess. Additionally, metastatic (or "hematogenous") abscesses, ones seeded via the bloodstream, can arise from infection in skin or lung, by IV drug use, in association with endocarditis, or in association with dental procedures.

Brain abscesses are usually recognized by contrast-enhanced CT or MRI scans. The importance of performing CT or MRI scans with contrast enhancement when testing for brain abscesses is demonstrated in Figure 7-1. Brain abscesses may be confused with brain tumors but are usually more spherical with thinner walls; gas, if present, is a valuable diagnostic feature indicating their bacterial etiology. Brain abscesses are often associated with marked degrees of cerebral edema.

Management of patients who have brain abscesses usually involves a combination of surgery for diagnosis and drainage or excision, antibiotic therapy, and treatment of cerebral edema. The bacterial flora causing brain abscesses are highly variable and are often composed of mixed aerobic and anaerobic bacteria. Staphylococci, anaerobic streptococci, and Bacteroides species predominate, but gram-negative bacilli may also be found in brain abscesses. Initial treatment should include a penicillinase-resistant penicillin such as nafcillin or oxacillin to treat a staphylococcal component, a third-generation cephalosporin for gram-negative organisms, and metronidazole for anaerobic streptococci and Bacteroides species. Some authors include an anti-Pseudomonas drug if the abscess complicates chronic otitis.

Stereotaxic surgical aspiration is advisable to establish bacteriologic diagnosis and is often useful to decompress large abscesses or abscesses that block or threaten to rupture into the ventricular system. Repeated aspirations may be necessary to control a mass effect. Abscesses tend to enlarge by extending toward the ventricular system, and they pose a risk for rupture into the ventricles with an often fatal outcome. Thus, drainage efforts must be especially vigorous with abscesses enlarging toward the ventricular surfaces. Extirpation of abscesses should be considered when they are solitary, well encapsulated, and surgically accessible. Surgical extirpation should be considered for posterior fossa abscesses because of their propensity to compress the brainstem and to obstruct the ventricular system.

Management of the cerebral edema that accompanies brain abscesses should include dexamethasone administered intravenously. Mannitol may be used, especially as a temporizing measure prior to surgical drainage. Note that the cessation of steroid therapy, used to diminish cerebral edema, may allow an increase in the inflammatory component of the abscess, with a resulting increase in the degree of enhancement of the abscess wall on contrast-enhanced CT scans. This phenomenon may unnecessarily raise alarm that the abscess is not yielding to therapy; but this conclusion may be erroneous in the face of steroid withdrawal.

Subdural Empyemas

Abscesses in the subdural space (subdural empyemas) are often associated with frontal, sphenoid, or ethmoid sinus infection. For reasons that are not understood, these empyemas are seen almost exclusively in males. Because the subdural space is continuous over the entire surface of the brain and between the hemispheres, large amounts of pus can be contained within it, causing widespread irritation and edema of the underlying brain. The organisms responsible are similar to those in brain abscesses, with aerobic streptococci, anaerobic streptococci, S aureus, and Bacteroides species predominating. In addition, S pneumoniae and H influenzae may cause these empyemas. Often there is associated meningitis if organisms and/or cells spread through the arachnoid into the subarachnoid space. In addition, involvement of cortical veins and venous sinuses in the inflammatory process and possibly with associated thrombosis can be seen.

Seizures are common. Because the CSF is usually abnormal and under raised pressure in these cases, the hazard of a spinal tap often outweighs the potential value of the information that can be gained. The diagnosis is most readily established by MRI or CT scan with contrast enhancement. The treatment consists of prompt surgical drainage through bilateral or multiple burr holes or by means of formal craniotomy. Provisional antibiotic choices can then be modified on the basis of Gram staining and culture of the aspirated pus.

Cerebral Venous Sinus Infections

Infections of the cerebral venous sinuses can be seen in association with any of the above purulent infections (meningitis, brain abscess, or subdural empyema) or as a consequence of mastoid or sinus infection. Usually the venous sinus involved is contiguous to an infected structure such as an infected sinus. The lateral venous sinuses thus may be involved when there is mastoid or ear infection, and cavernous sinus thrombosis may be associated with ethmoid or sphenoid sinus infection or with facial cellulitis. With extension of infective thrombus into cortical veins, seizures and cortical venous infarction are common. Infections of the cavernous sinus may produce proptosis and chemosis of the eye and palsies of the third, fourth, and sixth cranial nerves because these nerves traverse the cavernous sinus. This constellation of signs is also seen in diabetics with nasal or sinus infection caused by Mucor or Rhizopus fungal species. Involvement of the superior sagittal sinus frequently produces cortical vein thrombosis with seizures and may result in infection of the upper convexities of the brain with consequent leg paralysis.

The diagnosis of thrombosis of these venous structures is best made by MRI scanning, which can demonstrate the presence or absence of flow voids, clotted blood, engorgement of these structures, or some combination of these findings. The diagnostic certainty can be further enhanced by the use of magnetic resonance venography.

Treatment consists of antibiotics as for the treatment of brain abscesses or for other specific causative microorganisms that may be identified. Consideration should be given to administration of anticoagulants to inhibit the propagation of clots within the venous sinuses. However, the use of anticoagulants must be weighed against the possibility of worsening the process by hemorrhage, accompanying venous occlusion and infarction of brain.

Fungal Infections

Fungi may cause focal disease in the brain with a constellation of signs and symptoms similar to those considered above. Fungal infections are most often encountered in hosts with compromised cell-mediated and other types of immunity. They are thus seen more often in patients with AIDS, lymphoma, Hodgkin's disease, leukemia, or advanced diabetes or in patients receiving cytotoxic or immunosuppressive regimens. Cryptococcal infection usually presents as severe meningitis and should be considered in the differential of acute bacterial meningitides discussed earlier. Infection caused by Mucor or Rhizopus species occurs most frequently in diabetics with multiple episodes of acidosis. The infection may spread from the oropharynx or paranasal sinuses into the skull base, involving the orbit, cranial nerves two through six, and the cavernous sinus as well as the carotid artery. The clinical picture of a red or proptotic eye with third or sixth nerve paralysis in a diabetic should prompt aggressive biopsy and culture of affected tissues as well as culturing of the nasopharynx and sinuses for Mucor or Rhizopus species. Optimal management requires a combination of surgical debridement and therapy with high-dose amphotericin B or lipid-formulated amphotericin B.

The most frequent fungi associated with parenchymal infection of brain are Aspergillus and Candida species. These infections are seen most frequently in immunocompromised hosts, particularly in those with neutropenia. Aspergillus infections usually have their origins in pulmonary or sinus infections whereas Candida infections are often seen in patients with indwelling intravenous lines, in intravenous drug users, or in patients who have previously been treated with corticosteroids or broad-spectrum antibiotics.

These organisms, especially Aspergillus and Mucor or Rhizopus species, share a predilection for invading the walls of cerebral blood vessels with resulting thrombosis of the blood vessel. Thus, in addition to causing cerebral abscesses and meningitis, they often produce strokelike events as a result of thrombi forming in inflamed vessels. Treatment of these fungal infections is with high-dose amphotericin B or lipid-formulated amphotericin B. Therapy for Candida infection is amphotericin B or lipid-formulated amphotericin B with or without 5-fluorocytosine, depending on the patient's underlying disease and the species of the Candida strain (some strains of certain species of Candida, such as parapsilosis, are exquisitely susceptible to the synergism of amphotericin B with 5-fluorocytosine).


Toxoplasmosis in the CNS presents most commonly with multifocal lesions, causing focal deficits, seizures, and impairment of cognitive functions over a period of days to weeks. Before the advent of AIDS, CNS toxoplasmosis was encountered only rarely, and then usually in the setting of Hodgkin's disease, lymphoma, or other states of severe immunosuppression. It has become a frequent complication in AIDS patients and should be immediately considered in the AIDS patient who develops multifocal neurologic deficits over a period of a few days to weeks.

The disease is often easily visualized by contrast-enhanced CT or (preferably) MRI scans, most often appearing as multicentric solid or ringlike enhancing lesions in the brain; the appearances are often quite characteristic but can be mimicked by cerebral lymphoma, also an AIDS-associated condition. A negative immunoglobulin G antibody test for Toxoplasma gondii makes the diagnosis unlikely. If the immunoglobulin G antibody test is positive, some experts advocate a therapeutic trial of sulfadiazine pyrimethamine, and folinic acid, in association with monitoring the clinical course as well as the size of the cerebral lesions on MRI scan. If there is no response in 10-14 days or if there is deterioration, a brain biopsy to examine other diagnostic possibilities should be strongly considered.


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