Myopathy, Neuropathy, CNS Infections
Myopathy, Neuropathy, CNS
Infections
Rachel Garvin, MD
Assistant Professor, Neurocritical Care
Department of Neurosurgery
Objectives
Describe critical care myopathy and
neuropathy, causes, diagnosis and
management
Describe CNS infections, diagnosis and
management
Critical Illness Polyneuropathy (CIP)
and Myopathy (CIM)
Seen in conjunction with severe sepsis
and prolonged use of neuromuscular
blockade +/- steroids
Seen in up to 40% of ICU patients
CIM/CIP
First sign is often inability to wean from
ventilator
Not usually noted until patient at least 2
weeks on ventilator
Severe diffuse weakness and muscle
wasting
CIP
Diagnosis by EMG
Axonal degeneration of motor and
sensory fibers
CK is normal
Muscle biopsy shows denervation atrohpy
CIM
EMG shows myopathic muscle units
Elevated serum CK
Biopsy shows myopathy with loss of
myosin
Recovery/Management
No specific treatment – supportive care
Range of levels of recovery
CNS INFECTIONS
CNS Infections
Meningitis/Ventriculitis
Encephalitis
Brain Abscess
Meningitis
Bacterial (septic) vs Other infectious or
inflammatory (aseptic)
Most often caused by bacteremia that
seeds meninges by crossing BBB and
multiplying in CSF
Ventriculitis more common in those with
ventricular drains/shunts
Cerebral edema can occur d/t
inflammatory effects of infection leading
to vasogenic and cytotoxic edema
Meningitis
Classic signs of
fever
, HA and
meningismus may not always be present
(esp. elderly)
Also seen with photophobia, N/V, altered
consciousness
Pathogens dependent on:
◦
Adult in community: strep pneumo, neisseria,
listeria
◦
Hospitalized patient: gram negatives
Meningitis Dx: LP
Elevated opening pressure (>20cmH2O)
Increased protein (>100mg/dl)
Decreased glucose (<40% serum level)
Elevated nucleated cell count (usually
>100)
Complications
SIADH (50% of cases)
Seizures
Elevated ICP
risk of herniation
Treatment
Abx appropriate to pathogen
Ensure appropriate CNS dosing
Duration from 14-21 days depending on
pathogen
Encephalitis
Infection of brain parenchyma
Multiple modes of infection
Most are hematogenous spread except
for HSV and rabies which spread via
neurons
Most are viral
Encephalitis: Presentation
Varies as certain infections have certain
locations they affect:
HSV: inf/medial temporal lobes and
orbito-frontal cortex
Arboviruses (West Nile, equine): cortical
gray matter, brainstem and thalamic nuclei
Japanese B virus: brainstem nuclei and
basal ganglia
Encephalitis: Diagnosis
History and physical
Neuroimaging: CT and MRI
LP: many present as meningoencephalitis
HSV PCR may be falsely negative in first
48 hours and then again 10 days after
infection
Other viruses: IgM in CSF, viral culture
from blood, tissue or CSF
Encephalitis: Treatment and
Outcomes
Only treatment for HSV with Acyclovir
for 14 days
Other viruses are supportive care only
Brain Abscess
Encapsulated collection of pus within
brain parenchyma
Risk factors include: head and neck
infections, penetrating head injury,
immunocompromised state
Presentation often non-specific but can
have symptoms related to location of
abscess
Brain Abscess: Pathophysiology
Begins as a cerebritis, day 1-3 with
surrounding inflammation and edema
1 week into infection, central necrosis
develops
By 14 days, fibrous capsule apparent
which becomes more established
Brain Abscess: Diagnosis
History and Physical
CT + contrast
MRI
Needle-guided aspiration
Braun Abscess: Complications
Seizures are most common morbidity (up
to 70%)
Abscess rupture leading to
meningitis/ventriculitis
Formation of subdural empyema, epidural
abscess, septic thrombophlebitis
Brain Abscess: Treatment
IV abx based on pathogen or presumed
source (otitis, odontogenic)
Surgical drainage
CNS Fungal Infections
Seen mostly in immunocompromised
patients
Can present in any form (meningitis
abscess)
Often difficult to grow in culture
Treatment with ampho B
In this presentation, Dr. Rachel Garvin covers critical care myopathy and neuropathy causes, diagnosis, and management, as well as CNS infections, their diagnosis, and management. Learn about CIM/CIP, CIP diagnosis, CIM diagnosis, and recovery/management approaches. Explore CNS infections, including meningitis, ventriculitis, encephalitis, and brain abscesses. Understand the differences between bacterial and other infectious meningitis, its common causes, and classic signs.
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Presentation Transcript
Myopathy, Neuropathy, CNS Infections Rachel Garvin, MD Assistant Professor, Neurocritical Care Department of Neurosurgery
Objectives Describe critical care myopathy and neuropathy, causes, diagnosis and management Describe CNS infections, diagnosis and management
Critical Illness Polyneuropathy (CIP) and Myopathy (CIM) Seen in conjunction with severe sepsis and prolonged use of neuromuscular blockade +/- steroids Seen in up to 40% of ICU patients
CIM/CIP First sign is often inability to wean from ventilator Not usually noted until patient at least 2 weeks on ventilator Severe diffuse weakness and muscle wasting
CIP Diagnosis by EMG Axonal degeneration of motor and sensory fibers CK is normal Muscle biopsy shows denervation atrohpy
CIM EMG shows myopathic muscle units Elevated serum CK Biopsy shows myopathy with loss of myosin
Recovery/Management No specific treatment supportive care Range of levels of recovery
CNS Infections Meningitis/Ventriculitis Encephalitis Brain Abscess
Meningitis Bacterial (septic) vs Other infectious or inflammatory (aseptic) Most often caused by bacteremia that seeds meninges by crossing BBB and multiplying in CSF Ventriculitis more common in those with ventricular drains/shunts Cerebral edema can occur d/t inflammatory effects of infection leading to vasogenic and cytotoxic edema
Meningitis Classic signs of fever, HA and meningismus may not always be present (esp. elderly) Also seen with photophobia, N/V, altered consciousness Pathogens dependent on: Adult in community: strep pneumo, neisseria, listeria Hospitalized patient: gram negatives
Meningitis Dx: LP Elevated opening pressure (>20cmH2O) Increased protein (>100mg/dl) Decreased glucose (<40% serum level) Elevated nucleated cell count (usually >100)
Complications SIADH (50% of cases) Seizures Elevated ICP risk of herniation
Treatment Abx appropriate to pathogen Ensure appropriate CNS dosing Duration from 14-21 days depending on pathogen
Encephalitis Infection of brain parenchyma Multiple modes of infection Most are hematogenous spread except for HSV and rabies which spread via neurons Most are viral
Encephalitis: Presentation Varies as certain infections have certain locations they affect: HSV: inf/medial temporal lobes and orbito-frontal cortex Arboviruses (West Nile, equine): cortical gray matter, brainstem and thalamic nuclei Japanese B virus: brainstem nuclei and basal ganglia
Encephalitis: Diagnosis History and physical Neuroimaging: CT and MRI LP: many present as meningoencephalitis HSV PCR may be falsely negative in first 48 hours and then again 10 days after infection Other viruses: IgM in CSF, viral culture from blood, tissue or CSF
Encephalitis: Treatment and Outcomes Only treatment for HSV with Acyclovir for 14 days Other viruses are supportive care only
Brain Abscess Encapsulated collection of pus within brain parenchyma Risk factors include: head and neck infections, penetrating head injury, immunocompromised state Presentation often non-specific but can have symptoms related to location of abscess
Brain Abscess: Pathophysiology Begins as a cerebritis, day 1-3 with surrounding inflammation and edema 1 week into infection, central necrosis develops By 14 days, fibrous capsule apparent which becomes more established
Brain Abscess: Diagnosis History and Physical CT + contrast MRI Needle-guided aspiration
Braun Abscess: Complications Seizures are most common morbidity (up to 70%) Abscess rupture leading to meningitis/ventriculitis Formation of subdural empyema, epidural abscess, septic thrombophlebitis
Brain Abscess: Treatment IV abx based on pathogen or presumed source (otitis, odontogenic) Surgical drainage
CNS Fungal Infections Seen mostly in immunocompromised patients Can present in any form (meningitis abscess) Often difficult to grow in culture Treatment with ampho B
