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Chapter 18 : Central Nervous System Infections

Authors: Igen Hongo1, Karen C. Bloch2, Yi-Wei Tang3
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Affiliations: 1: Department of Internal Medicine, Musashino Red Cross Hospital, Tokyo 180-8610, Japan; 2: Departments of Medicine and Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232; 3: Departments of Pathology and Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232
Content Type: Monograph
Publication Year: 2009

Category: Clinical Microbiology

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Abstract:

This chapter provides a framework for the assessment and laboratory evaluation of immunocompromised patients presenting with central nervous system (CNS) infections. Infections of the meninges, brain, and spinal cord result in meningitis, encephalitis, and myelitis, respectively. While the chapter is limited to CNS infections, noninfectious conditions may be presented in a similar fashion. Mycobacterial and fungal meningitides tend to cause subacute or chronic meningitis. Granulomatous amoebic encephalitis in immunocompromised hosts is caused by species, free-living parasites that cause CNS infection characterized by multiple mass lesions throughout the brain. Myelitis is often seen in combination with encephalitis or meningitis and can be presented as either an acute or chronic condition. CNS manifestations of tuberculosis are diverse, but tuberculous meningitis is the most frequent form, with neuroimaging findings including basilar meningeal enhancement, hydrocephalus, and infarctions in the supratentorial brain parenchyma and/or brain stem. PCR amplification of viral nucleic acid in the cerebrospinal fluid (CSF) is sensitive and specific, and test turnaround time has been shortened significantly, to just a few hours, by incorporating either colorimetric enzyme immunoassay or real-time detection methods. While this chapter outlines many of the most common etiologic agents, with the emergence of new infections, the migration of infectious agents into new geographic niches, and the advent of an increasing array of medications with suppressive effects on the immune system, the field continues to evolve.

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
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Central Nervous System Infections
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Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
/content/10.1128/9781555815455.ch18.ch18fig01
Figure 1.
Management of immunocompromised adults with acute meningitis syndrome (fulminant course [<48 h], with fever, headache, impaired sensorium, or stiff neck). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, for patients on chronic corticosteroids, increase to stress dosing.
10.1128/9781555815455/f0401-01_thmb.gif
10.1128/9781555815455/f0401-01.gif
Image of Figure 1.
Figure 1.

Management of immunocompromised adults with acute meningitis syndrome (fulminant course [<48 h], with fever, headache, impaired sensorium, or stiff neck). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, for patients on chronic corticosteroids, increase to stress dosing.

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
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/content/10.1128/9781555815455.ch18.ch18fig02
Figure 2.
Management of patients with HIV/AIDS and subacute CNS infection syndrome (subacute illness [>3 to 7 days], with variable presence of fever, headache, progressive impairment of cognitive function, and/or focal defects). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, treatment decisions should factor in radiologic appearance, toxoplasma serology, and prophylaxis with trimethoprim-sulfamethoxazole. See the text for details.
10.1128/9781555815455/f0402-01_thmb.gif
10.1128/9781555815455/f0402-01.gif
Image of Figure 2.
Figure 2.

Management of patients with HIV/AIDS and subacute CNS infection syndrome (subacute illness [>3 to 7 days], with variable presence of fever, headache, progressive impairment of cognitive function, and/or focal defects). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, treatment decisions should factor in radiologic appearance, toxoplasma serology, and prophylaxis with trimethoprim-sulfamethoxazole. See the text for details.

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
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/content/10.1128/9781555815455.ch18.ch18fig03
Figure 3.
Management of transplant patients with subacute CNS infection syndrome (subacute illness [>3 to 7 days], with variable presence of fever, headache, progressive impairment of cognitive function, and/or focal defects). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, treatment decisions should factor in radiologic appearance, fungal antigen tests, and prophylactic antibiotic regimens. See the text for details.
10.1128/9781555815455/f0403-01_thmb.gif
10.1128/9781555815455/f0403-01.gif
Image of Figure 3.
Figure 3.

Management of transplant patients with subacute CNS infection syndrome (subacute illness [>3 to 7 days], with variable presence of fever, headache, progressive impairment of cognitive function, and/or focal defects). *, cultures for bacteria (aerobic/anaerobic), mycobacteria, and fungi; **, treatment decisions should factor in radiologic appearance, fungal antigen tests, and prophylactic antibiotic regimens. See the text for details.

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
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Tables

Central Nervous System Infections
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Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
/content/10.1128/9781555815455.ch18.ch18tab01
Table 1.
Microbiological methods used for laboratory diagnosis of CNS infections
Generic image for table
Table 1.

Microbiological methods used for laboratory diagnosis of CNS infections

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
/content/10.1128/9781555815455.ch18.ch18tab02
Table 2.
Major infectious causes of meningitis among immunocompromised hosts
Generic image for table
Table 2.

Major infectious causes of meningitis among immunocompromised hosts

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
/content/10.1128/9781555815455.ch18.ch18tab03
Table 3.
Infectious causes of encephalitis or mass lesions of the brain among immunocompromised hosts
Generic image for table
Table 3.

Infectious causes of encephalitis or mass lesions of the brain among immunocompromised hosts

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18
/content/10.1128/9781555815455.ch18.ch18tab04
Table 4.
Infectious causes of myelitis among immunocompromised patients
Generic image for table
Table 4.

Infectious causes of myelitis among immunocompromised patients

Citation: Hongo I, Bloch K, Tang Y. 2009. Central Nervous System Infections, p 391-408. In Hayden R, Carroll K, Tang Y, Wolk D (ed), Diagnostic Microbiology of the Immunocompromised Host. ASM Press, Washington, DC. doi: 10.1128/9781555815455.ch18

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