LUMBAR PUNCTURE, NEUROINFECTION Department of Children’s Infectious Diseases MUDr. Adriana Braunová Ph.D. 1 Bez popisku CLINICAL MANIFESTATION OF CNS INFECTIONS Classification by predominant symptoms - but impact is often combined Acute purulent meningitis – inflammatory impact on the meninges (purulent discharge), predominance of polymorphonuclear cells in the cerebrospinal fluid Acute serous meningitis – inflammatory impact on the meninges resulting in exudative serous inflammation, predominance of mononuclear cells in the cerebrospinal fluid Chronic meningitis – long history (weeks / months), abnormal findings in the CSF lasting at least 4 weeks Acute encephalitis – impaired consciousness prevails, possibly focal symptoms; meningeal symptoms minimal (purulent rare – secondary with sepsis; non-purulent – perivascul. lymphoplasmacytic infiltrates) Myelitis – Rarely a standalone condition / encephalomyelitis – fever, paraparesis weak … spastic Lesions processes (subdural empyema, epidural abscess, brain abscess) - per continuatem, hematogenous spread Etiology of purulent meningitis Examining meningeal signs https://www.wikiskripta.eu/thumb.php?f=Meninge%C3%A1ln%C3%AD_jevy.png&width=800 •Newborns / infants ( < 3 months) • • • •Childern • •Adults • •Adults > 50 years • Streptococcus agalactiae E-Coli (+ G- agens) Listeria monocytogenes Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae Streptococcus pneumoniae Neisseria meningitidis Staphylococcus aureus Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes G- agens, Staphyl. aureus 4 Etiology of aseptic meningitis Enteroviruses Arboviruses Herpetic viruses Respiratory viruses Spirochetes Rickettsiae, Legionella Aspergillosis Candidiasis Cryptococosis Echinococosis Cysticerkosis Amebiasis Bacterial pathogens in aseptic meningitis •spirochetes – B. burgdorferi s. l., T. pallidum, L. interrogans) •Rickettsiae, legionella, anaplasma •Mycoplasma pneumoniae • WHEN TO PERFORM A LUMBAR PUNCTURE (LP) Positive meningeal signs, fever, photophobia, cephalea, vomiting, phonophobia Focal neurological findings, impaired consciousness, convulsions, hemorrhagic symptoms CAUTION - newborn (non-specific signs, thermoregulation disorder, muscle tone, encephalic crying, does not feed properly.) HISTORY OF HEALTH RISKS (perinatal history, a tick latched on, epidemiological history, travel history, etc.) SUSPECTING A NEUROINFECTION – WE ALWAYS perform LP DIFFERENTIAL DIAGNOSTICS OF NEUROINFECTION Brain tumors, post-med reactions, convulsions, migraines, intracranial hemorrhaging, insolation, trauma, intoxication, thrombosis Meningism – signs of meningeal irritation without the inflammatory correlation in CSF - e.g. at high fevers - when the fever subsides, the meningeal symptoms also subside. CONTRAINDICATION – LP •Intracranial HT – risk of spinal cord conus •Severe coagulation disorders, skin lesions at the LP site, malformations of the L spine •Circulatory and ventilatory instability of the patient PRIORITIZING IMAGING METHODS •Interdisciplinary cooperation - neurologist (subacute conditions, or EEG) •Risk of delay in drug therapy (ATB < 1 hour!) •INDICATION – meets 1 criterion •Focal neurological findings (X paresis of the cranial nerves) •Newly occurring convulsions (max. 7 days) •Impaired consciousness (GCS < 10) •Significant immunodeficiency •CZ – papilledema on OP (with focal neurological findings) •Consider also: brain ultrasound (enlarged fontanelle) LP PREP Zkumavka PP 12x75mm s červeným uzávěrem 50ks Kapka krve — Stock Fotografie © julos #7506854 PCR tests from CSF - Test forms examples Náhled obrázku Náhled obrázku Panels or individual pathogens Bacteria Viruses (enteroviruses, herpetic, respiratory) Testing antibodies in blood + CSF – example Test forms Kapka krve — Stock Fotografie © julos #7506854 NOT PCR in these cases TBE, borrelia - IT syntesis of antibodies, cytokine CXCL13) Základy ošetřovatelských postupů a intervencí | Lékařská fakulta Masarykovy univerzity * PLPH – post-lumbar-puncture syndrome LP – TECHNIQUE 1 test tube - 15 drops (10 minimum) CAUTION – PCR sample – prevent contamination Rotating the needle https://upload.wikimedia.org/wikipedia/commons/thumb/f/f6/Diagram_showing_how_you_have_a_lumbar_pun cture_CRUK_157.svg/langcs-350px-Diagram_showing_how_you_have_a_lumbar_puncture_CRUK_157.svg.png Link to an LP video / Study materials in IS https://next.simu.med.muni.cz/s/gGCT29WcTEg5HmR Determining the puncture site Edges of the hip bone blades - junction - intervertebral space L3/4 - L4/5, upper side of the lower vertebra, marking the puncture site Preparing the site Disinfection, sterility, face-masks Needle direction Needle going slightly upwards, ca 15 degrees Conus rotated to the side – minim. tissue trauma Collecting the sample We collect the required amount drop by drop Concluding the LP Inserting the mandrin / up to 2/3 of length, removing the needle, compression, coverage Post-LP regime Flat pad 8-10 hrs. (1 hour supine position) / min. 6 (PLPH) Atraumatic needle (2-4 hrs.) CSF RESULTS ANALYSIS Guillain-Barré syndrome – acute demyelinating polyradiculoneuritis – proteinocytological dissociation in the cerebrospinal fluid (severe disorder of the H-L barrier) – acute, subacute course; weak limb paresis - mainly DK, risk of respiratory muscle paralysis; often infections (EBV, CMV, HBV, HIV, VZV, mycoplasma, chlamydia, Campylobacter jejuni) in pre-illness 1-3 weeks •Macroscopic •Color / transparency •XANTOCHROMIA – yellow, orange or pink discoloration - waste products of hemoglobin – 90 % patients after 12 hrs of subarachnoid hemorrhaging (newborns with hyperbilirubinemia) •Pressure •Microscopic •Cytology Pleocytosis (polymorphonuclear / mononuclear), Ery up to 20% in traumatic LP •Biochemistry •Total protein – significantly increased level in purul. inflammation, bleeding, Guillain-Barré syndrome, tumors, etc. (physiol. newborns) •Glycorrhachia – 2/3 glycemia, low in purul. inflammation •Lactate – purulent meningitis (significantly increased > 3.5 mmol/l) CAUSAL THERAPY ATB < 1 hour Empiric therapy by broad-spectrum ATB with penetration into CNS ACICLOVIR! – antivirals at suspect herpetic encephalitis •Antibiotics •Antivirals •Antimycotics HERPETIC ENCEPHALITIS Impairment of consciousness (qualitative / quantitative) – involvement of frontal and temporal lobes; clinical presentation - convulsions, focal neurol. symptoms, aphasia, symptoms of brain edema - ↑ PRIMARY INFECTION (Family history - HSV) SYMPTOMATIC THERAPY Improve the prognosis, hearing impairment prevention; I. dose shortly before/with ATB. CAUTION – if suspected herpetic encephalitis, we wait for the aciclovirus to come into effect, depending on the clinical condition, min. 3-4 days (controversial topic; x edema – we have to give to patient) Corticoids Not enough studies of use in children / not recommended for routine use. In CZ included in the entry treatment of purulent meningitis; at signs of severe intracranial hypertension or brain edema (ev. on CT). Across-the-board administration of antiepileptics, paracetamol, activated protein C, heparinization, hypothermia – NOT RECOMMENDED INTRAVENOUS IMMUNOGLOBULINS - YES •Infusion therapy, antipyretics, analgesics •Antiedematous treatment, elevated head •Anticonvulsants, or sedation upon restlessness •If sepsis – complex approach Mannitol Resources •http://infektologie.cz/DoporMenPur17t.htm (2017) •Beck D, Cabellos C, Dzupova O, Sipahi OR, Brouwer MC, ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clinical mikrobiology and infection. 2016 Usmívající se roztomilé dítě — Stock Fotografie © jenmax #22353557