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Part Ii – Neurological Disorders Part ii – Neurological Disorders CHAPTER 6 NEUROLOGICAL INFECTIONS Dr William P. Howlett 2012 Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania BRIC 2012 University of Bergen PO Box 7800 NO-5020 Bergen Norway NEUROLOGY IN AFRICA William Howlett Illustrations: Ellinor Moldeklev Hoff, Department of Photos and Drawings, UiB Cover: Tor Vegard Tobiassen Layout: Christian Bakke, Division of Communication, University of Bergen E JØM RKE IL T M 2 Printed by Bodoni, Bergen, Norway 4 9 1 9 6 Trykksak Copyright © 2012 William Howlett NEUROLOGY IN AFRICA is freely available to download at Bergen Open Research Archive (https://bora.uib.no) www.uib.no/cih/en/resources/neurology-in-africa ISBN 978-82-7453-085-0 Notice/Disclaimer This publication is intended to give accurate information with regard to the subject matter covered. However medical knowledge is constantly changing and information may alter. It is the responsibility of the practitioner to determine the best treatment for the patient and readers are therefore obliged to check and verify information contained within the book. This recommendation is most important with regard to drugs used, their dose, route and duration of administration, indications and contraindications and side effects. The author and the publisher waive any and all liability for damages, injury or death to persons or property incurred, directly or indirectly by this publication. CONTENTS NEUROLOGICAL INFECTIONS 123 ACUTE BACTERIAL MENINGITIS (ABM) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 124 EPIDEMIOLOGY � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 124 TUBERCULOUS MENINGITIS (TBM) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 131 CRYPTOCOCCAL MENINGITIS �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 136 VIRAL MENINGITIS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 139 VIRAL ENCEPHALITIS� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 139 HERPES ENCEPHALITIS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 140 RABIES �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 141 TETANUS� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 145 SYPHILIS � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 147 BRAIN ABSCESS �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 149 APPENDIX LUMBAR PUNCTURE � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 151 CHAPTER 6 NEUROLOGICAL INFECTIONS Introduction Infections of the nervous system are common in Africa and account for a significant percentage of all deaths. The causes of these infections are viral, bacterial, fungal and parasitic, protozoa and helminths. Their estimated frequency and mortality is presented in Table 6.1. These infections result in CNS illnesses characterized mainly by meningitis, focal neurological disorders and coma. Since the onset of the human immunodeficiency virus (HIV) epidemic in Africa three decades ago there has been a dramatic change in the overall pattern of CNS infections in Africa. CNS opportunistic infections related to HIV have now become commonplace and are the leading cause of death in adults in many countries. The main causes arecryptococcal meningitis (CM), cerebral toxoplasmosis (CT) and tuberculous meningitis (TBM). At the same time cerebral malaria, acute bacterial meningitis (ABM), tetanus, trypanosomiasis, neurocysticercosis and brain abscess remain as major causes of neurological illnesses. This chapter presents an overview of the main bacterial, fungal and viral infections including clinical features, diagnosis and management. After reading this chapter the student should aim to be able to diagnose, treat and prevent meningitis and know the other main CNS infections. Table 6.1 Estimated frequency & treated mortality of main neurological infectious disease in Sub Saharan Africa Disease Estimated frequency per Mortality rates (treated patients) year for whole population Acute Bacterial Meningitis 250,000 (children) 5-40% (children) 50/100,000 10-70% (adults) Opportunistic infections in HIV 5-700,000 cryptococcus 50% toxoplasmosis 10-20% TB >50% CNS TB (non HIV) 30,000 20-30% Cerebral malaria >0�5 million 10-20% Human African trypanosomiasis 40,000-300,000 20-30% Tetanus 100,000 40-60% Rabies 10-20,000 100% Leprosy 40,000 low William Howlett Neurology in Africa 123 CHAPTER 6 NEUROLOGICAL INFECTIONS Meningitis Meningitis is defined as inflammation of the pia and arachnoid meninges and the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord. The main infectious causes are viral, bacterial and fungal. Meningitis is classified clinically as either acute or chronic. Acute meningitis occurs within hours or days, whereas chronic meningitis evolves over weeks. Acute meningitis is classified as aseptic which is mostly viral in origin or septic or pyogenic which is caused by bacteria. The termacute bacterial meningitis (ABM) refers to acute infections caused by pyogenic bacteria. The main causes of pyogenic meningitis in Africa areStreptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and Haemophilus influenzae type b (Hib). Chronic meningitis by definition persists for weeks (four or more). The main causes in Africa are cryptococcal infection and tuberculosis. The overall pattern of meningitis in adults has changed in Africa, whereas ABM used to be the leading cause of meningitis, cryptococcus is now the most common cause followed by tuberculous meningitis (TBM) and ABM. Their exact order depends on the geographic location, the extent of HIV epidemic and the age group affected. ACUTE BACTERIAL MENINGITIS (ABM) EPIDEMIOLOGY ABM causes over a quarter of a million deaths globally each year with a large proportion of these occurring in Africa. ABM occurs mostly in young children, particularly in those <2 years but affects all age groups including adults. Africa has some of the highest rates of ABM in the world affecting as many as 1/250 of children <5 yrs, in mainly urban parts of West Africa. However as many as 1-2% of whole populations in the “meningitic belt” may be affected during cyclical meningococcal epidemics which occur every 5-10 years. It is estimated that ABM in Africa is 5-10 times more common (50/100,000/yr) as compared to high income countries. Risk factors for ABM in Africa are crowded living conditions, extremes of age, organism virulence and antibiotic resistance, and host predisposition. Individual host factors include HIV infection, malnutrition, sickle cell disease, splenectomy, a non functioning spleen, recent head injury with fracture or, post neurosurgery with CSF leak, middle ear infection and pneumonia. The overall frequency of ABM in adults in Africa appears to have remained relatively constant despite the current HIV epidemic there. Aetiology In children in Africa the main causative organisms of ABM are Hib, pneumococcus and meningococcus. In those countries where Hib vaccination has been instituted, Hib has now been replaced as the main cause by pneumococcus and meningococcus. Recently a new pneumococcal conjugate vaccine is being used in children in some countries, including South Africa, Gambia and Kenya. In adults the main causative organisms are pneumococcus and meningococcus. Other less common causes include group B streptococcus, nontyphoidal salmonella, (NTS), staphylococci, and Escherichia coli in neonates. Listeria monocytogenes may cause ABM in pregnancy and in HIV. Gram negative bacilli and salmonella may cause ABM in HIV and in the elderly. 124 Part ii – Neurological Disorders EPIDEMIOLOGY Streptococcus pneumoniae Pneumococcus is a gram positive coccus which exists in pairs (Fig 6.1) with many subtypes. It affects mostly infants aged <12 months, young children and adults, but all age groups may be affected. It may occasionally occur as epidemics. The main source of meningeal infection is haematogenous spread arising from the respiratory tract (pneumonia) and from otitis media, although individual host factors are also important. Sporadic invasive pneumococcal disease has increased significantly since the arrival of the HIV epidemic and is a significant cause of bacteraemia, pneumonia and death in HIV disease. It accounts for >90% of cases of ABM in adults in the main HIV affected areas in Africa. The main risk factors for ABM have already been outlined above. The case fatality rate (CFR) in Africa in treated pneumococcal meningitis is high, ranging from 30-40% in children to 50-70% in adults. Neisseria meningitidis Meningococcus is a gram-negative diplococcus and infection results in meningococcal disease (fig. 6.2). It is classified into serogroups with A, B, C, Y, W-135 and X predominating. The most common serogroup in Africa is A but there have been recent outbreaks there with serogroups W-135 and X. Epidemic strains are sometimes introduced by Hajj pilgrims returning from Mecca, where similar epidemics have occurred. Protective vaccines exist for serogroups A and C and more recently a quadrivalent vaccine for A, C, Y, and W-135 (meningococcal A-conjugate vaccine) but not for group B or X. The usual incubation period for meningococcal disease is 2-7 days.
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