Viral Infections Of The Nervous System
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Viral Infections of the Nervous System
Romeo Yu Enriquez, M.D. Angeles University College of Medicine
Six Viral Syndromes 1. Acute anterior poliomyelitis 2. Herpes Zoster gangionitis 3. Acute aseptic meningitis 4. Acute Encephalitis or meningoencephalitis • 5. Slow virus infections • 6. AIDS • • • •
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Etiology: – poliovirus – Coxsackie virus A and B – echoviruses
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Clinical Features – – – –
fever, malaise, headache, nausea and vomiting stiffness and aching muscles mild meningeal irritation weakness and paralysis of muscles • flaccid, lower motor neuron type • asymmetrical
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Pathology – destruction of anterior horn cells with phagocytosis by microglia, gliosis and perivascular meningeal infiltrates – Bulbar motor nuclei, dentate nuclei and motor cortex may also be involved
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Treatment: – Prevention with Oral polio vacine
Table of Contents
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • A.k.a. : Shingles • 3-5 cases / 100000 / year • more frequent in elderly and in those with malignancy • It probably reprsents reactivation of varicella infection in sensory ganglia
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • Clinical Manifestations – radicular pain – vesicular cutaneous eruption over two-three dermatomes( thoracic most frequent) – sensory impairment of dermatomes involved
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • Pathology – Acyclovir 800 mg 5 times/day – Prednisome may help reduce Post herpetic neuralgia – Carbamazepine, amitryptylline for Post herpetic neuralgia
Table of Contents
Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Headache, fever, signs of meningeal irritation • lymphocytic pleocytosis with normal glucose • photophobia and pain on eye movement • drowsiness and confusion may be present
Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Viral causes – – – – – –
Enteroviruses (80%) Mumps Herpes simplex, type 2, and Epstein-Barr virus Lymphocytic choriomeningitis Adenoviruses HIV Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Nonviral Causes – – – – –
Spirochetal infections Mycoplasma pneumoniae Bacterial infections overlying meninges Carinomatous meningitis Recurrent inflammatory meningitides
Table of Contents
Viral Infections of the Nervous System
The Syndrome of Acute Encephalitis • • • • •
Febrile illness syndrome of meningitis impairment of consciousness focal neurologic deficits usually seasonal
Viral Infections of the Nervous System
The Syndrome of Encephalitis Etiology – – – – – – – –
Mumps Arboviruses Herpes simplex Lymphocytic choriomeningitis Enteroviruses Cytomegalovirus Adenoviruses Rabies Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex Sporadic throughout the year due to type 2 herpes simplex virus fever, headache, confusion, stupor and coma over several days Pathology: lesions in the inferior and medial parts of the temporal lobes as well as inferior part of frontal lobes – Lesions: inflammation, pannecrosis, hemorrhage • intranuclear eosinophilic inclusions in neurons – – – –
Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex – Diagnosis • CT and MRI-temporal and frontal lobe lesions • CSF: mononuclear pleocytosis, elevated protein, normal glucose and RBCs • EEG: Periodic high voltage complexes in the teporal leads and sloe 2-3 per second slow waves
Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex – Prognosis: about half do not survive – Treatment: • acyclovir • No steroids • Supportive
Viral Infections of the Nervous System
Slow Viruses Subacute Sclerosing Panencephalitis • appears in children and adolescents years after a measles attack • dementia, focal or generalized seizures, ataxia, myoclonus • EEG: periodic complexes • CSF: elevated gammaglobulin and measles antibodies Table of Contents
Viral Infections of the Nervous System
Slow Viruses Progressive Multifocal Leukoencephalopathy • Usually associated with Hodgkin’s disease, lymphoma, chronic leukemia • 3-6 months development of focal cerebral, brainstem and cerebellar signs • Demyelinating lesions • Inclusion bodies in oligodendroglia and astrocytes • No treatment
Table of Contents
Viral Infections of the Nervous System
Slow Virus Infections Subacute spongifrom encephalopathy • • • • • • •
Creutzfeld-Jakob disease progressive dementia cerebellar ataxia heightened startle reaction diffuse myoclonic jerks CSF is normal EEG: Burst suppression
Table of Contents
Viral Infections of the Nervous System
Slow Virus Infections Subacute spongifrom encephalopathy • Creutzfeld-Jakob disease • invariably fatal • Pathology: – cerebral and cerebral cortices involved – diffuse loss of eurons, gliosis, vacuolation of tissues – no inflammatory changes
• Etology: prions Table of Contents
Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Acquired profound depression of cell mediated immunity • HTLV • Opportunistic infections
Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Brain:Nonfocal – AIDs dementia complez – encephalitis syndromes, CMV, HS – metabolic encephalopathies
• Spinal cord: – vacuolar myelopathy – Herpes simplex or zoster myelitis Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Brain: Focal – – – – – – – –
cerebral toxoplasmosis PML Cryptococcosis Varicella-Zoster virus encephalitis TB brain abscess or tuberculoma Neurosyphillis Primary CNS lymphoma Vascular disorders Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Meningitis – – – – –
aseptic meningitis Cryptococcal meningitis TB meningits Syphillitic meninigitis metastatic lymphomatous meningitis
• Peripheral nerve, roots, muscle and others Table of Contents
Viral Infections of the Nervous System
Romeo Yu Enriquez, M.D. Angeles University College of Medicine
Six Viral Syndromes 1. Acute anterior poliomyelitis 2. Herpes Zoster gangionitis 3. Acute aseptic meningitis 4. Acute Encephalitis or meningoencephalitis • 5. Slow virus infections • 6. AIDS • • • •
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Etiology: – poliovirus – Coxsackie virus A and B – echoviruses
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Clinical Features – – – –
fever, malaise, headache, nausea and vomiting stiffness and aching muscles mild meningeal irritation weakness and paralysis of muscles • flaccid, lower motor neuron type • asymmetrical
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Pathology – destruction of anterior horn cells with phagocytosis by microglia, gliosis and perivascular meningeal infiltrates – Bulbar motor nuclei, dentate nuclei and motor cortex may also be involved
Viral Infections of the Nervous System
The Syndrome of Acute Anterior Poliomyelitis • Treatment: – Prevention with Oral polio vacine
Table of Contents
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • A.k.a. : Shingles • 3-5 cases / 100000 / year • more frequent in elderly and in those with malignancy • It probably reprsents reactivation of varicella infection in sensory ganglia
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • Clinical Manifestations – radicular pain – vesicular cutaneous eruption over two-three dermatomes( thoracic most frequent) – sensory impairment of dermatomes involved
Viral Infections of the Nervous System
The syndrome of Herpes Zoster • Pathology – Acyclovir 800 mg 5 times/day – Prednisome may help reduce Post herpetic neuralgia – Carbamazepine, amitryptylline for Post herpetic neuralgia
Table of Contents
Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Headache, fever, signs of meningeal irritation • lymphocytic pleocytosis with normal glucose • photophobia and pain on eye movement • drowsiness and confusion may be present
Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Viral causes – – – – – –
Enteroviruses (80%) Mumps Herpes simplex, type 2, and Epstein-Barr virus Lymphocytic choriomeningitis Adenoviruses HIV Viral Infections of the Nervous System
The Syndrome of Aseptic Meningitis • Nonviral Causes – – – – –
Spirochetal infections Mycoplasma pneumoniae Bacterial infections overlying meninges Carinomatous meningitis Recurrent inflammatory meningitides
Table of Contents
Viral Infections of the Nervous System
The Syndrome of Acute Encephalitis • • • • •
Febrile illness syndrome of meningitis impairment of consciousness focal neurologic deficits usually seasonal
Viral Infections of the Nervous System
The Syndrome of Encephalitis Etiology – – – – – – – –
Mumps Arboviruses Herpes simplex Lymphocytic choriomeningitis Enteroviruses Cytomegalovirus Adenoviruses Rabies Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex Sporadic throughout the year due to type 2 herpes simplex virus fever, headache, confusion, stupor and coma over several days Pathology: lesions in the inferior and medial parts of the temporal lobes as well as inferior part of frontal lobes – Lesions: inflammation, pannecrosis, hemorrhage • intranuclear eosinophilic inclusions in neurons – – – –
Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex – Diagnosis • CT and MRI-temporal and frontal lobe lesions • CSF: mononuclear pleocytosis, elevated protein, normal glucose and RBCs • EEG: Periodic high voltage complexes in the teporal leads and sloe 2-3 per second slow waves
Viral Infections of the Nervous System
The Syndrome of Encephalitis • Herpes Simplex – Prognosis: about half do not survive – Treatment: • acyclovir • No steroids • Supportive
Viral Infections of the Nervous System
Slow Viruses Subacute Sclerosing Panencephalitis • appears in children and adolescents years after a measles attack • dementia, focal or generalized seizures, ataxia, myoclonus • EEG: periodic complexes • CSF: elevated gammaglobulin and measles antibodies Table of Contents
Viral Infections of the Nervous System
Slow Viruses Progressive Multifocal Leukoencephalopathy • Usually associated with Hodgkin’s disease, lymphoma, chronic leukemia • 3-6 months development of focal cerebral, brainstem and cerebellar signs • Demyelinating lesions • Inclusion bodies in oligodendroglia and astrocytes • No treatment
Table of Contents
Viral Infections of the Nervous System
Slow Virus Infections Subacute spongifrom encephalopathy • • • • • • •
Creutzfeld-Jakob disease progressive dementia cerebellar ataxia heightened startle reaction diffuse myoclonic jerks CSF is normal EEG: Burst suppression
Table of Contents
Viral Infections of the Nervous System
Slow Virus Infections Subacute spongifrom encephalopathy • Creutzfeld-Jakob disease • invariably fatal • Pathology: – cerebral and cerebral cortices involved – diffuse loss of eurons, gliosis, vacuolation of tissues – no inflammatory changes
• Etology: prions Table of Contents
Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Acquired profound depression of cell mediated immunity • HTLV • Opportunistic infections
Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Brain:Nonfocal – AIDs dementia complez – encephalitis syndromes, CMV, HS – metabolic encephalopathies
• Spinal cord: – vacuolar myelopathy – Herpes simplex or zoster myelitis Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Brain: Focal – – – – – – – –
cerebral toxoplasmosis PML Cryptococcosis Varicella-Zoster virus encephalitis TB brain abscess or tuberculoma Neurosyphillis Primary CNS lymphoma Vascular disorders Viral Infections of the Nervous System
The Acquired Immune Deficiency Syndrome • Meningitis – – – – –
aseptic meningitis Cryptococcal meningitis TB meningits Syphillitic meninigitis metastatic lymphomatous meningitis
• Peripheral nerve, roots, muscle and others Table of Contents
Viral Infections of the Nervous System
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