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Learning Objective 23- Immunological Basis of Vaccinations

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Please scroll to the 15. that is LO 15 and ignore the LO 11 appearing, I've made another tab.

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Note - LO 15 appears in the word doc, but I've made a tab for it too

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Relevant micro-organisms

·      The organisms most commonly involved in brain abscesses are:

o   Streptococci - Viridans streptococci

o   Staphylococci

o   Enterobacteriacae

o   Anaerobes

·      Often have mixed bacteria present in an abscess.

·      Rarely Toxoplasma gondii, a protozoan organism, can present with a mass lesion similar to a brain abscess. (it can also present as a diffuse encephalitis). It is seen more commonly in immunocompromised patients, e.g. HIV positive patients. It is treated with cotrimoxazole.

·      Nocardia (filamentous Gram-positive bacilli) is another cause of brain abscesses in immuno-compromised patients, including transplant patients.

Pathogenesis

·      Bacterial infection of the brain usually provokes an inflammatory response that limits spread of the organisms and results in the formation of an abscess within the brain tissue.

·      Organisms reach the brain via the blood or by local spread. Brain abscess are usually secondary to sepsis at another site, e.g. middle ear, sinuses or lung. Abscesses can also result from trauma to the skull, allowing direct access by infecting organisms.

Pathology

·      See Pathogenesis

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LO 13 - Outline the epidemiology (determinants, distribution, prevention and control) of meningococcal disease in South Africa. 

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LO 13 - Outline the epidemiology (determinants, distribution, prevention and control) of meningococcal disease in South Africa. 

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LO 6 Discuss the interpretation of CSF laboratory investigations for the different types of meningitis and other conditions

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LO 9 - Discuss chronic meningitis specifically focusing on Cryptococcus neoformans, syphilis and TB. 

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LO 9 - Discuss chronic meningitis specifically focusing on Cryptococcus neoformans, syphilis and TB. 

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2. Discuss CSF production, flow and drainage/reabsorption, and its related structures.

Production:

CSF is mainly produced by choroid plexus in floor of lateral ventricles and roof of third and fourth ventricle. The choroid plexus is formed by choroidal epithelium cells (cuboidal epithelium) that are joined by tight junctions -> seals off plexus. The choroid plexus is essentially the extension of vascularized tissue into the ventricles via villi extensions of plexus.

Plexus contains = choroidal epithelium, fenestrated blood capillary surrounded by a loose connective tissue matrix. Fenestrated capillary allows blood plasma to exit capillary -> CSF is formed from this blood plasma. Active and facilitated transport of substances out from villi into ventricles (already containing CSF) creates a gradient for the secretion of CSF from choroid plexus to ventricle. *the microvilli on the villi increase surface area for absorption of CSF into villi and substances can be cleared from CSF.

Flow:

General pattern of flow of CSF: lateral ventricles -> interventricular foramen -> 3rd ventricle -> cerebral aqueduct -> 4th ventricle = 10% enters central canal of spinal cord, 90% to median and lateral apertures -> enters subarachnoid space.

Drainage/reabsorption:

CSF is reabsorbed into dural venous sinuses through arachnoid villi. The CSF pressure is higher than venous blood pressure therefore this is a passive process. The arachnoid villi acts as one way valves -> collapse to prevent venous blood from entering subarachnoid space and only allow one way flow of CSF from subarachnoid space into venous circulation.

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https://www.aafp.org/afp/2003/0915/p1103.html

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Lumbar puncture
chest X ray
CSF sent for testing
Given Ceftriaxone
Family given prophylaxis
Parent training recommended by audiologist

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Sensorineural loss
Bacterial Meningitis

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Pyrexial
drowzy
neck stiff
bulging anterior fontanelle

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* Anathi 1 year old
* 4 bedroom house
* lives with mother
* Mother divorced from father (Father is an alcoholic)

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Anathi is a one-year-old who lives with her mother, Ms Mkhize, and their extended family of 8 people
in a small two bedroomed brick house. Ms Mkhize brings Anathi to the clinic because she has been
very irritable over the last 24 hours and has been vomiting and not wanting to eat. The doctor
examines her and finds that she is pyrexial (40°C), drowsy and has neck stiffness and a bulging
anterior fontanelle. He refers Anathi to Red Cross Children’s Hospital (RXH) urgently as he suspects
meningitis. While waiting for transport Anathi is given a dose of Ceftriaxone.
Dr Smith, the casualty officer at RXH performs a lumbar puncture on Anathi as she has no focal
neurological signs and after a CT brain scan shown no features of brain herniation. The cerebrospinal
fluid (CSF) is sent for microscopy, biochemical tests and routine culture. Her chest X-ray shows no
significant abnormalities. Anathi is admitted to hospital and intravenous Ceftriaxone treatment
continued. Dr Smith asks Anathi’s mother if she ever received a vaccination for meningitis, but she
does not remember saying she has been stressed because she had recently divorced Anathi’s alcoholic
father. After 72 hours the CSF has grown Haemophilus influenzae type B. Anathi is discharged after
10 days in hospital.
The doctor at RXH completes the required notification forms, as this is a category 2 notifiable disease.
In order to classify Anathi’s case and in order to contain the disease, Dr Smith asks Ms Mkhize if
there are any other close contacts that exhibited similar symptoms as Anathi in the past week or two.
He informs Ms Mkhize that prophylaxis will be offered to the family. Ms Mkhize wonders how
common this disease is and what could have been done to prevent it.
A month after being discharged from hospital, Ms Mkhize brings Anathi to the clinic again as she is
concerned that he is very quiet and makes no attempt to speak despite the fact that, previously, she
was speaking some words such as “mamma”. She is referred back to RXH where she is found to
have sensorineural hearing loss by the audiologist. The audiologist recommends that Ms Mkhize
commence with “parent training” to be taught how to communicate with Anathi and encourage her
to sign and lip read which will support her development.

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*Identify modes of transmission of different bugs that causes meningitis
* Identify notifiable diseases
* What exerts the pressure that results in intracranial pressure?
* What are the values of the  intracranial pressure
* Which cell types respond to viral vs bacterial infections

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Prior knowledge, interrogate, analyse and identify gaps

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Identify key issues using hybrid SOAP Model

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Read and classify terms