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Parasitic Infections of the Central Nervous System

Protozoans and helminths are responsible for a significant burden of human disease, disproportionately affecting resource-limited countries worldwide. These agents are collectively referred to as parasites, implying dependence on an adversely affected host, but in this context they are no different from other infectious agents, such as bacteria and viruses. Protozoan parasites are single-celled, microscopic organisms that generally undergo multiplication in the mammalian host. In contrast, helminthic…

Fungal Infections of the Central Nervous System

Recognition of fungal infections of the central nervous system (CNS) is increasing in frequency due to the growing population of immunocompromised patients and improvements in diagnostic techniques. Published information on the diagnosis and treatment of these diverse infections ranges from extensive to nonexistent. Therefore, a comprehensive survey of the literature coupled with clinical experience informs the diagnosis, pathophysiology, and management of these potentially life-threatening infections. Major…

Neurologic Complications of Transplantation and Immunosuppressive Agents

Advances in solid organ and hematopoietic cell transplantation (HCT) have revolutionized the treatment of many previously fatal diseases. Immunologic and procedural innovations in tandem with the development of new immunosuppressive agents have increased the number, type, and durability of these transplantations. Post-transplant complications affecting the nervous system are particularly devastating in some cases. Neurology consultants are often asked to evaluate transplant recipients who have a wide…

HIV and Other Retroviral Infections of the Nervous System

Human immunodeficiency virus type 1 (HIV-1) infection involves the central nervous system (CNS) beginning during primary viremia and continuing over the course of untreated infection. Although the majority of patients with HIV infection do not present with neurologic symptoms, HIV disease has protean manifestations in the CNS determined largely by host characteristics such as immune status, treatment history, and access and adherence to antiretroviral therapy (ART).…

Nervous System Complications of Systemic Viral Infections

Invasion of the central nervous system (CNS) by viruses typically produces a meningoencephalitis in which either meningitis or encephalitis may predominate. Viruses may also infect cranial or spinal blood vessels leading to ischemic injury. Systemic or CNS infection by viruses or other infectious agents may elicit a host immune response that is cross-reactive with components of neural tissue, resulting in autoimmune encephalitis, demyelinating or hemorrhagic encephalomyelitis,…

Leprosy

Introduction Leprosy is one of the oldest diseases known to afflict humans, with descriptions of the disease present in sixth century BCE Indian texts. It is caused by Mycobacterium leprae ( M. leprae ), the organism first identified by the Norwegian physician, Gerhard Hansen, in 1873. It is an obligate intracellular acid-fast bacillus, which is detected in tissues by the modified Fite-Faraco stain ( Fig. 41-1…

Tuberculosis of the Central Nervous System

Tuberculosis in all its forms remains a challenging clinical problem and a public health issue of considerable magnitude. Each year there are an estimated 10 million new cases of active disease worldwide and 1.3 million deaths attributable to tuberculosis. In 2018, 9,029 new cases of active tuberculosis were reported in the United States, an incidence rate of 2.8 cases per 100,000 persons. Pulmonary tuberculosis accounts for…

Spirochetal Infections of the Nervous System

Spirochetes cause a broad range of human illnesses, including relapsing fever, yaws, pinta, leptospirosis, and periodontal disease. Although leptospirosis and relapsing fevers can cause severe headaches and myalgias in conjunction with high fever and severe systemic illness, two spirochetal infections target the nervous system specifically: syphilis and Lyme disease. Both are the subject of popular mythology and have been blamed for far more than they could…

Acute Bacterial Infections of the Central Nervous System

Acute bacterial infections of the central nervous system (CNS) include meningitis, brain abscess, subdural empyema, epidural abscess, and septic intracranial thrombophlebitis. The etiology, clinical presentation, diagnosis, and treatment of each of these bacterial infections are discussed in this chapter. Acute Bacterial Meningitis Bacterial meningitis is an acute purulent infection in the subarachnoid space, associated with an inflammatory reaction in the brain parenchyma and cerebral vasculature. During…

Concussion

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide. The vast majority of injuries are classified as “mild” using current diagnostic criteria, and concussion is considered the mildest form of TBI. Concussion and mild TBI (mTBI) are terms that are often used interchangeably, with some controversy. Many position statements and clinical practice guidelines from professional organizations use the term “concussion/mTBI,” and while…

Abnormalities of Thermal Regulation and the Nervous System

Thermoregulatory System Mammals maintain their core body temperature within a narrow range despite exposure to a broad range of environmental temperatures. This thermoregulation is achieved by activating a set of thermoeffector systems that generate or dissipate heat, as necessary. Basal metabolic activity produces heat, and within a narrow range of ambient temperatures called the thermoneutral zone the core temperature can be maintained by adjusting the metabolic…

Neurotoxin Exposure in the Workplace

Occupationally related disorders are commonly due to injury or to working conditions that involve physical strain, such as hand-arm vibration or performing the same movement repetitively. These disorders are not the focus of the present chapter, which is concerned instead with the consequences of exposure to neurotoxins in the workplace. Many of the chemical agents present in the workplace environment may produce behavioral, cognitive, motor, sensory,…

Neurologic Complications of Recreational Drugs

Recreational drug use can lead to neurologic problems stemming from both acute intoxication and chronic use, and physicians must be aware of these complications when faced with any patient presenting with neurologic symptoms. The landscape of drug use has shifted from primarily illicit substances manufactured with the sole purpose of recreational drug use, to the realization that many drugs of abuse are prescription medications. No longer…

Alcohol and the Nervous System

Who could have foretold, from the structure of the brain, that wine could derange its functions? Hippocrates (c. 460 BCE to 370 BCE) Alcohol is the most commonly used recreational psychoactive substance worldwide. While moderate drinking may be beneficial to cardiovascular health, excessive use can result in alcohol use disorder, which is characterized by compulsive alcohol use despite harmful consequences and is often accompanied by serious…

Drug-Induced Disorders of the Nervous System

Adverse drug reactions are a common and important cause of morbidity and hospital admission and are a major burden on the healthcare budget. Drug reactions commonly involve the nervous system, causing a variety of disorders that may be serious and even life-threatening, and may mimic naturally occurring neurologic disorders. Unlike many of these, most drug-induced disorders are readily reversible if the offending agent is identified early…

Pregnancy and Disorders of the Nervous System

Neurologic disorders may present first during pregnancy, and their investigation and treatment may be complicated by concerns for the safety of the developing fetus. Furthermore, the natural history of certain pre-existing diseases may be affected by pregnancy, and obstetric management may be influenced by the neurologic disturbance. These aspects are considered in this chapter. Concerns about the use of imaging studies in pregnancy merit comment. In…

Sexual Dysfunction in Patients with Neurologic Disorders

Sexual excitement and satisfaction from adequate stimuli are a normal component of a fulfilled life. The somatic and psychosocial factors involved may be compromised by neurologic disease. Sexual dysfunction may occur as the presenting symptom of a developing neurologic disease (e.g., erectile dysfunction in multiple system atrophy) or as an isolated phenomenon after local nerve injury (e.g., painful clitoral dysesthesia after pudendal nerve lesion), or it…

Lower Urinary Tract Dysfunction and the Nervous System

Lower urinary tract dysfunction is common in patients with neurologic disease. The neurogenic bladder can result from lesions affecting any part of the nervous system. Symptoms are often bothersome and may have a significant impact on quality of life. Some patients may also be at risk of developing changes in the upper urinary tract and even renal impairment. Neurologic Control of the Bladder The essential function…

Neurologic Complications of Chemotherapy and Radiation Therapy

Chemotherapy and radiation therapy (RT) are two of the major modalities used to treat cancer. Their goal is to kill or inactivate enough cancer cells that the body’s own defenses can control the disease without unacceptable damage to normal tissue. Unfortunately, both RT and chemotherapy are relatively nonspecific and depend on their ability to do more damage to rapidly dividing cancer cells. The therapeutic/toxic ratio is…

Paraneoplastic and Nonparaneoplastic Autoimmune Syndromes of the Nervous System

The term paraneoplastic syndrome is often used to refer to symptoms or signs resulting from dysfunction of organs or tissues caused by a cancer, but which are not a direct effect of invasion by the neoplasm or its metastases. Perhaps most accurately, the term is used in a restricted sense to describe specific neurologic disorders that occur with increased frequency in patients with certain cancers, and…