CNS

Question 1

What are sx of meningitis?

Answer 1

Cns infection sx (fever, nausea, vomiting, seizures, headache) + stiff neck, meningismus, photophobia

Question 2

Your patient presents with confusion plus cns sx

Answer 2

Encephalitis

Question 3

Encephalitis presents with which sx?

Answer 3

Nausea, vomiting, headache, fever + confusion

Question 4

Your patient presents with cns sx and focal neurological findings

Answer 4

Brain abscess

Question 5

Meninges are separated in 3 layers

Answer 5

Pia, arachnoid, dura

Question 6

Meningitis is an infection of

Answer 6

Arachnoid or pia

Question 7

Most common cause of bacterial meningitis?

Answer 7

Strep pmeumo

Question 8

Most common etiology of neonatal meningitis

Answer 8

Group B Strep

Question 9

Most common etiologies of bacterial meningitis

Answer 9

S. Pneumo
GBS
H.influenza
N.meningitis
Listeria, in immunocompromised (add ampicillin!)
Staph (if recent surg)

Question 10

Meningitis can give you focal abnormalities in which percentage of pts?

Answer 10

30%

Question 11

If there is confusion you should…

Answer 11

Do a CT and an LP

Question 12

What are specificities of cryptococcal meningitis?

Answer 12

Slow, goes on several weeks

Question 13

Pt with stiff neck, photophobia, AIDS with

Answer 13

Cryptococcus

Question 14

Stiff neck, photophobia, joint pain, target like rash, camper, facial palsy, most likely dx is

Answer 14

Lyme

Question 15

Cryptococcus meningitis presents most likely in a patient with?

Answer 15

AIDS CD4>100

Question 16

Lyme meningitis presents more often in a patient with?

Answer 16

Rash, joint pain, facial palsy, camper, hiker, tick remembered in 20 %

Question 17

Patient is a hiker, has a rash that moved from arms and legs to trunk and stiff neck and photophobia

Answer 17

Rocky mountain spotted fever (Rickettsia)

Question 18

Patient that has stiff neck and photophobia and TB?

Answer 18

Tuberculosis

Question 19

Stiff neck and photophobia but nothing else :/

Answer 19

Viral meningitis

Question 20

Stiff neck, photophobia, adolescent with petechial rash

Answer 20

Neisseria

Question 21

Best initial test in meningitis?

Answer 21

LP

Question 22

CSF evaluation in meningitis

Answer 22

Neutrophils: 1000s in bacterial, 10s-100s in crypto, lyme, rickettsia, TB and viral
Proteins: elevated in bacterial, crypto, lyme, rickettsia and specially TB, normal in viral
Glucose: decreased in all except viral
Gram stain and culture: positive in bact

Question 23

In meningitis when is head CT the best initial test?

Answer 23

Papilledema
Seizures
Focal neurological abnormalities
Confusion (you cant do an accurate neuro exam in a confused pt)

Question 24

If there is a contraindication to immediate LP, what is the best first step in management?

Answer 24

Antibiotics: ceftriaxone, vancomycin

Steroids

Question 25

When is bacterial agglutination test indicated?

Answer 25

Those who received antibiotics prior to LP, cause culture may be falsely negative Careful, if negative not sufficient to exclude bacterial meningitis

Question 26

What is the most accurate test for TB?

Answer 26

Acid fast stain and culture on 3 high volume LPs Centrifuge to concentrate organisms TB has high CSF protein Uncentrifuged sample of CSF is 10% sensitive

Question 27

What is the most accurate dx for lyme and rickettsia?

Answer 27

Specific serologic testing, ELISA, western blot, PCR

Question 28

What is the most accurate dx test for cryptococcus?

Answer 28

India ink is 60-70% sensitive | Crypto antigen is 95% sensitive and specific

Question 29

What is the best dx test for viral meningitis?

Answer 29

None, it is a dx of exclusion

Question 30

Best initial tx for bacterial meningitis? | You should base your tx answer on which test?

Answer 30

Ceftriaxone, vancomycin and steroids | Cell count

Question 31

Your patient has sx of meningitis, on PL has 1000s of neutrophils and is immunocompromised what tx should you start?

Answer 31

Ceftriaxone, vancomycin and steroids, add ampicillin because immunocompromised to cover listeria

Question 32

Listeria monocytogenes is resistant to? | Sensitive to?

Answer 32

Resistant to all forms of cephalosporins | Sensitive to penicillins : add ampicillin to tx

Question 33

Risks factors for listeria monocytogenes infection

Answer 33

``` Elderly Neonates Steroid use AIDS/HIV immunocompromised (alcoholism) Pregnant Bone marrow transplant, leukemia, lymphoma etc. ```

Question 34

Patients with neisseria meningititis, who should benefit from prophylaxis?

Answer 34

Their close contacts: major respiratory fluid contacts, household contacts, kissing, sharing cigarettes or eating utensils. Close contacts should be treated with rifampin or cipro

Question 35

Your patient has neisseria meningitis, when do you qualify as a "close contact"?

Answer 35

Intubated the patient Performed suction Have contact with resp secretions

Question 36

Man comes to ER with fever, severe headache, stiff neck and photophobia. He has weakness in his left arm and leg, what is the best next step in management?

Answer 36

Ceftriaxone, vancomycin and steroids BEFORE head CT

Question 37

What is the most common deficit of untreated bacterial meningitis?

Answer 37

VIII CN deficit or deafness

Question 38

What is the most common cause of encephalitis?

Answer 38

Herpes simplex

Question 39

What are specific sx of encephalitis?

Answer 39

Fever and confusion

Question 40

What is the best initial test to do if encephalitis is suspected (cns infection signs plus confusion)

Answer 40

Head CT

Question 41

What is the most accurate test of herpes encephalitis?

Answer 41

PCR of CSF

Question 42

What is e best initial therapy for herpes encephalitis?

Answer 42

Acyclovir IV

Question 43

In which situation would you use foscarnet?

Answer 43

In there is acyclovir resistant herpes encephalitis

Question 44

A woman with herpes encephalitis confirmed by PCR gets 4 days of acyclovir. Her creatinine level rises. What is the most appropriate next step in management?

Answer 44

Reduce the dose of acyclovir and hydrate, you cannot stop acyclovir even if she has renal insufficiency

Question 45

What is the problem (SE) with acyclovir?

Answer 45

Renal insufficiency, | Even worse with foscarnet

Question 46

Your patient presents with stiff neck, photophobia and meningismus, the most likely dx is

Answer 46

Meningitis