Bacterial Infections of the Parenchyma and Meninges and Complex Infections

Question 1

A comatose middle-aged male was brought to emergency after roadside accident. After 3 days, he still showed no improvement in consciousness level and was observed to have cerebrospinal fluid (CSF) rhinorrhea. His vaccination status was not known. According to the CDC recommendation, which vaccination should be given in this case to prevent post-traumatic meningitis?
● A. Tetanus toxoid
● B. MMR
● C. IPV
● D. Pneumococcal
● E. Recommence EPI schedule

Answer 1

D. Pneumococcal

Question 2

What is the most common cause of Waterhouse–Friderichsen syndrome?
● A. Neisseria meningitidis
● B. Cryptococcus neoformans
● C. WFS prions
● D. Herpes simplex
● E. Varicella zoster

Answer 2

A. Neisseria meningitidis

Question 3

What is the most common etiology for aseptic meningitis?
● A. Carcinomatous meningitis
● B. Viral meningitis
● C. Fungal meningitis
● D. TB meningitis
● E. Intraoperative rupture of cyst leading to spilling of contents

Answer 3

B. Viral meningitis

Question 4

Surgical excision for cerebral abscess should be attempted when the abscess is in which histological phase?
● A. Early cerebritis
● B. Late cerebritis
● C. Delayed cerebritis
● D. Early capsule
● E. Late capsule

Answer 4

E. Late capsule

Question 5

Histopathology of a tissue obtained from brain abscess shows neovascularity, necrotic center, and reticular network surrounds (less well-developed alongside-facing ventricles). What will be the histological grade in this case?
● A. Early cerebritis
● B. Late cerebritis
● C. Early capsule
● D. Late capsule
● E. Inconclusive

Answer 5

C. Early capsule

Question 6

For medical treatment of meningitis and cerebral abscess, the dose of vancomycin to achieve trough of 15 to 20 mg/dL is what?
● A. 5 mg/kg TDS
● B. 10 mg/kg TDS
● C. 15 mg/kg BD-TDS
● D. 30 mg/kg BD-TDS
● E. 100 mg/kg OD

Answer 6

C. 15 mg/kg BD-TDS

Question 7

What is the most common pathogen to cause cerebral abscess in AIDS patient?
● A. MRSA
● B. MSSA
● C. Streptococcus pyogenes
● D. Toxoplasma gondii
● E. Cryptococcus neoformans

Answer 7

D. Toxoplasma gondii

Question 8

According to modified Vellore grading system (mVG) for hydrocephalus in tuberculous meningitis, patient with GCS score 9–14 (altered sensorium but easily arousable) ± dense neurologic deficit is which grade?
● A. Grade 0
● B. Grade I
● C. Grade II
● D. Grade III
● E. Grade IV

Answer 8

D. Grade III

Question 9

Lyme disease (LD) is a complex multisystem disease caused by various species of what?
● A. Cryptococcus
● B. Yeasts
● C. Borrelia spirochetes
● D. Nocardia
● E. Pneumocystis carinii

Answer 9

C. Borrelia spirochetes

Question 10

Which of the following is the most common cause of bilateral Bell’s palsy?
● A. Toxoplasmosis
● B. Lyme’s disease
● C. PCNSL
● D. Cysticercosis
● E. Nocardiosis

Answer 10

B. Lyme’s disease

Question 11

A 21-year-old female presents to OPD with tuberculous meningitis. She is started on ATT and is given rifampicin, INH, pyrazinamide, and ethambutol for initial 2 months. For how long will INH and rifampicin be continued in the next phase?
● A. 9 to 12 months
● B. 7 to 10 months
● C. 4 to 6 months
● D. 12 to 18 months

Answer 11

B. 7 to 10 months

Question 12

To which of the following drugs should a mycobacteria strain be resistant to, to be labeled as MDR TB?
● A. Isoniazid and rifampin
● B. Isoniazid and pyrazinamide
● C. Rifampicin and ethambutol
● D. Isoniazid and ethambutol
● E. Rifampicin and pyrazinamide

Answer 12

A. Isoniazid and rifampin

Question 13

A 17-year-old boy is started on ATT for MDR TB. How long should the treatment be continued according to the WHO guidelines?
● A. 9 to 12 months
● B. 12 to 18 months
● C. 18 to 24 months
● D. 20 to 24 months
● E. 18 to 36 months

Answer 13

C. 18 to 24 months

Question 14

A 25-year-old boy presents with new-onset seizures and weight loss along with fever. He undergoes MRI of brain which reveals a ring enhancing frontal lesion with perilesional edema. There is low signal on DWI in the center of the lesion.
What is the type of lesion?
● A. Caseating granuloma
● B. Noncaseating granuloma
● C. Liquefactive necrosis
● D. Healed tuberculoma
● E. Calcified lesion

Answer 14

A. Caseating granuloma

Question 15

A patient presented with meningitis 6 days after a neurosurgical procedure. Usual organisms in this patient could be staphylococci coagulase negative, S. aureus, Enterobacteriaceae, pseudomonas, or pneumococci. What are the empiric antibiotics in this patient?
● A. Vancomycin 15 mg/kg every 8 to 12 hours + cefepime 2 g IV every 8 hours
● B. Aztreonam 2 g IV every 6 to 8 hours + ciprofloxacin 400 mg IV every 8 hours
● C. Intrathecal antibiotics like vancomycin, gentamycin, amikacin, colistin
● D. Liposomal amphotericin B 3–4 mg/kg IV daily + flucytosine 25 mg/kg PO QID for 2 weeks
● E. A, B, and C

Answer 15

A. Vancomycin 15 mg/kg every 8 to 12 hours + cefepime 2 g IV every 8 hours

Question 16

Post-traumatic meningitis is mostly caused by organism Gram-positive cocci (Staphylococcus haemolyticus, S. warneri, S. cohnii, S. epidermis, and Streptococcus pneumoniae) and Gram-negative bacilli (E. coli, Klebsiella pneumonia, Acinetobacter anitratus). Following are suggested recommendations of pneumococcal vaccination for patients with CSF leak except?
● A. Children 6 to 18 years of age who have not received pneumococcal conjugate vaccine (PCV 13) before should receive a single dose of PCV 13
● B. Children 2 to 18 years of age should receive a dose of pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks after any dose of PCV 13
● C. For adults with unknown vaccination status or with no pervious vaccination, one dose of PCV 13 should be given
● D. One dose of PPSV23 at least 8 weeks after giving PCV 13
● E. Patients above 65 years of age do not need more dose of PPSV23

Answer 16

E. Patients above 65 years of age do not need more dose of PPSV23

Question 17

Following statements are true regarding chemical meningitis except?
● A. Chemical meningitis cannot occur spontaneously
● B. It can occur after intrathecal administration of certain drugs such as methotrexate or contrast agents
● C. CSF WBC is found no more than 7,500/μL in most patients
● D. CSF glucose should not be less than 10 mg/dL
● E. Treatment is removal of the offending agent, systemic steroid, and serial lumbar punctures

Answer 17

A. Chemical meningitis cannot occur spontaneously

Question 18

Cerebral abscess is most likely to be formed in patients with pulmonary abscess or AV fistula, congenital cyanotic heart disease, immunocompromised host, chronic sinusitis, or after dental procedures. What is the most common pathogen in general for cerebral abscess?
● A. Streptococcus
● B. Staphylococcus aureus
● C. Enterobacteriaceae
● D. Actinomyces
● E. Staphylococcus epidermidis

Answer 18

A. Streptococcus

Question 19

Which of the following is true regarding histologic staging of cerebral abscess?
● A. Early cerebritis stage (1–3 days) is early infection and inflammation with poor demarcation from surrounding brain and no resistance to aspirating needle
● B. Late cerebritis (4–9 days) is formation of reticular matrix and developing necrotic center with intermediate resistance to aspirating needle
● C. Early capsule (10–13 days) is formation of neovascularity, necrotic center, and reticular network with no resistance to aspirating needle
● D. Late capsule (> 14 days) is formation of collagen capsule and necrotic center with no resistance to intermediate resistance to aspirating needle
● E. Abscess leaves a glial scar after healing

Answer 19

E. Abscess leaves a glial scar after healing

Question 20

Cerebral abscess shows which of the following characteristics on MRI of brain?
● A. On diffusion-weighted MRI, it is bright on DWI and dark on ADC
● B. MR spectroscopy shows peaks of lactate and acetate
● C. Cerebritis stage is hypointense on T1 and hyperintense on T2
● D. Capsular stage is shown as hypointense center with bright capsule on T1 and hyperintense center with dark capsule on T2
● E. All of the above are true

Answer 20

E. All of the above are true

Question 21

Medical management for cerebral abscess is indicated for patients in early cerebritis stage and size of abscess less than 3 cm with vancomycin, meropenem given IV for 6 to 8 weeks. Following are indications for surgical management of these lesions except?
● A. Significant mass effect exerted by lesion
● B. Lesion far from ventricle
● C. Traumatic abscess with foreign material
● D. Fungal abscess
● E. Multiloculated abscess

Answer 21

B. Lesion far from ventricle

Question 22

What is the mainstay of surgical treatment of cerebral abscess along with IV antibiotics?
● A. Needle aspiration
● B. Surgical excision
● C. External drainage
● D. Instillation of antibiotics
● E. All of the above

Answer 22

A. Needle aspiration

Question 23

A patient presents in neurosurgical OPD with history of fever, headache, and signs of meningismus and hemiparesis. MRI shows crescentic extracerebral lesion with high signal on T2 MRI. What is the most likely diagnosis?
● A. Brain abscess
● B. Chronic subdural hematoma with meningitis
● C. Subdural empyema
● D. EDH with meningitis
● E. None of the above

Answer 23

C. Subdural empyema

Question 24

Following statements are true except?
● A. Toxoplasmosis in brain usually shows more than five lesions in brain while primary CNS lymphoma (PCNSL) shows multiple lesions in brain but less than five in number
● B. Toxoplasmosis lesions show ring enhancement while PCNSL shows homogenous enhancement and PML shows no enhancement
● C. Lesion in toxoplasmosis is in basal ganglia and gray–white junction; in PCNSL it is subependymal while limited to white matter in PML
● D. All three lesions (toxoplasmosis, PCNSL, and PML) produce mass effect
● E. PML is high signal on T2 and low signal on T1 MRI

Answer 24

D. All three lesions (toxoplasmosis, PCNSL, and PML) produce mass effeat