CNS Flashcards
Describe cervical myelopathy signs
Myelopathy (UMN signs below the level of lesion) - due to cord compression
Radiculopathy (LMN signs at level of lesion) - due to nerve root compression
Elevated 14-3-3 protein
Creutzfeldt-Jakob disease
Nonspecific marker of neuronal cell death
Anti-Hu antibody
Paraneoplastic syndrome (SCLC, patients who smoke)
Anti-NMDA receptor antibody
Anti-NMDA receptor encephalitis - associated with ovarian teratomas
Median age 21, 4x greater in women
Low alpha-synuclein; round, eosinophilic inclusions of it
Parkinson dementia if in basal ganglia/midbrain, dementia with Lewy bodies if in cerebral cortex
Low hypocretin/orexin
Narcolepsy type 1
Creutzfeldt-Jakob disease - signs
- Rapidly progressive dementia
- Myoclonus provoked by startle
- Mood symptoms (e.g. depression)
- Hypersomnia
CSF noninflammatory, contains elevated 14-3-3 protein (marker of neuronal cell death), elevated tau
Test for abnormally folded proteins using real-time quaking induced conversion (RT-QuIC) assay - mix abnormally folded proteins with normally folded proteins and watch for increased fluorescence following conformational changes in normal proteins
Most common sites of hypertensive hemorrhage in descending order
- Basal ganglia (putamen)
- Cerebellar nuclei
- Thalamus
- Pons
- Cerebral cortex
Cerebellar hemorrhage - signs
- Occipital headache (may radiate to neck/shoulders
- Neck stiffness (extension of blood into 4th ventricle)
- Nausea/vomiting
- Nystagmus
- Ipsilateral hemiataxia of trunk (vermis) and/or limbs (hemispheres) as corticopontocerebellar fibers decussate twice
What hemorrhage and damage would cause pinpoint pupils?
Large pontine hemorrhage - damage to descending sympathetic fibers
What is a useful screening test for hemineglect?
Drawing a clock - requires both sensory and motor components
Malignant hemispheric infarction
When an ischemic stroke causes:
1. Massive cerebral edema - from enthothelial dysfunction and breakdown of BBB –> mass effect, ICP, brain herniation
2. And/or hemorrhagic transformation - from blood extravasation from injured cerebral vessels into brain parenchyma (larger infarcts –> greater risk)
What is the difference between viral and fungal (Cryptococcus)/tuberculous meningitis on CSF?
Both have slightly elevated protein and lymphocytic predominance, but viral has normal glucose
Diagnostic confirmation of Cryptococcus
After CSF, India ink stain or polysaccharide antigen testing
How does Botulinum toxin work?
Cleaves SNARE proteins, preventing ACh release from neuron at neuromuscular junction
Botulinum vs myasthenia gravis
Myasthenia gravis spares pupillary function, autonomic dysfunction is less prominent, and symptom progression typically less rapid
Both are descending weakness
Cauda equina vertebral levels and corresponding effect
L2-sacrum + coccygeal nerve:
S1-S2: absence ankle reflex
S2-S4: saddle anesthesia
S3-S5: bowel, bladder, or sexual dysfunction (e.g. urinary straining)
Can have asymmetric lower extremity weakness/sensory loss
Conus medullaris vs cauda equina
- Conus medullaris is L1-L2
- Severe pain limited to lower back (vs radiating into leg)
- Numbness symmetric and limited to perianal area
- Weakness symmetric
- UMN findings such as hyperreflexia (vs absent ankle reflex)
Who is at increased risk of internal carotid artery dissection?
- Connective tissue disease (Ehlers-Danlos)
- Smoker
- Uncontrolled HTN
- Oral contraceptives
Why does internal carotid artery dissection only present with partial Horner syndrome?
Ptosis and miosis but not anhidrosis - sympathetic fibers for facial diaphoresis travel along the external carotid artery
Dementia with Lewy bodies
Dementia plus >=2 of the following:
1. Visual hallucinations
2. Parkinsonism
3. Fluctuating cognition
4. REM sleep behavior disorder
Blurred optic disc margins
Papilledema
Jervell and Lange-Nielsen syndrome - presentation
Congenital long QT syndrome
Inheritable sensorineural hearing loss due to mutations affecting endolymph production
Presents in childhood with profound bilateral deafness and episodes of arrhythmia-induced syncope during stress
What causes relative afferent pupillary defect?
Optic nerve injury - most often caused by indirect high-intensity force to orbit and transmission of shearing forces
Vision improves with conservative management in half of patient
Surgical decompression may be required
Loss of light perception is associated with worse prognosis
Abnormal red reflex is seen with what traumatic injury?
Vitreous hemorrhage from head trauma –> decreased visual acuity, relative afferent pupillary defect, and abnormal red reflex
Peripheral vertigo nystagmus
- Never purely vertical
- Inhibited by gaze fixation
- Fatigable (<1 min duration)
- Latency period (2-40 seconds)
How are patients predisposed to acute-closure glaucoma?
Lens is located more forward against the iris, impairing flow of aqueous humor through pupil into anterior chamber, increasing IOP
Women >40 yo, Asians and Inuits, farsightedness
Exacerbation can be due to pupillary dilation:
1. Anticholinergics (e.g. tolterodine)
2. Sympathomimetics
3. Low ambient light
Sulfonamides can trigger ACG due to swelling of structures in posterior chamber
Tourette syndrome - treatment
Counseling unless severe, disabling, or distressing:
Behavioral therapy - habit reversal training
Pharmacological:
1. Vesicular monoamine transporter 2 (VMAT2) inhibitors (e.g. tetrabenazine)
2. Antipsychotic
3. Alpha-agonist (e.g. guanfacine, clonidine) - helpful when ADHD or behavioral issues are also present
Central vertigo from posterior circulation ischemia - signs
- Limb ataxia or dysmetria (e.g. abnormal finger-to-nose or heel-to-shin)
- Postural instability - falling to side of lesion
- Headache - due to trigeminal innervation of much of cerebral arterial vasculature
Subarachnoid hemorrhage - timeline of complications
First day - rebleeding with rapid neurologic deterioration (urgent repair by coiling or clipping will reduce risk of rebleeding)
3-14 days - delayed cerebral ischemia due to vasospasm (caused by vasogenic metabolites from degraded blood) presenting with stroke-like symptoms - reduce risk via nimodipine
2 weeks - communicating hydrocephalus due to degraded blood products interfering with CSF reabsorption
Idiopathic intracranial hypertension - epi, signs, diag
Obese women of childbearing age
Excessive weight gain
Positional headaches worse when flat
Pulsatile tinnitus (due to increased vascular pulsations)
Blurry vision (due to increased pressure on optic nerves)
MRI often with MR venography to rule out cerebral vein thrombosis
Lumbar puncture reveals elevated opening pressure (>250)
Guillian-Barre syndrome
After acute infection (e.g. GI, resp, HIV)
Ascending motor deficits, hyporeflexia, back pain
Sensation classically unaffected (although paresthesias are common)
Dx with clinical, CSF analysis, and nerve conduction studies showing demyelination
CSF - albuminocytologic dissociation (increased total protein, normal CSF cell count)
Guillain-Barre treatment
IVIG or plasmapheresis
Most common artery causing Wernicke (receptive) aphasia
Inferior division of MCA - dominant temporal lobe
Also affects:
1. Right upper visual field
2. Somatosensory association cortex (processing of somatosensory information)
3. Lateral parietal and temporal heteromodal association cortex (integration of different sensory modalities - visual, somatosensory, etc)
These thus lead to difficulty using objects
Most common artery causing Broca (expressive) aphasia
Superior division of MCA - dominant frontal lobe
Also affects:
Contralateral hemiparesis
Nondominant frontal lobe lesion affects…
how a patient conveys emotion through speech (motor aprosodia)
Contralateral weakness due to impact on primary motor cortex
Nondominant temporal lobe lesion affects…
- Ability to comprehend emotional gestures (sensory aprosodia)
- Contralateral homonymous quadrantanopia due to impact on optic radiations
Dominant parietal lobe lesion affects…
- Contralateral sensory loss
- Contralateral inferior homonymous quadrantanopia - involvement of superior optic radiations
Nondominant parietal lobe lesion affects…
Anosognosia - denial of one’s disabilities
Apraxia - inability to carry out learned, purposeful movements
Spinal muscular atrophy affects which cells?
Anterior horn cells
As do poliomyelitis and ALS
Organophosphate poisoning - signs
Weakness accompanied by multisystem cholinergic symptoms
Diseases of neuromuscular junction
- Botulism
- Organophosphate poisoning
- Myasthenia gravis (improves with rest)
- Lambert-Eaton
Labyrinthitis
Inflammation of labyrinth and vestibular nerve –> acute-onset hearing loss and vertigo, +/- nausea/vomiting
If no hearing loss, it is called vestibular neuritis
Usually follows viral syndrome, may last few days
Main manifestation of vestibular schwannoma
Sensorineural hearing loss
Sometimes imbalance and tinnitus
True vertigo not typical because slow growth allows for development of compensation
Foramen magnum meningioma - signs
- Compression of brainstem at level of medulla - hypoglossal nerve dysfunction (tongue deviates toward side of lesion between strong part pushes weak side); bilateral corticospinal tracts run through medulla –> UMN signs (Babinski, spastic gait)
- Impaired CSF outflow –> increased ICP
Time course of following strokes:
Cardiogenic emboli
Flow limitation or embolization from carotid artery atherosclerosis
Lacunar stroke
Hemorrhagic
Cardiogenic emboli: multiple infarcts cause patchy neurologic findings - onset abrupt and maximal at start
Flow limitation or embolization from carotid: ipsilateral ocular and/or cerebral hemisphere ischemia - cerebral edema over hours-days, not rapid
Lacunar stroke: quite small, severe focal symptoms depending on area, not global
Hemorrhagic: minutes-hours, initially focal but soon ICP –> decreased consciousness
Dandy-Walker syndrome
Congenital atresia of foramina of Luschka and Magendie –> prevents CSF outflow into subarachnoid space –> hydrocephalus
Flattened gyri and sulci indicate…
Generalized cerebral edema due to increased hydrostatic pressure of hydrocephalus, allowing CSF to flow to parenchyma
Atypical Parkinsonian disorders (Parkinson-plus)
- Multiple system atrophy
- Progressive supranuclear palsy
- Corticobasal degeneration
Wide-based gait
Cerebellar or sensory ataxia
1. Cerebellar - stumbling/lurching ipsilaterally
2. Sensory - high-stepping, stamping gait; worsens in dark
Narrow-based, scissoring gait
Bilateral leg weakness with spasticity from UMN lesion (e.g. cerebral palsy, spinal cord injury)
Waddling gait
Myopathic weakness - proximal more than distal usually
Weakness of pelvic girdle muscles –> excessive pelvic tilt that shifts with each step
Putaminal hemorrhage
Involves adjacent internal capsule:
1. Contralateral hemiparesis and hemianesthesia (corticospinal and somatosensory fibers in posterior limb)
2, Conjugate gaze deviation toward side of lesion (damage of frontal eye efferents in anterior limb)
Brainstem stroke
Contralateral motor deficits with ipsilateral cranial nerve deficits (i.e. crossed signs)
Medulla involvement: tongue deviation, contralateral paralysis, contralateral loss of position sense (dorsal column medial lemniscus)
Saccular aneurysms vs Charcot-Bouchard
Saccular - spontaneous subarachnoid hemorrhage - severe headache with maximal intensity within hour + meningeal irritation
Charcot-Bouchard - Intraparenchymal hemorrhage of small penetrating arteries (same places as lacunar infarcts)
Elevated ICP tends to cause what eye palsy?
Bilateral abducens nerve palsies - long intracranial course makes it vulnerable to compression or stretching at skull base
Parinaud syndrome
Seen with pinealoma
- Limitation of upward gaze
- Light-near dissociation (pupillary light reaction impaired while the near reaction (accommodation) remains intact)
- Eyelid retraction
Who has carotid sinus hypersensitivity? Dx and treatment
Elderly men with atherosclerotic disease - baroreceptors are overly sensitive and trigger exaggerated vagal response from minimal tactile stimulus (e.g. shaving, rubbing of shirt color)
Dx - carotid massage + tilt table (note: avoid with suspected carotid artery stenosis)
Treat - permanent pacemaker
Who has hyperkyphosis?
Ankylosing spondylitis
Ankylosing spondylitis complications
- Osteopenia/osteoporosis - increased osteoclast activity iso chronic inflammation
- Spinal rigidity increases risk of vertebral fracture
- Aortic regurgitation
- Cauda equina syndrome
Signs:
1. Thoracic wedging
2. Hyperkyphosis
Which nucleus carries pain and temperature from face?
Spinal trigeminal nucleus
Descending sympathetic fibers travel close to what tract?
Spinothalamic tract (pain and temperature)
Midbrain stroke signs
Ipsilateral oculomotor (CN III) palsy
Contralateral hemiparesis (corticospinal tract)
Ataxia - dysfunction of red nucleus
Parkinson disease dementia - timeframe
Parkinsonism predates cognitive impairment by >1 year (as opposed to Lewy body, where cognitive impairment is before or at same time)
Progressive supranuclear palsy
- Parkinsonism
- Impaired vertical gaze
- Falls
White matter edema in bilateral posterior cerebral hemispheres with sparing of cortical gray matter
Reversible posterior leukoencephalopathy syndrome (RPLS)
Most often caused by hypertensive emergency or rapid fluctuations in BP
Failure of cerebral autoregulation results in brain hyperperfusion and extravasation of fluid and blood products
Treat with gradual BP reduction; antiepileptics if seizures present
Uremic encephalopathy signs
Tremor, asterixis and/or myoclonus
Widespread edema on neuroimaging (white + gray)
Confusion + seizures
Red flags of Parkinson
- Early postural instability (pull test)
- Early bulbar dysfunction (e.g. dysarthria, dysphagia)
- Absence of nonmotor signs (e.g. sleep disturbance, constipation)
- Severe orthostatic hypotension (>=30 systolic drop)
- Symmetric symptoms, hyperreflexia
Huntington disease - where is atrophy?
Caudate
Characterized by chorea, dementia, and psychiatric symptoms
Autism brain findings
Accelerated head growth during infancy, increased total brain volume
OCD brain findings
Structural abnormalities in orbitofrontal cortex and basal ganglia
Thalamic pain syndrome
Stroke (lacunar) in thalamus –> burning pain (allodynia) and hyperesthesia (extreme sensitivity)
Internal capsule stroke affects…
Motor deficits (alone or with sensory) from disruption of corticospinal fibers in posterior limb
T2 hypersensitivity of spinal cord without compressive lesion
Transverse myelitis - inflammatory infiltrates increases water content of spinal cord
Lumbar puncture shows lymphocytosis, elevated IgG
Treat with glucocorticoids; plasmapheresis for significant motor symptoms or poor response to steroids
- Vesicular rash on auditory canal
- Ipsilateral facial paralysis
Herpes zoster oticus (Ramsay Hunt syndrome) - reactivation from geniculate ganglion affects motor fibers of CN VII and spread to CN VIII
Leading cause of Bell palsy
Reactivation of HSV-1
Acute-onset, unilateral facial paralysis
Dietary treatment for drug-resistant epilepsy
Ketogenic (high-fat, low-carb) - due to downstream ketosis (anticonvulsant effects of fatty acids, altered GABA metabolism, vagal nerve stimulator)
Management of migraines in pregnancy
Nonpharmacological interventions –> acetaminophen –> antiemetics (e.g. promethazine), codeine, caffeine –> NSAIDS (e.g. naproxen; only in 2nd trimester) –> opioids (e.g. oxycodone)
Parenteral antiemetics (e.g. metoclopramide are used acutely
Eyelids, grip tightness slow to relax
Myotonic dystrophy - myotonia of muscles, as well as atrophy and weakness
Involves distal musculature
Frontal (apraxic) gait is seen in what?
Normal pressure hydrocephalus
Frontal lobe degeneration
Magnetic gait - gait (Bruns) ataxia - caused by damage to corticocortical white matter tracts of frontal lobe
Magnetic gait with slow, wide-based steps
Characteristic in NPH
Gait in cerebellar degeneration (e.g. alcoholic)
Wide-based, shuffling gait
Also dysarthria, postural instability
Spastic gait
Pyramidal or corticospinal tract lesions
Gait appears stiff or rigid with circumduction (spastic leg abducted and advanced while in extension and internal rotation) and plantar flexion of affected limb
Internal capsule stroke should show what?
Contralateral hemiparesis of arms and legs, plus UMN facial palsy (spares upper face)
Precentral gyrus stroke signs
Contralateral hemiparesis plus VANS:
Visual disturbances
Aphasia
Neglect
Sensory disturbances
Facial weakness sparing upper face (UMN) indicates lesion above what levels?
Above the pons
CN III palsy is lesion at what level?
Midbrain
Results in ptosis, cannot constrict pupil, down-and-out
Vitamin A toxicity causes what ICP increase?
Idiopathic intracranial hypertension
Which absorbs CSF?
Cerebral venous sinus - blockage can cause ICP increase and diffuse edema
Both cerebral venous sinus and cerebral vein thrombosis can cause increase in venule/capillary pressure, causing hemorrhage or local ischemia and edema
C5/C6 facet dislocation
C6 radiculopathy: weakness of wrist extension, numbness of forearm and thumb
C6/C7 facet dislocation
C7 radiculopathy: weakness of triceps extension and wrist flexion; numbness of index and middle finger
Capelike loss of pain and temperature sensation, possibly flaccid paralysis
Syringomyelia - fluid-filled cavity in spinal cord
Generalized slowing with periodic sharp wave complexes
Creutzfeldt-Jakob
Also see increased 14-3-3 protein in CSF
Progressive supranuclear palsy
Vertical supranuclear palsy (inability to look up)
Dementia
Parkinsonism
Postural instability
Traumatic brain injury leads to risk of secondary injury from…
Acute traumatic coagulopathy:
1. Hypocoagulability from consumptive coagulopathy
2. Hyperfibrinolysis - breaks down necessary clots
These can worsen or cause delayed intracranial hemorrhage
Where can MRI pick up stroke better than CT?
Brainstem or cerebellum pathology
Who more commonly gets subdural hematoma?
Those with cerebral atrophy (elderly, chronic alcohol use) - bridging veins must traverse longer distance and are more susceptible to tears
Symptoms classically occur gradually (e.g. over 1-2 days)
Subdural hematoma - what is torn?
Tearing of bridging veins –> slow bleeding into subdural space
Describe uncal herniation progression
Ipsilateral pupillary dilation (CN III compression) + contralateral hemiparesis (compression of ipsilateral cerebral peduncle) –> ipsilateral hemiparesis (compression of contralateral cerebral peduncle)
Above what level cord compression does urinary retention occur?
Above S2 (autonomic descending motor tract involvement)
What causes most cases of trigeminal neuralgia?
Vascular compression as nerve root enters the pons
MS, in contrast, has inflammatory plaques that affect the nuclei or compress the nerve roots
What are causes of bilateral trigeminal neuralgia?
- MS (trigeminal sensory nuclei close to midline)
- Internuclear ophthalmoplegia (medial longitudinal fasciculus is close to midline
Sleep-onset insomnia - pathophysiology, treatment
ACh dysregulation may play role
Treatment: Dual orexin receptor antagonists (e.g. lemborexant)
Central cord syndrome - pathophysiology, diagnosis
Older individual with stenotic cervical spinal canal (e..g. due to cervical spondylosis) experiences hyperextension injury to neck –> compression –> damage to grey matter of central spinal cord (generally sparing lateral spinal tracts running to sacrum)
Diagnose with cervical myelogram
Internal capsule components
Posterior limb: corticospinal tract
Genu: Corticobulbar tract
Partial ipsilateral Horner syndrome seen with…
Carotid artery dissection (i.e. intimal tear)
Ptosis and miosis without anhidrosis
Greatest risk factors for TIA or stroke
- Hypertension
- Smoking
- Diabetes
- Hypercholesterolemia
Pons cranial nerves
VI-VIII
How to improve muscle spasticity in multiple sclerosis?
- Baclofen - GABA-B receptor agonist
- Tizanidine - a2 agonist - perhaps by decreasing alpha motor neuron excitability
Autonomic dysreflexia; above what level would there be continued vasoconstriction involving both splanchnic and peripheral vasculatures, causing severe hypertension?
Spinal cord injury:
Noxious stimulus below lesion triggers sympathetic activity but without parasympathetic modulation
Lesions at or above T6: prolonged, severe HTN may cause headache, intracranial hemorrhage
Where is norepinephrine produced in brain?
Locus coeruleus
Where is serotonin produced in brain?
Raphe nuclei
Acute dystonia - treatment
Benztropine (anticholinergic)
Not used for tardive dyskinesia
Akithisia - treatment
Propranolol
Not used for tardive dyskinesia
Frontotemporal dementia gene
TDP-43: TAR (transactive response) DNA-binding protein
Tardive dyskinesia - treatment
Valentine or deutetrabenazine (vesicular monoamine transporter 2 (VMAT2) reversible inhibitor)
When is trihexyphenidyl preferred for Parkinson disease?
Anticholinergic:
Tremor predominant symptom
Younger age (fewer side effects)
Catatonia
- Immobility or excessive purposeless activity
- Mutism, stupor
- Negativism (resistance to instructions and movement)
- Posturing (against gravity)
- Waxy flexibility
- Echolalia, echopraxia
Treat with benzos (lorazepam), ECT
Akinetic mutism vs catatonia
Lesions in frontal cortex vs syndrome associated with mood disorders, psychotic, autism, general medical illnesses
No echophenomena
REM sleep behavior disorder is associated with what neuro disorder?
Parkinson disease - development of alpha-synuclein neurodegenerative disorders
MS - treatment
Acute attacks: High-dose glucocorticoid
Disease-modifying (requires having met diagnostic criteria): dimethyl fumarate
Cerebellar drift
Ipsilateral upward arm drift
Pyramidal lesion leads to downward arm drift
Clasp-knife phenomenon
Velocity-dependent resistance to passive movement of limb
Seen in hypertonia dur to pyramidal tract disease
Signs of anti-NMDAR autoimmune encephalitis
Psychiatric symptoms
Cognitive impairment
Autonomic instability
Rigidity
Hyperreflexia
Dystonia
Focal seizure
Temporal arteritis is associated with…
Polymyalgia rheumatica
Temporal arteritis commonly presents with what specific optic symptoms?
Anterior ischemic optic neuropathy
Amaurosis fugax
Blepharospasm - signs, treatment
Forceful contraction of eyelid muscles; form of focal dystonia
If associated with spasm of lower face: Meige syndrome
Triggered by bright lights, terminated by touching/brushing skin around eye (sensory trick)
Treatment: botulinum toxin for more significant symptoms
How does multiple system atrophy add to Parkinson? Management?
Early falls
Autonomic dysfunction
Pyramidal (eg hyperreflexia)
Cerebellar (eg wide based gait)
Supportive:
Intravascular volume expansion with fludrocortisone, salt supplementation, alpha agonists, compression stockings
Shoulder abduction relief test
For cervical radiculopathy - both diagnostic and therapeutic
ALS treatment
Riluzole - glutamate inhibitor
Edaravone - antioxidant
How does anterior cord syndrome differ in limbs affected compared to central or posterior?
Think about how the lateral corticospinal react is arranged radially (arm, trunk, leg from inside to outside)
Anterior: upper and lower extremities affected equally
Central: mostly upper
Posterior: lower, if involved
“Dancing eyes and feet”
Opsoclonus-myoclonus syndrome; antibody-mediated from neuroblastoma
Where is anterior spinal cord ischemia most likely?
T10-T12, aortic dissection causes interruption of arteries that feed anterior spinal cord
What is subacute sclerosing panencephalitis?
Fatal complication of measles, personality changes -> dementia -> death
Aquaporin-4 autoantibody
Neuromyelitis optica
Neuromyelitis optica vs multiple sclerosis
> =3 spinal cord involvement, negative oligoclonal bands, gray matter affected, aquaporin-4 autoantibody
Optic nerves, spinal cord, area postrema of brainstem affected, causing optic neuritis, transverse myelitis, and vomiting/hiccups, respectively
How does Parkinson’s lead to orthostatic hypotension?
Autonomic dysfunction due to degenerative changes -> impaired norepinephrine release -> drop in BP with standing without compensatory increase in HR
Miller Fisher syndrome
Variant of GBS with only ophthalmoplegia, ataxia, and areflexia
Finger to nose vs heel shin tests
Finger to nose tests limb coordination, while heel shin tests postural
In alcoholic cerebellar degeneration, postural is affected but not limb
Bell palsy typically due to what virus?
HSV reactivation
Cremasteric reflex - spinal cord levels
L1-L2
Dexamethasone should be added to bacterial meningitis treatment for which bacteria?
S pneumo and Hib - decreases complications
Toxoplasmosis - treatment
Pyrimethamine (high-dose, PO) + sulfadiazine and leucovorin (folic acid analog to prevent hematologic toxicity)
Clindamycin if sulfa allergy
