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MSII Unit 3 > CNS Infections & Nerve & Muscle > Flashcards

CNS Infections & Nerve & Muscle Flashcards

1
Q

What are the 3 general pathways that viruses can enter the CNS?

A
  1. Neural
  2. Olfactory
  3. Hematogenous
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2
Q

What condition does this describe:

– Inflammation of the lining of the brain

A

Meningitis

– Aseptic meningitis is NOT caused by bacteria

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3
Q

What is the major type of virus that causes aseptic meningitis?

A

80% enterovirus
10% HSV-1&2
10% arboviruses
<1% other viruses

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4
Q

Nuchal rigidity is a sign of what CNS condition?

A

Nuchal rigidity is a sign of meningitis
• “Brudzinski’s sign” is a symptom of meningitis.
• The neck is so stiff that the knees flex when the
neck is flexed.

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5
Q

What is the distinguishing feature of meningitis that differentiates it from encephalitis?

A

In meningitis, the patients mental status is NORMAL

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6
Q

What is the distinguishing feature of encephalitis that differentiates it from meningitis?

A

Mental status is altered in encephalitis and you get intracerebral hemmorage

Encephalitis is URGENT if unrespeonsive/coma, seizure or paralysis

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7
Q

How to diagnose aseptic meningitis?

Tx:

A

Spinal tap
Elevated white blood cell count in spinal fluid (no bacteria)
– Viruses may be detected in CSF
tx: supportive care, drugs exist for HSV, funcal and mycobacterial infections

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8
Q

How to diagnose encephalitis?

Tx:

A

Spinal tap indicates inflammation in CSF, blood may be present and viruses may be detected → PCR is gold standard for definitive diagnosis
– EEG is suggestive of seizures
– Brain MRI or CT scan may show foci of inflammation or hemorrhage
Tx: supportive care and symptom relief (acyclovir if caused by herpesvirus)

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9
Q

Postinfectious encephalitis follows viral infection by 1-2 weeks
This is called what?

A

Acute disseminated encephalomyelitis (ADEM)
-Associated with measles, mumps, VZV, influenza, parainfluenza viruses
– Autoimmune disorder

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10
Q

What type of viruses infect via neuronal spread?

A

Herpesvirus (alphaherpesviruses)

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11
Q

What type of viruses infect via fecal-oral spread?

A

Picornaviruses (enteroviruses)

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12
Q

What type of viruses infect via insect vectors (arboviruses)

A

Flaviviruses

Togaviruses

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13
Q

If infected with HSV, which type (HSV 1 or 2) will more often cause meningitis during their primary infection?

A

HSV-2&raquo_space; HSV-1 primary infections often cause meningitis
• Recurrent HSV-1 infections can also cause encephalitis
• Other herpesviruses: VZV, CMV, EBV meningitis occur
more often in immunocompromised patients
• In a weak host, these CNS infections often progress to severe encephalitis
• Treat HSV and VZV aggressively with acyclovir!

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14
Q

What is the route of infection for HSV-1

A

-Primary HSV-1 in the oropharynx → trigeminal nerve → CNS
– Recurrent HSV-1 → trigeminal nerve → CNS

HSV-1 is the most common cause of sporadic viral encephalitis.

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15
Q

How to diagnose HSV-1 Encephalitis?

A

Remember that an altered mental state is characteristic of encephalitis (NOT meningitis)
Gold standard: PCR of CSF for HSV and other viruses
– Brain imaging: MRI shows predominantly
unilateral temporal lobe abnormalities

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16
Q

If you have a very young or very old patient with encephalitis in the summer time, which virus should you most suspect?

A

Enterovirus, but also think arboviruses with seasonal vectors

17
Q

Viral infections of the central nervous system cause meningitis, encephalitis, or both, and have many common symptoms. What is a distinguishing characteristic of encephalitis?
A. Virus detected in the CSF by culture or PCR
B. Intracerebral hemorrhage.
C. Stiff neck, also known as Brudzinski’s Sign
D. Headache.
E. Prognosis may be good, with few sequelae

A

B. Intracerebral hemorrhage.

18
Q 
A patient diagnosed with viral encephalitis in the summer is most likely infected with what type of virus?
A. Enterovirus
B. Cytomegalovirus
C. Herpes Simplex Virus Type 2
D. Rabies virus
E. Mumps virus
A

A. Enterovirus

19
Q

Viremia can result in skin rashes, congenital infections, and CNS infections. What is an alternate route for viruses to enter the CNS?
A. Extravasation through meningeal or cerebral capillaries
B. Implantation of an organ from a donor infected with HSV-1
C. Retrograde transport from peripheral nerve endings or nasal mucosal
D. Bites from Aedes, Culex, or Culiseta mosquitos carrying Togaviruses

A

C. Retrograde transport from peripheral nerve endings or nasal mucosal

20
Q

Repetitive brief unilateral headaches lasting 15min-3h. Excruciating periorbital pain with lacrimation and rhinorrhea. More common in males.
What is tx?

A

Cluster headache

tx: 100% O2, sumatriptan, DHE

21
Q

Bilateral headaches lasting >30min (typically 4-6h); constant, steady pain with no photophobia or phonophobia. No aura
Tx:?

A

Tension headache
Tx: analgesic NSAIDs, (aspirin, acetaminophen, naproxen, ibuprofen)

Prevention tx: amitriptyline, SSRIs (fluoxetine, paroxetine, sertraline)

22
Q

Unilateral pulsating pain with nausea, photophobia, or phonophobia. May have
“aura.” Due to irritation of CN V, meninges, or blood vessels (release of substance P, calcitonin gene–related peptide, vasoactive peptides).
Tx:?

A

Migraine
Tx: Sumatriptan-take early
Ergotamine
Dihydroergotamine (DHE)-works in later stages of migrane
Opiates (codeine) can be used for acute tx of migraines

23
Q 
A healthy 16 year-old girl has been suffering from continuous bi frontal pressure like headache of mild to moderate intensity for a year. No associated migraine symptoms. Not taking any pain medicines. P/E and Neurological, Normal. Which one of the following is the preferred treatment for Headache Prevention?
A. Propranolol
B. Amitriptyline
C. Discontinue analgesics
D. Sumatriptan
E. Indomethacin
A

Answer: B. Amitriptyline.

Amitriptyline is still the premier drug for chronic tension-type headache.

24
Q 
A 40 year-old woman seeks help for migraines that became daily several months ago and are requiring more frequent daily doses of ibuprofen or Excedrin to enable her to function. Which one of the following is the preferred treatment for preventing headache development?
A. Propranolol
B. Amitriptyline
C. Discontinue analgesics
D. Sumatriptan
E. Indomethacin
A

Answer: C. Discontinue analgesics
Rebound migraines won’t disappear without withdrawal from the overused analgesics

The frequent daily doses of ibuprofen and excedrin can result in rebound headaches (medication-overuse headaches), which are caused by regular, long-term use of medication to treat headaches, such as migraine. Pain relievers offer relief for occasional headaches. … Rebound headaches usually stop when you stop taking the pain medication

25
Q 
A healthy 26 year-old man has been having one to two, often severe, hour-long, right-orbital headaches with mild watering of the right eye on most days for the past week. Some awaken him from sleep. He had a period of identical headaches a year ago. Which one of the following is the preferred treatment for preventing headache development?
A. Propranolol
B. Fluoxetine
C. Prednisone
D. Discontinue analgesics
E. Indomethacin
A

Dx: cluster headache
Answer: C. Prednisone
Prednisone is the quickest acting and one of the most effective medications for cluster
headache.
The recent Headache literature recommends Greater Occipital Nerve Blocks with Steroid and Local
Anesthetic as the preferred treatment.

A. Propranolol (B-blocker) is used for migraine prevention
B. Fluoxetine (SSRI) is used for migraine and tension headache prevention, and for co-existing depression with chronic headache

26
Q 
A 30 year-old woman has been having one or two severe, throbbing, nauseating, day-long headaches per week for the past year. Which one of the following is the preferred treatment for preventing headache development?
A. Propranolol
B. Fluoxetine
C. Prednisone
D. Discontinue analgesics
E. Indomethacin
A

Answer: A. Propranolol
Propranolol is an FDA-approved migraine preventive medication with Level A effectiveness.
SSRIs, although sometimes used for migraine prevention, are actually not FDA approved for migraine, so from these options, propranolol would be the best one. from the choices above.
Topiramate also will be equally effective ; the choice will depend on individual co morbidity and preferences

27
Q 
A slender, healthy, 20 year-old woman with prior periods of mild depression has had her studies in college adversely affected by a continuous pressure headache of fluctuating intensity of 8-months duration. She did not receive much relief from over-the-counter analgesics. A preventive had never been prescribed. Select the best treatment to prevent the patient’s headache(s).
 (A) Amitriptyline.
 (B) Feverfew.
 (C) Gabapentin.
 (D) Propranolol.
 (E) Divalproex.
A

Answer: A. Amitriptyline
Discussion: Amitriptyline remains the only drug validated as a preventive for chronic tension-type headache.

28
Q

An otherwise healthy 35 year-old man has had episodes of severe throbbing headaches affecting either temporal area associated with photophobia, lacrimation and nausea for the past 5 years. The headaches last for hours and occur about twice per month. Which one of the following headache treatments is the most appropriate?
(A) Oxycodone tablets.
(B) Combination of aspirin, acetaminophen and caffeine tablets.
(C) High-flow oxygen delivered through a non-rebreather mask.
(D) Almotriptan tablets.
(E) Tizanidine tablets.

A

Answer: D. Almotriptan tablets
Discussion: This man has a headache syndrome most consistent with migraine headache without aura. Opioids are in general poor migraine alleviatives. High flow oxygen is an effective therapy for cluster headache but not for migraine. Tizanidine is sometimes used for
tension-type headaches but not for acute relief of migraine. A combination of aspirin, acetaminophen
and caffeine was shown to be effective in moderate migraine. Triptans on the other hand, are considered the premier migraine abortive medication, are effective for severe migraine providing relief to about 80% of migraine sufferers.

29
Q 
A 22 year-old woman consults for episodic migraine headaches with aura of 5-year-duration, which occur on average once a month. Initially she used over-the-counter analgesics with modest improvement, but over time she began using prescription medications. Despite working well, she is not pleased with the injectable medication she is currently using because it causes vomiting. Unfortunately she doesn’t recall its name. However, based on her description, which one of the following injectable medications is she most likely referring to?
(A) Ergotamine
(B) Dihydroergotamine
(C) Zolmitriptan
(D) Sumatriptan
(E) Ondansetron
A

Answer: B. Dihydroergotamine
Discussion: Dihydroergotamine (DHE) comes in IM and IV forms and nausea and vomiting are common side effects.

Zolmitriptan is not available in an injectable form.
Sumatriptan is the only available injectable triptan in the US. Common side effects of triptans include flushing, tingling, dizziness and chest discomfort. Although possible, vomiting is not a common side effect of triptans.
Ondansetron is an anti-emetic medication.
Vomiting is a common side effect of Ergotamine, but this medication is only available as an oral tablet or suppository.

30
Q

T/F: Analgesic NSAIDs can be used for the acute treatment of moderate migraines; acute treatment of
tension headaches?
Side effects?

A

True

Side effects include medication overuse headaches (MOH)

31
Q

What use do opioids have in the treatment/prevention of headaches/migraines?

A

Not first line treatment. Acute treatment of migraines; patients with infrequent headaches with no response to other measures.

32
Q

What use does botox have in the treatment/prevention of headache/migraines?

A

Preventive treatment of chronic migraine
headaches
The only FDA approved treatment for chronic migraine.

33
Q

What is the only FDA approved treatment for chronic migraine.

A

botox injections

34
Q 
The treatment of acute migraines involves all of the following except which drug?
(A) Ergotamine
(B) Dihydroergotamine
(C) Sumatriptan
(D) Opioids
(E) Amitriptyline.
A

(E) Amitriptyline.

Amitriptyline remains the only drug validated as a preventive for chronic tension-type headache.

35
Q

_______remains the only drug validated as a preventive for chronic tension-type headache.

A

Amitriptyline

36
Q

What drug would be usevful in a patient with a hx of depression and also has chronic daily headaches?

A

SSRIs (Fluoxetine, paroxetine, sertraline)

37
Q

What drug used for migraine prevention may also cause side effects of worsening of depression, decreased
libido, hypotension, memory disturbance, and dizziness

A

Propanolol (B-blockers)

Only Propranolol and Timolol FDA approved

38
Q

What drug is used for migraine prevention, particularly useful in prolonged or disabling aura, or complicated migraine syndromes (e.g., hemiplegic migraine, Migraine with Brainstem aura];
Also the drug of choice in longterm prevention of Cluster Headaches

A

Verapamil, Diltiazem

39
Q

For which type of headache is Oxygen 100% high volume via non-rebreathable mask used?

A

Actute tx of cluster headaches

MSII Unit 3 (9 decks)

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