CNS specific

Question 1

3 main causes pyogenic meningitis

Answer 1

S pneumo

N meningitidis groups A B C W and Y

H influenzae type B

Question 2

Spell 3 causes of a eosinophilic CSF in meningitis

Answer 2

PT BAG

Paragonimus westermani
Taenia solium (cysticercosis)
Baylisascaris procyonis (racoon)
Angiostrongylus cantonesis
Gnathostoma spinigerum

[Gnathostoma has all the edges and spini round]

Question 3

CSF stain for bacteria? TB? Cryptococcal?

Answer 3

Gram
ZN or auramine
india ink

Question 4

Pneumococcal meningitis not responding to cef?

Answer 4

Meropenem

Question 5

Who gets H. influenza meningitis

Answer 5

Kids

Question 6

Meningococcal outbreak management

Answer 6

Early recognition Eg >15 cases / 100,000
Identify organism and drug sensitivities
Alert authorities
Produce diagnostic algorithms and case definitions
Mass chemoprophylaxis/vaccination

Question 7

What is cryptococcus? full name? Usually found in the environment due to?

Answer 7

Yeast like fungus
cryptococcal neoformans

Bird droppings

Question 8

Usual mechanism for infection with cryptococcus ? Presentation?

Answer 8

Inhalation
Subacute / chronic meningitis (similar to TB)

Question 9

Dx cryptococcal meningitis…csf stain?
blood test?

Answer 9

Either with india ink of CSF
CSF/ blood culture
Latex agglutination tests detect Cryptococcal polysaccharide antigen (CrAg)

Question 10

Cryptococcal meningitis Rx ?
Consolidation phase?
Secondary prophylaxis ?

Answer 10

Amphotericin B (10mg/kg single dose)
+ flucytosine (25mg/kg QID) for 2 weeks
+fluconazole 1200mg QID for 2 weeks

Consolidation phase 8 weeks fluconazole 800mg

Fluconazole 200mg daily for life works

Question 11

Cryptococcal meningitis prevention

Answer 11

screening for CrAg and rx with fluconazole (especially if HIV positive)

Question 12

When fluconazole prophylaxis in HIV

Answer 12

CD4 <100

Question 13

Arboviruses are transmitted by?

Answer 13

Insects
Arbo = ARthropod BOrn

Question 14

3 key types of of arbovirus causing CNS disease

Answer 14

Flavivirus
-Japanese encephalitis / West Nile / tick-borne
-[dengue / zika / yellow fever - less likely CNS]

Alphaviruses
Bunyaviruses

Question 15

Japanese encephalitis 70k cases per year - how many have long term neurological sequale?

Answer 15

50%
20-30% die

Question 16

vector and hosts of japanese encephalitis? Geography

Answer 16

culex mosquito (Eg Culex tritaeniorhynchus)
-Mostly birds [egret/heron]
-Domestic pigs major amplifying host

China, SE Asia and India

Question 17

Japanese encephalitis sx

Answer 17

10% develop Non specific fever with systemic upset …

<1% develop meningeal/encephalitis reduced consciousness with
- focal CNS eg seizures/parkinsonism
-or flaccid paralysis (polio-like) or Ascending (guillian-barre like)

Question 18

Japanese encephalitis ix? where are characteristic changes on imaging?

Answer 18

CSF - MAY be normal early in disease
-Viral picture (lymphocytes, normal glucose, mild rise protein)
- ELISA IgM of CSF
[PCR often already negative as viraemia transient]

CT/MRI - Midbrain changes

Question 19

Japanese encephalitis control

Answer 19

Vaccination
Treating rice paddys with neem cake (insecticide)
Individual protective measures from mosquito bites

Question 20

West nile flavivirus geography? transmission?

Answer 20

More or less everywhere (africa, asia, middle east, Europe, USA
Culex pipens mosquito

Question 21

Tick bourne ecephalitis virus spread by? Features

Answer 21

ixodes ticks spread through rodents and other small mammals

high fever for 1 week, then afebrile
then meningoencephalitis

Question 22

The historical key cause of acute flaccid paralysis? Sx?

Answer 22

Polio

Fever - then afebrile period followed by assymetrical flaccid paralysis of one or more limbs (may be painful)

Question 23

Where do viruses affect to cause flaccid paralysis

Answer 23

Direct viral damage to the anterior horn cell

Question 24

Compare cause of flaccid paralysis Gilllian barre vs direct viral damage. Onset? pattern? Time to reach max paralysis? sensory ? csf findings?

Answer 24

Direct viral - Eg Enterovirus 71 / Polio
Rapid onset eg 2 days often with fever
Asymmetrical
No sensory
CSF lymphocytosis

GBS
Slow onset eg 2 weeks and often weeks after illness
symmetrical
common sensory issues
Raised protein in CSF

Question 25

Which countries' polio still an issue?

Answer 25

Pakistan, Afghanistan and Nigeria

Question 26

virus causing acute flaccid paralysis endemic in Asia that isn't polio?

Answer 26

Enterovirus 71

Question 27

Nipple / bellybuten sensory level

Answer 27

T4 T10

Question 28

Name 2 Ways TB can cause paralysis

Answer 28

Potts disease - TB of vertebral bones -> collapse and cord compression TB meningitis -> secondary arteritis and cord infarction Tuberculoma compresses cord

Question 29

Most common cause of spinal epidural abscess? Triad of Sx?

Answer 29

S aureus Fever, Back pain, radiculopathy -> spastic paralysis, bladder/bowel dysfunction, sensory loss

Question 30

Transverse myelitis caused by many viruses and which key bacteria?

Answer 30

mycoplasma pneumonia [HIV, schisto, syphylis, denge, scrub typus, lime disease, leptospirosis...]

Question 31

When do you get HIV myelopathy? Other considerations if this is a differential?

Answer 31

Often with AIDS-dementia complex -Due to direct viral damage - consider lympoma, cryptococus and herpes in AIDS

Question 32

Subacute degeneration of the spinal cord due to B12 deficiency. What infections may cause this? Super common signs?

Answer 32

Tropical spure Fish tapeworm - diphyllobothrium lactum Upgoing planters with a reduced knee jerk. Macrocytosis [pernicious anaemia, coeliac, IBD, surgery]

Question 33

HIV negative with progressive spastic paralysis, loss of proprioception and vibration. Bowel / bladder dysfunction? cause? transmission?

Answer 33

Tropical spastic paraparesis Human T lymphotropic virus type 1 (HTLV-1) breast milk or rarely blood born

Question 34

What is rabies

Answer 34

Bullet shaped RNA Rhabdovirus

Question 35

Rabies mostly found in salavia of infected animals - how does it get to CNS

Answer 35

Along peripheral nerves -> Longer time to symptoms if bitten on hand/foot compared with face bite

Question 36

Rabies is usually clinical diagnosis - how might you confirm?

Answer 36

Saliva for NAAT / PCR testing only reliable way Brain biopsy if dead

Question 37

Rabies Rx if high risk exposure in unvaccinated?

Answer 37

Rabies Ig + 4 site post exposure vaccine

Question 38

When commence ART if dx with crptococcal meningitis

Answer 38

After 4-6 weeks

Question 39

When investigating flavivirus what Ix do you need to do

Answer 39

CSF/Serum serology (IgM) [PCR often negative by time of presentation ]

Question 40

59 yo male returned from a vacation in Bali with fever, headache, confusion Developed flaccid paralysis, altered mentation, respiratory failure CSF lymphocytosis, N protein, glc Respiratory failure, pneumonia, and death Most likely?

Answer 40

Japanese encephalitis

Question 41

Which travellers should get Japanese encephalitis vaccine?

Answer 41

>4 wks to endemic region during transmission season

Question 42

Name 3 main types of enterovirus? Diagnosis of these is based on?

Answer 42

Polio Coxsackie Echovirus PCR - serotyping (monoclonal antibodies) - microneutralization

Question 43

Polio transmission

Answer 43

Faecal oral

Question 44

Polio most commonly is asymptomatic 1000:1? What are the other presentations?

Answer 44

GI upset Paralysis - due to anterior horn infection Hypogammaglobulinemia/Agammaglobulinemia -Encephalitis

Question 45

What is post polio syndrome

Answer 45

Slow continuous decline in strength over years following acute polio

Question 46

Name a benefit of live attenuated oral polio and inactivated polio vaccine.

Answer 46

Live oral - spread to close contacts ie protects more than just the person getting vaccine -High levels of luminal antibodies (and that's how polio gets in) IPV - Can give to immunocompromised -No Vaccine-associated Paralytic Polio

Question 47

Where in the world is meningitis most prevalent

Answer 47

Meningitis belt across Africa

Question 48

Contraindications to LP before CT scan in meningitis

Answer 48

- Focal neurologic deficits (except CN palsies) - New onset seizures - Severely altered mental status (GCS <10) - Severely immunocompromised state

Question 49

What physiological issue prevents gent from working

Answer 49

Low pH

Question 50

Listeria monocytogenes meningitis rx

Answer 50

Ampicillin + gent

Question 51

Strep agalacticae meningitis rx

Answer 51

Ampicillin

Question 52

Name 3 bacteria that present as an aseptic meningitis

Answer 52

Leptospira interrograns Orienta tsutsugamushi Rickettsia ssp eg prowazekii / typhi

Question 53

Name 3 DDx of subacute meningitis

Answer 53

Tuberculosis Cryptococcal disease Noninfectious (Sarcoid, malignancy) Spirochetes (Syphilis, Lyme) [Less common Other fungi (e.g. Histo, cocci), Other bacteria (Brucella, Melioidosis, Scrub typhus, Whipple’s) Parasites (T solium) vasculitis]