Infections and Inflammation

Question 1

A 35 yo F PTC PTC after she noticed blurred vision and difficulty breathing. Her symptoms including abdominal pain, n/v, malaise, and dizziness abruptly started after eating a meal the night before (12 hours). PE revealed ptosis, diplopia, fixed/dilated pupils, suppressed gag reflex, and symmetrical descending paralysis.

What do you suspect? What’s your next step?

Answer 1

Botulism (food bourne)

Investigation:

• Toxin may be identified in serum, stool, vomitus, gastric aspirate, and suspected foods.
• R/O CNS pathologies with CT, MRI

Tx:
- ER!!! Airway management, anti-toxin therapy, and IV penicillin therapy.

Question 2

An earliest and most common symptom of infant botulism? Other signs?

Answer 2

Constipation

Others: general weakness, a weak cry, a poor sucking reflex, irritability, lack of facial expression, and loss of head control, trouble breathing.

Question 3

The general course of botulism: early vs later symptoms?

Answer 3

Early: cranial nerve complication

Later: paralytic ileus, severe constipation, urinary retention, respiratory failure

Question 4

Drug for Rickettsia rickettsii?

Answer 4

Doxycycline

Question 5

Drug for herpes simplex encephalitis and varicella-zoster virus?

Answer 5

Acyclovir

Question 6

Most sensitive image for brain abnormalities?

Answer 6

MRI > CT

Brain - MRI/CT/EEG

Question 7

Gold standard for encephalitis investigation?

Answer 7

Brain biopsy, histological exam

Question 8

The presence of Negri bodies in the hippocampus and cerebellum indicates?

Answer 8

Rabies

Question 9

Encephalitis caused by Poliovirus causes

Answer 9

Muscle paralysis (destroys upper and lower motor neurons)

Question 10

Most common cause of AIDS dementia

Most common viral CNS infection in AIDS

Answer 10

HIV → AIDS dementia

Cytomegalovirus → Cytomegalovirus

Question 11

36 yo M PTC feeling ill. Prior to his symptoms, he notes that he was sick with fever, HA, n/v, malaise, and myalgia about 7 days ago (viral prodrome). He appears in the office today with a rash and lymph node enlargement. He notes that his symptoms are progressively getting worse and is now having issues with memory.

PE revealed lymphadenopathy, hepatosplenomegaly, positive Brudzinski’s sign, photophobia, and behavior disturbances with a decreased level of consciousness

What do you suspect? Next step?

Answer 11

Encephalitis

1. Brain biopsy
2. CBC
3. Serum glucose for hypoglycemic symptoms and compare to CSF glucose value

WBC is elevated in bacterial, but may be normal in viral

Question 12

PCR and Tzanck test

Answer 12

HSV

Question 13

Diagnosis for encephalitis and meningitis

Answer 13

Lumbar puncture → CSF (viral) → blood culture (bacterial)

but start with CT/MRI for those at high risk (increased intraocular pressure)

Question 14

A 34 yo F PTC after a recent fall. She noticed lower limbs (bilateral) weakness a few days back that has progressed up to her upper limbs. She is having difficulty with breathing and started to notice difficulty pronunciation words.

PE revealed areflexia, ataxia, facial droop, diplopia, pupillary disturbances, arrhythmias, slurred speech, respiratory weakness and bladder dysfunction.

What do you suspect? Investigaton? Tx?

Answer 14

Guillain-Barré syndrome - ascending and symmetrical motor weakness

1. Spinal tap - high CSF, normal glucose and WBC
2. Electromyography and nerve conduction studies shows conduction block

Senf to ER! Plasmapheresis and infusion IV immunoglobulin or plasma exchange. Respiratory ventilation.

Question 15

A 29 yo M PTC with pruritic rash on left side of the body. He notices some radicular pain and itching before the rash appeared. What do you suspect? Tx? How do you prevent this condition?

Answer 15

Herpes zoster (shingles)

Varicells-zoster vaccine to prevent

Tx:

• Acyclovir, Valacyclovir
• Gabapentin 300-600mg PO tid for post-herpetic neuralgia

Question 16

A 19 yo F PRC with fever and headache. She notes stiffness and recently had seizures, level of consciousness, n/v. what do you suspect? Next step? Tx?

Answer 16

Meningitis

Investigation - same as encephalitis: lumbar puncture and obtain CSF, culture.

ED!

Question 17

Viral and bacterial meningitis?

Increased CSF protein, increased total CSF leukocyte, normal CSF glucose, gram stain negative

Answer 17

Viral meningitis

Question 18

Viral and bacterial meningitis?

Increased CSF protein, increased total CSF leukocyte, decreased CSF glucose, gram stain positive, culture positive test

Answer 18

Bacterial

Question 19

Investigating options for neuralgia

Answer 19

Neurological testing

MRI for vascular compression - low sensitivity

Question 20

Peripheral neuropathy causes (4)

Answer 20

1. Diabetes Mellitus
2. Alcohol, heavy metals
3. Drugs - phenytoin
4. Thiamine, Vitamin B12, pyridoxine deficiency

Question 21

Peripheral neuropathy tx

Answer 21

Anti-seizure medicationL Gabapentin, carbamazepine, phenytoin

TCA: Amitryptyline (chronic pain)

Question 22

This condition first starts with a prodrome of fever, paresthesia in and around the wound site, headache, and sore throat. It causes acute encephalitis leading to hyperactivity, agitation, confusion, and seizures. Spasms of the thread muscles when swallowing liquid result in hydrophobia and foaming of the mouth. In worst case, it can cause coma and death due to respiratory center dysfunction. What do you suspect? Tx?

Answer 22

Rabies

Wound cleaning, debriefment, heal by secondary intention to allow drainage of wounds and prevent infection.

Passive immunization with Human Rabies immunoglobulin into wound site

Active immunization with killed rabies virus vaccine

Question 23

How do you check for rabies?

Answer 23

Direct fluorescent antibody test, viral cuture, PCR

• saliva
• CSF: monocytosis
• Brain tissue: Negri bodies are pathognomonic
• Blood analysis: normal to elevated WBC count

Question 24

A 38 yo M PTC with lockjaw and jaw stiffness, neck rigidity, restlessness, and reflex spasms. He appears hot, sweating, and has difficulty speaking and breathing. He notes that he is starting to feel tension around his facial muscles and to the extensors of the limbs. What do you suspect? Next step?

Answer 24

Tetanus via clinical diagnosis

Clean wound
Metronidazole
Spamolytic medication

Question 25

Drug for tetanus

Answer 25

Metronidazole

Question 26

Most common neuralgia

Answer 26

Trigeminal neuralgia

Question 27

Patient presents noting that they have the worst headache of their life. They experience facial pain, alterations in consciousness, seizures, weakness, hemisensory loss, language disturbance, memory loss, blurred vision, and epistaxis. What do you suspect? Next step?

Answer 27

Cerebral aneurysm

1. CT angiogram
2. MRI
3. Angiogram

SEND TO ER