Infectious Nervous

Question 1

West Nile Virus Encephalitis

Answer 1

fever, headaches, and altered mental status. A prominent finding in WNE is muscular weakness (30 to 50 percent of patients with encephalitis), often with lower motor neuron symptoms, flaccid paralysis, and hyporeflexia with no sensory abnormalities. Rare form.

Question 2

Most common causes of viral meningitis?

Answer 2

1) Enterococcus (coxsackie, poliovirus, rhinovirus)
2) HSV 2,
3) HSV 1, VZV, HIV, Lyme, VDRL, EBV, LCMV

Question 3

West Nile Meningitis

Answer 3

Occurs in older, immunocompromised people. Rare form

Question 4

What is the work up for a lymphocytic predominant meningitis in immunocompetent patient?

Answer 4

Blood: cultures, ESR, ANA, rheumatoid, Sjogren’s, SPEP, angiotensin converting enzyme,

CSF: cytology, antibodies to B. burgdorferi, Brucella, histoplasma, coccidioides, PCR M. tuberculosis.

Question 5

Enterovirus v. Lyme

Answer 5

EV 6x as frequent as lyme

Median pediatric age 10 Lyme v 5 EV

Prodrome duration 12 d Lyme, 1 day EV

Lyme has facial palsy

Question 6

fever, HA, nuchal rigidity, facial palsy

Answer 6

Lyme meningitis

Question 7

fever, HA, nuchal rigidity, sacral pain

Answer 7

HSV 2 meningitis
But most hsv2 meningitis occurs without genital herpes.

Chronic prophylaxis
Acyclovir, valacyclovir

Question 8

lymphocytic predominant meningitis in HIV patient differential diagnosis?

Answer 8

Virus: enterovirus, HSV 1, 2, 6, 7 VZV, CMV, EBV, HIV, WNV

Bacteria: endocarditis, parameningeal infection, mycoplasma, M tuberculosis, T pallidum

Fungi: Cryptococcus neoformans, H capsulatum, C immitis

Parasites: T. gondii

Noninfectious: carcinomatosis, posttransplant lymphoproliferative d/o, CNS vasculitis, ADEM (Acute disseminated encephalomyelitis)

Drug Reactions: NSAIDS, Cox-2 I, azathioprine, Bactrim, isoniazid, IVIG, OKT-3, intrathecal chemo.

Question 9

When do you need to do a CT before an LP?

Answer 9

Yale criteria:

Question 10

Cryptococcal meningitis CD4 count?

Answer 10

100

If WBC

Question 11

What is IRIS syndrome

Answer 11

Immune reconsitition inflammatory syndrome

esp concerning in aids patient treated for cryptococcus meningitis
weeks after appropriate tx, worsening of sx or new neuro sx.

prevent by delaying HAART therapy.

+CRP with sterile tap

Question 12

Inflammatory PML:

Answer 12

MS sx: weakness, changes in vision, personality, movement

Fast progressive

caused by JC virus and MS treated with Natulizamab

Multifocal non contrast enhancing lesions on MRI

Prognosis: 1/3-1/2 die in first month

Question 13

multiple lesions in brain in AIDS patients

Answer 13

Multiple enhancing brain lesions. Usually brain abscesses (rarely encephalitis).

Dx: Serology
If congenital: periventricular calcifications

Rx: pyrimethamine/sulfadiazine and folinic acid

Question 14

right ear pain followed by weakness of lid closure, eyebrow lifting, and lower face weakness.
No hearing loss, tip of tongue is numb

Answer 14

Bell’s palsy
Most common cause: 2/3 of are VZV, median ag 40, equal gender, recurrance rare

20-30% may have permanent disfiguring facial weakness &/or synkinesis, hyperacusis, loss of taste/tearing.

Tx with prednisone in first 48hr and valacyclovir.

Question 15

Causes of one time Bell’s palsy

Answer 15

diabetes, HTN, HIV, Lyme, Ramsay Hunt (zoster), sarcoidosis, parotid disorders, Sjogren’s, pregnancy, amyloidosis, intranasal flue vaccine, WNV

Question 16

Recurrent/Bilateral Facial N. Palsy

Answer 16

lymphoma, sarcoid, Lyme, pontine lesion, m. gravis.

Question 17

Neurologic signs suspicious for Lyme’s disease

Answer 17

Facial palsy, unilateral or bilateral. Meningeal signs with or without cranial neuritis, Radiculopathy, mononeuropathy multiplex, encephalomyelitis, encephalopathy

Question 18

Lyme Pearls

Answer 18

2.Diagnostic testing should be done if there
is likelihood of tick exposure
3.Lyme accounts for only 25% su mertime 7th nerve
palsies in endemic areas
4.Onset of headache and meningeal symptoms is
less acute than in viral meningitis
5.Many patients with erythema migrans do not
yet have measurable antibody response
6.ELISA does not provide measure of disease activity
or treatment response and can remain positive for years
7.Early increase B cells, IgG synthesis, bands, possibly
due to chemokineCXCL 13
8.Borrelia burgdorferi is very sensitive to beta-lactam s
and tetracyclines with no sig nificant resistance 9.Persistent symptoms with negative laboratory tests after appropriate treatment are not Lyme disease

Question 19

Old man with high temp, stiff neck, unrousable, generalized seizure, no papilledema or lateralizing abn.

Answer 19

Dexamethasone (to reduce hearing loss)
Abx: for S. penumo, gnr, listeria,
CT
LP

Question 20

If low sugar in CSF:

Answer 20

cancer, Bacterial , TB
Herpes simplex (sometimes) Fungal (sometimes) Neurosarcoidosis

Question 21

Necrotic encephalitis, psychiatric symptoms. Mixed poly, lymphocytic encephalitis, RBC 400

Answer 21

HSV encephalitis

Dx PCR`

Question 22

Left leg weakness over 1 day to 3/5 strength. Areflexic in both legs. Speech arrest. Mild bilateral facial weakness. Normal sensory exam. rapid obtundation. CSF: 125 WBC 50% polys, glucose 75, protein 104

Answer 22

Polio like
West Nile Virus
Dx: IgM
older, immunocompromised people.

facial nerve

Question 23

Acute confusional states with limbic features

Answer 23

Psychiatric diagnosis, Drugs, Wernicke’s, Seizures/status –ddx, Infection: HSV 1>2, HHV 6, Paraneoplastic syndromes

Question 24

Encephalitis Causes4

Answer 24

vira: St. Louis, Equine, WNV, Japanese

Bacterial: rocky mt spotted fever, ehrlichiosis, anaplasmosis, lyme, leptospirosis

Amebae: aegleria, acanthamoeba

Non seasonal:
HSV 1, 2, 6, VZV, EBV, CMV, Rabies, H1N1, Toxoplasmosis

Question 25

Earl neurologic manifestations of Lyme

Answer 25

aseptic meningitis, facial n palsy,

Question 26

HSV encephalitis

Answer 26

temporal lobes

seizures, olfactory hallucinations, memory disturbances, elevated reds in csf + leukocytosis.

Question 27

Toxoplasmosis

Answer 27

AIDS patient
presents with headache, mental status change, focal neurologic signs and symptoms
fever
Multiple ring-enhancing lesions in basal ganglia.

Question 28

Neurocysticercosis

Answer 28

Caused by Taenia Solium. 
Seizure, headache, increased ICIP. 
multiple cystic lesions which can be ring-enhancing or calcified!
Seen in s america/latin america.  
Tx with albendazole and steroids.

Question 29

HIV associated dementia

Answer 29

after prolonged immunosuppresion.

MRI: patchy T2 hyperintensity in white matter and cerebral atrophy.

Question 30

PML

Answer 30

Demyelinating of CNS caused by infection of oligodendrocytes by JC virus.

Question 31

Cryptococcus Meningitis

Answer 31

markedly elevated ICP! + imunocompromised

Tx with amphotericin B and flucytosine

Question 32

Bacterial Meningitis

Answer 32

associated with hearing loss and visual loss. Low sugar and elevated poly count and hallmarks.

Question 33

TB meningitis

Answer 33

basilar meningitis with multiple cranial neuropathies, raised ICP, hydrocephalus, low sugar

Question 34

basilar meningitis with multiple cranial neuropathies, raised ICP, hydrocephalus, low sugar

Answer 34

TB meningitis

Question 35

40 yo man with double vision on looking to left for 2 days. stiff neck. inattentive and lethargic. mildly enlarged ventricles

Answer 35

TB meningitis

Question 36

Neiserria meningitides

Answer 36

can also cause septicemia – purple rash on abd

proflylaxis with rifampin or cirpofloxacin.

Question 37

Acyclovir SE

Answer 37

Nephrotoxicity, ATN

Question 38

Posterior fossa syndrome

Answer 38

CSF pleocytosis without microbial growth after posterior fossa surgery

Question 39

Congenital CMV

Answer 39

hearing loss, spasticity, hyperintensities along ventricular margins on MRI