Meningitis and Encephalitis

Question 1

What is the definition of meningitis?

Answer 1

Inflammation of the protective membranes covering the brain and spinal cord

Question 2

What is the protective covering of the brain called?

Answer 2

Meninges

Question 3

Which on an LP would indicate meningitis?

Answer 3

Elevated CSF, WCC and protein

Question 4

At what age is the highest incidence of bacterial meningitis?

Answer 4

45-65 years

Question 5

What is the mortality rate of bacterial meningitis?

Answer 5

20%

Question 6

What type of bacterial meningitis has a higher mortality rate?

Answer 6

Pneumococcal meningitis

Question 7

What type of meningitis are older adults and immunocompromised individuals more likely to get?

Answer 7

Listeria monocytogenes

Question 8

What % of meningitis is viral?

Answer 8

50-80%

Question 9

What is Kernig’s sign?

Answer 9

Flex hip at 90 degrees and extend knee.
Patient resists full knee extension when hip flexed.
Sign of meningeal irritation

Question 10

What is Brudzinki sign?

Answer 10

Passive flexion of neck causes flexion of both legs and thighs.
Sign of meningeal irritation.

Question 11

How is suspected meningitis managed (no signs of brain shift)?

Answer 11

A-E
Blood cultures
Lumbar puncture
Ceftriaxone or Cefotaxime 2g immediately after LP
Dexamethasone 10mg IV

Question 12

When can cause papilloedema and what is it?

Answer 12

Swelling of the optic disc due to elevated intracranial pressure

Question 13

If LP is not done within first hour of suspecting meningitis, when are abx given?

Answer 13

straight after blood cultures

Question 14

Is a CT head indicated in suspected meningitis?

Answer 14

Not usually as it’s a clinical diagnosis.
Not indicated if no shock, sepsis or signs of brain shift.

Question 15

How is suspected meningitis managed (with signs of brain shift)?

Answer 15

Brain shift = raises ICP
A-E
High flow O2
Bloods - FBC, U+E’s, Clotting, cultures
Dexamethasone 10mg IV
Ceftriaxone or Cefotaxime 2g immediately after blood cultures
Delay LP
Arrange neuroimaging

Question 16

What is the difference between the management of meningitis with and without signs of brain shift?

Answer 16

With brain shift - delay LP and get neuro imaging. Abx (Ceftriaxone/Cefotaxime 2g) after blood cultures.

Without brain shift - Urgent LP with abx (Ceftriaxone/Cefotaxime 2g) after LP. Neuro-imaging not usually indicated.

Question 17

How is severe sepsis or a rapidly evolving rash managed (with or without signs of meningitis)?

Answer 17

ITU support
A-E
Sepsis 6
Delay LP
Ceftriaxone or Cefotaxime 2g IV after blood cultures

Question 18

What type of rash do you see in meningococcal septicaemia?

Answer 18

Petechial rash
Can progress to purpura and ecchymoses and clotting system fails

Question 19

What type of rash is this?

Answer 19

Question 20

What type of rash is this?

Answer 20

Question 21

Which alternative abx would be given in suspected meningitis if pen/Cephalosporin allergic?

Answer 21

Chloramphenical 25mg/kg

Question 22

Which abx would you give in someone over 60 or immunocompromised with meningitis?

Answer 22

Cefttriaxone/Cefotaxime + Amoxicillin 2g IV

If allergic to amoxicillin - give Chloramphenicol and Co-trimoxazole 10-20mg/kg

Question 23

Which abx would you give in someone with suspected meningitis who has had recent travel to somewhere with a risk of penicillin resistant pneumococci?

Answer 23

Ceftriaxone/Cefotaxime + Vancomycin 15-20mg/kg IV or Rifampacin 600mg IV/PO dependent on trust.

Question 24

At which vertebral level is a LP done?

Answer 24

L3/4 or L4/5

Question 25

What is CSF fluid in a LP sent off for?

Answer 25

Measure opening pressure MCS Protein Glucose (with concurrent blood glucose) Meningococcal and pneumococcal PCR Enteroviral, Herpes Simplex + Varicella Consider TB investigations

Question 26

What are the common organisms in bacterial meningitis?

Answer 26

Neisseria Meningitidis Streptococcus pneumoniae

Question 27

What type of bacteria is neisseria meningitidis?

Answer 27

Gram negative rod

Question 28

What type of bacteria is streptococcus pneumoniae?

Answer 28

Gram positive cocci

Question 29

When should you delay a LP?

Answer 29

Question 30

What are the signs of brain shift?

Answer 30

Question 31

How long does it take to develop symptoms of TB meningitis?

Answer 31

Weeks Other types are more sudden

Question 32

Where is there a high incidence of TB meningitis?

Answer 32

Africa Indian sub-continent

Question 33

How is TB meningitis treated?

Answer 33

Rifampicin, Isoniazid and Pyrazinamide for 9 months +/- steroids

Question 34

What are the complications of TB meningitis?

Answer 34

Hydrocephalus Tuberculomas (mass) Seizures

Question 35

What is the mortality of TB meningitis?

Answer 35

60%

Question 36

What would you see in histology of TB meningitis?

Answer 36

Acid-fast bacilli on Ziehl-Neilson staining

Question 37

How long is TB meningitis samples kept for before they can be said to be negative?

Answer 37

6 weeks

Question 38

If all four ventricles of the brain are dilated, where would the site of obstruction be?

Answer 38

Either the foramina of Luschka or Magendie or in the subarachnoid space

Question 39

What type of fungus can be seen in meningitis?

Answer 39

Cryptococcus. Treated with amphoteracin.

Question 40

How does viral meningitis present?

Answer 40

Neck stiffness, headache, photophobia. Not usually reduced consciousness.

Question 41

How is viral meningitis treated?

Answer 41

Treated as if bacteria until proved otherwise. CSF PCR - Enterovirus, herpes simplex, varicella roster. No evidence for aciclovir Treat with IVI and analgesia

Question 42

What is the definition of encephalitis?

Answer 42

Inflammation of the brain

Question 43

What is the difference between meningitis and encephalitis?

Answer 43

Meningitis - inflammation of meninges. Encephalitis - inflammation of brain

Question 44

What is a combination of encephalitis and meningitis called?

Answer 44

Meningioencephalitis

Question 45

Is encephalitis a clinical or pathological diagnosis?

Answer 45

Pathological

Question 45

What markers can suggest encephalitis?

Answer 45

abnormal CSF or neuroimaging

Question 46

What causes encephalitis?

Answer 46

Question 47

What is ADEM?

Answer 47

Acute Disseminated Encephalitic Myelitis Patient has had a vaccine or infection several weeks earlier (2-3), produce antibodies to fight infection that attacks brain instead.

Question 48

Which is the most common type of viral encephalitis?

Answer 48

Herpes simplex Majority is HSV-1, 10% if HSV-2 (in immunocompromised) Varicella zoster also common Cytomegalovirus in immunocompromised.

Question 49

What age does viral encephalitis peak?

Answer 49

Young and elderly

Question 50

Which type of virus can cause an aseptic meningitis which can then cause encephalitis?

Answer 50

Enterovirus

Question 51

How does herpes simplex cause encephalitis?

Answer 51

The CNS infection is secondary to active infection elsewhere in the body, or more commonly reactivation of dormant infection.

Question 52

What are the neuropathological features of herpes simplex encephalitis?

Answer 52

Question 53

What is the clinical presentation of encephalitis?

Answer 53

Question 54

How is encephalitis managed?

Answer 54

Question 55

Where does herpes simplex encephalitis typically go in the brain?

Answer 55

Right temporal lobe

Question 56

Which abnormalities do you see on an EEG in encephalitis?

Answer 56

Periodic lateralising epileptiform discharges

Question 57

How is viral encephalitis treated?

Answer 57

Question 58

What is auto-immune encephalitis?

Answer 58

Body's immune system attacking brain causing inflammation

Question 59

Which antibodies can cause autoimmune encephalitis?

Answer 59

NMDAR LGI1 CASPR2

Question 60

How can autoimmune encephalitis present?

Answer 60

Altered cognition Altered psychiatric state Seizures

Question 61

What paraneoplastic conditions can cause auto-immune encephalitis

Answer 61

NMDA receptor encephalitis caused by teratomas

Question 62

How is auto-immune encephalitis managed?

Answer 62