Revision

Question 1

What are the 5 most common viral causes of meningitis?

Answer 1

1) Enteroviruses e.g. coxsackie

2) HSV

3) VZV

4) CMV

5) Mumps

Question 2

Describe different aspects of CSF in viral meningitis:

a) appearance

b) glucose

c) protein

d) white cell count

Answer 2

a) clear
b) normal or mildly raised
c) normal or mildly raised
d) raised, lymphocytes

Question 3

Describe different aspects of CSF in bacterial meningitis:

a) appearance

b) glucose

c) protein

d) white cell count

Answer 3

a) cloudy
b) low
c) raised
d) raised, neutrophils

Question 4

Describe different aspects of CSF in TB meningitis:

a) appearance

b) glucose

c) protein

Answer 4

a) cloudy, fibrin web
b) low
c) ++ raised

Question 5

Mx of viral meningitis

Answer 5

Typically viral meningitis is self-limiting, with symptoms improving over the course of 7 - 14 days.

Can give aciclovir in HSV meningitis

Question 6

What are the 5 main causes of bacterial meningitis?

Answer 6

1) Neisseria meningitidis

2) Strep. pneumoniae

3) H. influenzae

4) GBS (neonates)

5) Listeria monocytogenes (neonates)

Question 7

What is the most common cause of bacterial meningitis?

Answer 7

Neisseria meningitidis (meningococcus)

Question 8

What 2 special tests can look for meningeal irritation?

Answer 8

1) Kernig’s

2) Brudzinski’s

Question 9

Where is the needle inserted in an LP?

Answer 9

L3/4 or L4/5

Spinal cord ends at L1/2

Question 10

Where does spinal cord end?

Answer 10

L1/2

Question 11

Management of children in 1ary care with suspected meningitis AND a non-blanching rash?

Answer 11

Urgent dose of IM or IV benzylpenicillin whilst waiting transfer to hospital (shouldn’t delay transfer).

If true penicillin allergy, transfer should be the priority rather than other antibiotics.

Question 12

If meningococcal meningitis is suspected, what investigation should be done?

Answer 12

Meningococcal PCR

Question 13

There should be a low threshold for treating suspected meningitis, particularly in babies and younger children. Always follow the local guidelines.

What are the typical antibiotics used in babies:
a) under 3 months
b) over 3 months

Answer 13

a) IV cefotaxime + amoxicillin

b) IV ceftriaxone

Question 14

When & why are steroids indicated in meningitis?

Answer 14

Indicated in bacterial meningitis

To reduce risk of hearing loss

Question 15

Who are steroids avoided in in meningitis?

Answer 15

Babies <3 months old

Question 16

What steroids are given in bacterial meningitis?

Answer 16

Dexamethasone

Question 17

Which types of meningitis are notifiable diseases to the UK Health Security Agency?

Answer 17

Bacterial

Question 18

What is the usual post-exposure prophylaxis against meningococcal infection?

Answer 18

Single dose of ciprofloxacin

Question 19

What is the most common complication of meningitis?

Answer 19

Sensorineural hearing loss

Question 20

Patients with meningococcal meningitis are at risk of Waterhouse-Friderichsen syndrome.

What is this?

Answer 20

Failure of adrenals 2ary to adrenal haemorrhage

Question 21

What is the most common cause of encephalitis in neonates?

Answer 21

HSV-2 (from genital herpes contracted during birth)

Question 22

What GCS is a contraindication for an LP?

Answer 22

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Question 23

What is anti-NMDA receptor encephalitis?

Answer 23

A paraneoplastic syndrome.

Question 24

What is detected in up to 1/2 of female adult patients with anti-NMDA receptor encephalitis?

Answer 24

Ovarian teratoma

Question 25

Mx of anti-NMDA encephalitis?

Answer 25

IV steroids

Question 26

What testing is indicated in all patients with encephalitis?

Answer 26

HIV testing

Question 27

Mx of CMV encephalitis?

Answer 27

ganciclovir

Question 28

What is usually performed to ensure successful treatment prior to stopping antivirals in encephalitis?

Answer 28

Repeat LP

Question 29

When should patient's with Bell's palsy be referred urgently to ENT?

Answer 29

If no improvement in symptoms after 3 weeks

Question 30

What is pituitary apoplexy?

Answer 30

Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) 2ary to haemorrhage or infarction.

Question 31

Precipitating factors for pituitary apoplexy? (4)

Answer 31

1) HTN 2) pregnancy 3) trauma 4) anticoagulation

Question 32

Clinical features of pituitary apoplexy?

Answer 32

1) sudden onset headache (similar to SAH) 2) vomiting 3) neck stiffness 4) visual field defects: classically bitemporal superior quadrantic defect 5) features of pituitary insufficiency - hypotension/hyponatraemia 2ary to hypoadrenalism 6) extraocular nerve palsies

Question 33

What investigation is diagnostic of pituitary apoplexy?

Answer 33

MRI

Question 34

Mx of pituitary apoplexy?

Answer 34

1) urgent steroid replacement due to loss of ACTH 2) careful fluid balance 3) surgery

Question 35

Is IV or oral ciprofloxacin used as prophylaxis for contacts of patients with meningococcal meningitis?

Answer 35

Oral

Question 36

What triad is seen in shaken baby syndrome?

Answer 36

1) retinal haemorrhages 2) subdural haematoma 3) encephalopathy

Question 37

Is a history of rash with penicillin a contraindication to using benzylpenicillin or ceftriaxone in meningococcal sepsis?

Answer 37

No

Question 39

What features of trigeminal neuralgia suggest a serious underlying cause?

Answer 39

- Sensory changes - Deafness or other ear problems - History of skin or oral lesions that could spread perineurally - Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally - Optic neuritis - A family history of multiple sclerosis - Age of onset before 40 years URGENT referral for specialist assessment

Question 40

Gold standrd for diagnosis of venous sinus thrombosis?

Answer 40

MRI venography

Question 41

Is HIV a notifiable disease?

Answer 41

No

Question 42

What is Ramsay Hunt syndrome?

Answer 42

AKA herpes zoster oticus Caused by reactivation of the VZV in the geniculate ganglion of CN VII.

Question 43

What is often the 1st feature of Ramsay Hunt syndrome?

Answer 43

Auricular pain

Question 44

Features of Ramsay Hunt syndrome?

Answer 44

- auricular pain - facial nerve palsy - vesicular rash around the ear - other features include vertigo and tinnitus

Question 45

Mx of Ramsay Hunt syndrome?

Answer 45

Oral aciclovir & steroids

Question 46

Give 2 key neurocomplications of HIV?

Answer 46

Focal neuro lesions: 1) Toxoplasmosis (most common) 2) Primary CNS lymphoma

Question 47

CT results in HIV associated toxoplasmosis?

Answer 47

Usually single or multiple ring enhancing lesions, mass effect may be seen

Question 48

CT results in HIV associated primary CNS lymphoma?

Answer 48

single or multiple homogenous enhancing lesions

Question 49

What is cryptococcus neoformans?

Answer 49

An encapsulated yeast and an obligate aerobe that can live in both plants and animals. Infection with this organism is termed cryptococcosis.

Question 50

What can cryptococcus infection in immunocompromised cause?

Answer 50

Fungal meningitis and encephalitis can occur A key group of patients are HIV +ve