Week 3 - C - CNS infections (meningitis and encephalitis)

Question 1

Is grey or white matter in the inside or outside in the brain and spinal cord?

Answer 1

Brain Grey matter outside White matter inside Spinal cord Grey matter inside White matter outside

Question 2

Pyogenic means involving or relating to the production of pus Is pyogenic meningitis bacterial or viral?

Answer 2

Pyogenic meningitis is also known as bacterial meningitis

Question 3

What are the leptomeninges? Pyogenic meningitis shows a thick layer of suppurative exudate covers the leptomeninges over the surface of the brain. What cells are found in the subarachnoid space in pyogenic meningitis?

Answer 3

The leptomininges are the arachnoid and pia mater collectively Neutrophils are found in the subarachnoid space

Question 4

What is an acute infection of the brain parenchyma known as?

Answer 4

This is acute encephalitis

Question 5

What are the three main bacterial causes of community acquired meningitis?

Answer 5

Pneumococcus (streptococcal pneumonia) Meningococcus (Neisseria meningitidis) Haemophilus influenza type b

Question 6

What is given as the immediate treatment of bacterial meningitis?

Answer 6

Give IV ceftriaxone and IV dexamthasone

Question 7

Once the cause of bacterial meningitis is confirmed, ie streptococcal pneumonia (pneumococcal), neissiria meningitidis (meningococcal) or haemophilus influenza, what happenes with the cntinuation of dexamthesone?

Answer 7

Dexamthasone is only continued if the bacterial cause is found to be streptococcal pneumonia

Question 8

In what cases is listeria monocyogenase cover required? What are the antibitoics given for this?

Answer 8

If patient is over 60, meningitis off the new born, or immunocompromised (includes alcohol dependency and diabetes)

Give IV ampicillin or IV amoxicillin

Question 9

If patient is beta lactam/penicillan resistant, what is given instead of ceftriaxone in bacterial community aqcquired meningitis? what is given instead of amox/ampicillin to cover the listeria monocytogenase?

Answer 9

Chloramphenicol is given instead of ceftriaxone

Co-trimaxazole is given instead of amp/amoxicillin

Treatment would be chloramphenicol + co-trimoxazole if someone was pen allergic (or beta lactam resistant)

Question 10

What is given for pneumococcal meningitis? What is given for meningococcal and Hinfluena type B? What is given if the patient is above 60, or immunocompressed, or newborn and why? What is given if pen allrgic?

Answer 10

Pneumococcal meningitis - IV ceftriaxone and IV dexamethasone

Meningococcal and HiB - IV ceftriaxone - stop the dexamethasone

Above, 60, newborn, immunocompromised - Listeria cover, give ampicillin or amoxicillin (IV)

Give chlorampehnicol instead of ceftriaxone and co-trimaxoaole instead of amox/ampicilkin if pen allergy

Question 11

What is the most common cause of viral meningitis? How is it diagnosed?

Answer 11

Entoviruses most commonly Echo virus Diagnosed by throat swab, stool culture and CSF PCR

Question 12

Once it is confirmed that the meningitis was caused by a virus, what is carried out?

Answer 12

Once it is confirmed, stop the IV ceftriaxone and dexamethasone - treatment from here is sually supportive and self limiting

Question 13

Viral meningitis commonly occurs in late autumn/winter, what is generally the treatment?

Answer 13

Generally the treatment is self limiting

Question 14

If the viral cause of the viral meningitis is HSV or VZV, what treatment is started?

Answer 14

Start on IV acyclovir (Initial early management and treatment for viral meningitis is same as for community acquired bacterial meningitis.) Stop antibacterials, antivirals and steroid treatment if enteroviral or mumps meningitis is diagnosed and manage symptomatically. Continuation of antivirals for HSV/VZV should be discussed with ID.

Question 15

What is encaphilitis? What are the clincial feature of encephalitis?

Answer 15

Encephalitis is infection of the brain parenchyma Clinical features include an insidious onset of stupor and confusion, fever and difficulty speaking

Question 16

What investigations should be carried out when suspecting encephalitis?

Answer 16

CT then LP (Lumbar puncture), EEG and MRI

Question 17

In encephalitis, if there is a delay in diagnosis, what is the treatment that is given if it suspected? What is the most common cause of encephalitis?

Answer 17

Start patient on IV acicylovir Most common cause is herpes simplex virus

Question 18

What are the symptoms of meningitis?

Answer 18

Stiff neck Photophobia Seizures High temperature Drowsiness Vomiting Petechial rash that does not blanch

Question 19

What are the bulging soft spots in the babies head in mengitis?

Answer 19

These are bulging fontanelles, soft spots before they close - they should all be closed by the 2year mark

Question 20

What is the main fungis to cause meningitis? What type of patients is it seen in?

Answer 20

Although anyone can get fungal meningitis, people with weakened immune systems, like those with HIV infection or cancer, are at higher risk. The most common cause of fungal meningitis for people with weakened immune systems is Cryptococcus Cryptococcus neoformans Seen in patients wth HIV

Question 21

What is the viral infection usually seen in children that appears in people with a weakened immune system? Cryptoccal meningitis skin lesions can mimic this virus in HIV patients

Answer 21

Molluscum contagiosum

Question 22

How is cryptococcal meningitis diagnosed? It causes a chronic type of meningitis eg with no neck stiffness What is given as treatment of cryptococcal meningitis?

Answer 22

Diagnosed using INdia Ink stain Treatment - oxford clinical handbook pg 411 1st line - amphotericin B + 5-flucytosine Give fluconazole as follow up

Question 23

What are the three common cause of bacterial meningitis in the neonate? What is the most common cause of bacterial meningitis in children?

Answer 23

Neonates - Listeria (monocytogenase), Group B streptococci, E.coli Children - H.Infleunza B

Question 24

Vaccines are causing the prevalence of Hinfluenza bacterial meningitis to decrease When are the vaccinations given?

Answer 24

8 weeks, 12 weeks, 16 weeks, one year

Question 25

What is the most common cause of meinigitis in patients aged 10-21?

Answer 25

Neisseria meningitidis - causes meningococcal meningitis

Question 26

What are the two most common cause of bacterial meningitis in patients over 21? What is the most common causes in over 65s?

Answer 26

Streptococcus pneumonia is most common closely followed by Neisseria meningitidis in over 21s Streptococcus pneumonia is most common closely followed by Liseria monocytogenase in over 65s

Question 27

Caues of meningitis Neonates? Children? 10-21years? Over 21? Over 65?

Answer 27

Neonates - Listeria monocytogenase, Group B strep, E.coli Children - H.influenza 10-21 - Neisseria menignitidis Over 21 - Strep pneumonia > Neisseria meningitis Over 65 - Strep pneumonia > Listeria monocytogenase

Question 28

What bacteria is common in the immunocmpromised state? Name another bacteria common here?

Answer 28

Listeria monocytogenase Strep pneumonia and Neisseria meningitidis are both more common here also

Question 29

If there is a cribifrom plate of ethmoid bone fracture, which bacteria is likely to be the cause of meningitis?

Answer 29

Streptococcus pneumonia

Question 30

What is the treatment of streptococcus pneumonia?

Answer 30

IV ceftriaxone and IV dexamethasone Give IV amp/amoxicillin if neonate, immunocompromised or elderly - this will cover against listeria -

Question 31

Overall across all age groups, what is the main cause of meningitis?

Answer 31

Streptoccous pneumoniae

Question 32

What are the two cranial nerves that are at risk of damage to due to the meninges exudate in meningitis?

Answer 32

This would be CN III and CN VI

Question 33

What percentage of patients with meningitis who survive an initial diagnosis of meningitis and septicaemia will live with life-altering after-effects? These can be as disabling as limb loss, deafness, blindness, cerebral palsy, quadriplegia and severe mental impairment.

Answer 33

25% of patients

Question 34

Which type of bacteria causes meningococcal meningitis? And how is it thought that it gains access to the meninges?

Answer 34

Neisseria meningitis - gram negative bacteria Thought to gain access through the bloodstream

Question 35

Where is neisseria (the meningococcal bacteria) thought to clonise?

Answer 35

Thought to colonise the nasopharynx in humans

Question 36

N. meningitidis causes meningococcal meningitis.  Found in the throats of healthy carriers. What other is found in the normal throat flora? Can cause epiglottitis

Answer 36

This is H.influenza type B - treat with ceftriaxone

Question 37

What type of bacteria is listeria monocytogenase? What is it treated with?

Answer 37

This is a gram positive bacilli Treat with IV ampicllin/amoxicillin

Question 38

Tuberculosis meningitis typically occurs in the elderly if reactivated due to age and ill health What is the treatment? What is usually seen on CXR?

Answer 38

RIPE Rifampicin Isoniazid Pyrazinamide Ethambutol Usually see gramulatous lesions on CXR upper lobe

Question 39

In patients with suspected meningitis, what initial tests are ordered? this is in a patient where meningococcal meningitis is not suspected

Answer 39

Blood cultures, LFTs and clottin screen, and glucose Throat swab and a bacterial culture Lumbar puncture to analyse the CSF

Question 40

In patients with suspected meningitis, what initial tests are ordered? This is in a patient with suspected meningococcal meningitis WHat features would cause you not to order a lumbar puncture in this patient?

Answer 40

Blood cultures, LFTs, clotting screen, glucose Bacterial throat swab culture Lumbar puncture unless any of the following features - Anticoagulant therapy/known thrombocytopenia Respiratory or cardiac compromise Signs of severe or rapidly evolving rash GCS less than or equal to 12, Focal neurological signs Papilloedema , infection at site of LP Continous or uncontrollable seizures

Question 41

What are the 8 features that indicate against carrying out a lumbar puncture?

Answer 41

Severe or signs of evovling rash Anticoagulant therapy/known thrombocytopenia GCS less than or equal to 12 Infection at site of LP Respiratory or cardiac compromise Focal neurological signs Papilloedma Continous or uncontrollable seizures

Question 42

Which of the 8 features should neuroimaging be performed before deciding whether to carry out a lumbar puncutre in suspected meningococcal meningintis?

Answer 42

Focal neurologicial signs Papilloedema - both of these suggest raised ICP Controlled or uncontrollable seizures GCS less than or equal to 12 Immunocompromised state

Question 43

What are the three features of the glasgow coma score and what is the maximum score?

Answer 43

Eye opening response Best verbal response Best motor response

Question 44

How many points in the glasgow coma scale are offered for each of the three sections? What GCS indicates not to carry out a lumbar puncture?

Answer 44

Eye opening response - 4 points Best verbal response - 5 points Best motor response - 6 points GSC score less than or equal to 12

Question 45

What is given to a patient with suspected meningitis with no penicillin or cephalsporin allergy? What is given if they do have these allergies?

What is added if the patient is over 60?

Answer 45

Suspected meningitis no allergies - IV ceftriaxone (or cefotaxime) + IV dexamethasone

Suspected meningitis with allergies - IV chloramphenicol + IV dexamthasone

• Patient over 60 no allergies - add IV amoxicillin or IV ampicllin
• Patient over 60 with allergies - add IV co-trimaxozole (trimethorpim + sulfamethoxazole)

Question 46

If a penicllin/cephalosporin resistant pneumococci is possible, what is given? What is the only bacteria where dexamthasone is continued?

Answer 46

Give IV ceftriaxone + Vancomycin + dexamthasone Only continue dexamethasone if pneumococcal (streptococcus pneumoniae)

Question 47

What are the three main clinical signs of bacterial meningitis? What are the other symptoms of bacterial meningitis?

Answer 47

Stiff neck Altered level of consciousness Fever Symptoms = headache, vomiting, photphobia

Question 48

When considering a lumbar puncture, should antibiotics be given before or after?

Answer 48

Give antibitocs before lumba puncuture

Question 49

What is Neisseria meningitis on gram stain? What is streptococcus pneumoniae on gram stain? What is Hingluenza on gram stain? What is E.coli on gram stain? What is listeria monocytogenase on gram stain?

Answer 49

Neisseria meningitis - gram negative cocci (pink) (diplococci) Strep pneumoniae - Gram positive cocci Hinfluenza - gram negative bacilli Ecoli - gram negatve bacilli (coliform) Listeria monocytogenase - gram positive bacilli

Question 50

* Gram negative bacilli, what is this? * Gram negative bacilli (coliform), what is this? * Gram positive cocci, what is this? * Gram positive bacilli? * Gram negative cocci? (diplococci to be exact)

Answer 50

* Gram negative bacilli - haemophilus influenza * Gram negative bacilli (coliform) - E.coli * Gram positive cocci - streptococcus pneumoniae (pneumococcal) * Gram positive bacilli - listeria monocytogenase * Gram negative cocci (diplococci) - Niesseria meningitis

Question 51

What are the normal CSF values for the White cell count, red cell count, protein content and glucose?

Answer 51

White cell count - <5/mm3 Red cell count - 0-5mm 3 Protein in CSF -150-450mg/L Glucose - 60-70% of blood glucose concentration (2.3-4.5mmol/l)

Question 52

In bacterial meningitis, state what the typical CSF findings usually are: Polymorphs (neurtofils) or lymphocytes on gram stain? Gram stain for bacteria? Protein in CSF? Glucose? What are the findings in viral?

Answer 52

Bacteria - There will be predominantly polymorphs in the gram stain Gram stain will be positive for bacteria Protein content of the gram stain will prove to be high Glucose should be less than 70% of blood glucose Viral Lymphocytes mainly on gram stain with negative bacteria on stain, normal or slightly high protein with a normal glucose

Question 53

Describe the CSF findings of bacterial meningitis vs viral?

Answer 53

Bacterial - predominantly polymporphs (10 1 - 10 4 ), gram stain for bacteria positive, high protein on stain, glucose less than 70% blood Viral - predominantly lymphocytes (10 1 - 10 3 ), gram stain negative for bacreria, normal or slightly raised protein, usually normal glucose

Question 54

Is the appearance of the CSF clear or cloudy in bacterial or viral meningitis?

Answer 54

The CSF is cloudy in bacterial The CSF is clear in viral

Question 55

What is the term used to mean non-pyogenic bacterial meningitis ? What are usually the findings on CSF?

Answer 55

This is aseptic meningitis It usually has a minimally elevated protein, normal glucose and a low white cell count

Question 56

So when a patient arrives to hospital with suspected meningitis, what are the initial tests and procedures carried out?

Answer 56

Take blood for culture and coagulation screen Give empirical antibitoics (usually IV ceftriaxone and dexamethasone) Take a throat swab Lumbar puncture for CSF unless patient has prevously mentioned things (CT scan may be needed before LP)

Question 57

Which patients should undergo a CT scan prior to a lumbar puncutre?

Answer 57

Immunocomprmised patient History oF CNS disease New onset seizure Papilloedema Abnormal level of consciousness - GCS less than 12 focal neurological signs present or past

Question 58

All adult patients with suspected meningitis except when a clear contraindication exists or of there is a confident clinical diagnosis of meningococcal infection with a typical meningococcal rash or given an early lumbar puncutre What should be given before the lumbar puncutre? What level is the lumbar puncture carried out?

Answer 58

Give antibiotics before Lumbar puncutre carried out at L3/4 spinal level

Question 59

Susepcted meningitis No raised ICP, no signs of shock, no repsiratory failure, no signs of rash What do you do? Suspected meningitis Raised ICP What do you do?

Answer 59

Lumbar puncture and give IV antibitocs + dexamethasone Carry out a CT scan of head before lumbar puncture but give IV antibiotics + dexamethasone

Question 60

Prevention of secondary cases of meningitis include - Telephone reporting to Public Health or Health Protection all clinically suspected cases as soon as possible after admission will ensure that appropriate measures to minimise the chance of secondary cases are put in place What is usually given as the prophylactic treatment? (above and below 12 years of age)

Answer 60

In the UK, ciprofloxacin is the recommended chemoprophylaxis of choice and rifampicin is a suitable alternative (Ceftriaxone can be given but must be given by injection