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Meningitis and Encephalitis

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Acute Neuro Care

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Abstract

A 26-year-old male presented to the emergency department (ED) with a history of headache and fever since the past 1 day, and altered sensorium for the past 6 h. His past medical history revealed a history of sinusitis. On physical examination, the patient was confused, with a stiff neck, but no focal neurological deficits. His vitals revealed a heart rate of 102 beats/min, blood pressure 106/64 mmHg, respiratory rate 26/min, SpO2 99%, and temperature 38.8 °C. On arrival in the ED, the patient was resuscitated with iv fluids, antipyretics were administered for temperature control, and blood samples were sent for routine laboratory investigations, along with blood cultures. A shot of dexamethasone 10 mg iv was administered, and parenteral antibiotics—Inj Ceftriaxone 2 g iv and Inj Vancomycin 1 g iv were begun prophylactically. The patient was shifted to the ICU for close neuromonitoring. A diagnostic lumbar puncture was performed, which revealed a cell count of 5600 cells/cu mm with 98% neutrophils, glucose 20 mg/dL, and proteins 1244. The gram’s stain showed gram positive cocci, and the CSF PCR revealed Streptococcus pneumoniae. Ceftriaxone 2 g iv BD/Vancomycin 1 g iv BD were continued, along with dexamethasone 10 mg iv QID. The patient improved neurologically over the next 2 days, and was shifted to the ward. The CSF culture & sensitivity also revealed Streptococcus pneumoniae, which was sensitive to both ceftriaxone and vancomycin. Steroids were administered for 3 days and then stopped. Antibiotics were continued for 14 days, and the patient was discharged with no residual deficits.

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Author information

Authors and Affiliations

  1. Medanta-the Medicity, Gurugram, India

    Vasudha Singhal

  2. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

    Prasanna Udupi Bidkar

Authors
  1. Vasudha Singhal
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  2. Prasanna Udupi Bidkar
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Editor information

Editors and Affiliations

  1. Division of Neuroanaesthesiology, Department of Anaesthesiology and critical care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

    Prasanna Udupi Bidkar

  2. Senior consultant and Head, Neuroanaesthesiology & Neurocritical care, MGM Healthcare Pvt Ltd, Chennai, Tamil Nadu, India

    Ponniah Vanamoorthy

Multiple Choice Questions (MCQs)

Multiple Choice Questions (MCQs)

  1. 1.

    Which of the following is the least common identifiable cause of bacterial meningitis in neonates?

    1. (a)

      Streptococcus agalactiae

    2. (b)

      E.Coli

    3. (c)

      Listeria monocytogenes

    4. (d)

      Pseudomonas aeruginosa

  2. 2.

    What is the recommended prophylactic antibiotic regime for an 84-year-old immunocompromised adult presenting with fever and altered sensorium?

    1. (a)

      Ceftriaxone only

    2. (b)

      Ceftriaxone/Vancomycin

    3. (c)

      Ceftriaxone/Vancomycin/Ampicillin

    4. (d)

      Vancomycin only

  3. 3.

    A patient with suspected bacterial meningitis is shifted to the ICU after receiving a 3-day course of antibiotics elsewhere. Which of the following statements about the administration of steroids is true?

    1. (a)

      Administer dexamethasone 10 mg IV irrespective of the antibiotic status

    2. (b)

      Administer dexamethasone if the patient shows focal neurological deficits

    3. (c)

      Do not administer dexamethasone if the patient has already received antibiotics

    4. (d)

      Administer dexamethasone if the patient is elderly and immunocompromised

  4. 4.

    Which of the following CSF findings distinguishes tubercular meningitis from bacterial meningitis?

    1. (a)

      Low glucose

    2. (b)

      High proteins

    3. (c)

      Lymphocytic pleocytosis

    4. (d)

      High cell count

  1. 5.

    Which of the following CSF parameters may be diagnostic in nosocomial meningitis after a recent neurosurgery?

    1. (a)

      Raised lactates

    2. (b)

      High proteins

    3. (c)

      Elevated cells

    4. (d)

      Neutrophilic dominance

  2. 6.

    A 45-year-old female presented to the ED with seizures and altered sensorium. Based on clinical suspicion, she was started on Inj Ceftriaxone 2 g IV BD and Inj Acyclovir 750 mg TDS, and a diagnostic LP was performed. Which of these parameters need daily monitoring?

    1. (a)

      Liver function tests

    2. (b)

      Renal function tests

    3. (c)

      Platelet count

    4. (d)

      Coagulation profile

  3. 7.

    In which of the following case scenarios, a brain CT scan is not indicated prior to performing a diagnostic LP?

    1. (a)

      GCS 12

    2. (b)

      Age 50 years

    3. (c)

      Seizure at presentation

    4. (d)

      History of prior stroke

  1. 8.

    A patient presenting with seizures and altered sensorium was begun on Inj Acyclovir based on clinical suspicion of viral encephalitis. A diagnostic LP was performed, and the CSF PCR revealed enterovirus. What is the most appropriate line of management?

    1. (a)

      Continue Acyclovir for 7 days

    2. (b)

      Stop acyclovir and continue supportive therapy

    3. (c)

      Administer acyclovir and dexamethasone till the patient improves clinically

    4. (d)

      Continue acyclovir for at least 14–21 days

  1. 9.

    Which of the following regions of the brain may be most affected in HSV encephalitis as seen on an MRI?

    1. (a)

      Temporal and orbitofrontal lobes

    2. (b)

      Basal ganglia

    3. (c)

      Limbic system

    4. (d)

      Thalamus

  1. 10.

    What is the antifungal agent of choice in cryptococcal meningitis?

    1. (a)

      Echinocandins

    2. (b)

      Voriconazole

    3. (c)

      Liposomal amphotericin B

    4. (d)

      Flucytosine

Answers: 1. (d), 2. (c), 3. (c), 4. (c), 5. (a), 6. (b), 7. (b), 8. (b), 9. (a), 10. (c).

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Singhal, V., Bidkar, P.U. (2020). Meningitis and Encephalitis. In: Bidkar, P., Vanamoorthy, P. (eds) Acute Neuro Care. Springer, Singapore. https://doi.org/10.1007/978-981-15-4071-4_15

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  • DOI: https://doi.org/10.1007/978-981-15-4071-4_15

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  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-15-4070-7

  • Online ISBN: 978-981-15-4071-4

  • eBook Packages: MedicineMedicine (R0)

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