Mcqs & case discussion meningitis
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This document discusses meningitis and provides information on various types through multiple questions and case studies. It begins by stating that meningococcal meningitis has a case fatality rate of 80% without treatment, which can be reduced to less than 10% with early diagnosis and treatment. Vaccination is recommended for adolescents. Rifampicin or meningococcal vaccine is used for chemoprophylaxis of close contacts. The case studies provide details on patients presenting with meningitis caused by Neisseria meningitidis, group B streptococcus, and enterovirus.
Mcqs & case discussion meningitis
- 1. MCQs & Case Discussion MENINGITIS - Dr. Ankur Kumar
- 2. 1. True about meningococcal meningitis is: a. Causative agent is a gram –ve diplococci b. Cases are the most important source of infection c. Treatment with penicillin eradicates carrier state d. Vaccine can be given in pregnancy
- 3. • Case Fatality Rate (CFR) of Meningococcal meningitis : 80% • With early diagnosis and treatment, CFR declines to < 10% • Meningococcal disease is endemic in India • Treatment with Penicillin doesn’t eradicate the carrier state in meningococcal meningitis • Isolation of cases is not useful in epidemics of meningococcal meningitis as carriers outnumber case
- 4. 2. The following statements about meningococcal meningitis are true, except: a. The source of infection is mainly clinical cases b. The disease is more common in dry and cold months of the year c. Chemoprophylaxis of close contacts of cases is recommended d. The vaccine is not effective in children below 2 years of age
- 5. • Carriers are more important source of infectionthan casesin: – Meningococcal meningitis – Diphtheria
- 6. 3. Vaccine for meningococcal meningitis should be routinely given to: a. Laboratory workers b. Young adolescents c. 4-8 years old children d. Elderly population
- 7. Meningococcal Vaccine Recommendations: Routinely: – All adolescents 11-12 years age (1st dose at 11-12 years age, followed by Booster dose at 16 years age) • Other groups: – Adolescents 13-18 years – Young people 19-21 years –2 years and above (Splenectomized/Chronic diseases/ Lab workers/Travelers to endemic areas)
- 8. 4. Prophylaxis of meningococcal meningitis is: a. Ciprofloxacin b. Rifampicin c. Penicillin d. Gentamycin
- 9. • Rifampicin 600 mg BD×2days OR Meningococcal vaccine
- 10. Case-1 The patient was a 45-year-old male with a long-standing history of cirrhosis of the liver secondary to alcohol abuse, chronic hepatitis C infection, and diabetes. The patient presented to the emergency department with altered consciousness, confusion, and agitation. A family member noted that the patient had nausea and vomiting prior to arrival. No seizure activity or fevers were noted. On physical examination his vital signs were normal but he was confused and agitated, making a neurologic examination not possible. Chest was clear to auscultation. He was without rashes. He did have abdominal distension with ascites.
- 11. Case-1 Laboratory tests were significant for a peripheral white blood cell (WBC) count of 27,800 cells/μl with 95% neutrophils. The patient was anemic and had a blood glucose level of 483 mg/dl. Because of his high WBC count and altered mental status, a lumbar puncture was performed, which revealed an opaque cerebrospinal fluid (CSF) containing 5,600 red blood cells (RBCs)/μl and 31,400 WBCs/μl with 95% neutrophils and 5% monocytes. The patient’s CSF protein was 1,422 mg/dl and CSF glucose was 124 mg/dl. A Gram stain of the patient’s CSF is shown in Fig. The organism’s susceptibility is shown in Fig. He was begun on vancomycin and ceftriaxone. The patient’s condition deteriorated rapidly, and despite intubation and aggressive cardiac resuscitation, he died of cardiopulmonary arrest in the emergency department. Q. Based on the patient’s history and physical and laboratory findings, what condition did this patient likely have? What would be your differential diagnosis in this case? What did the CSF Gram stain tell you?
- 13. Case-2 • A 3-year-old girl was brought to the emergency room by her parents because of fever and loss of appetite for the past 24 hours and difficulty in arousing her for the past 2 hours. The developmental history had been normal since birth. • She attended a day care center and had a history of several episodes of presumed viral infections similar to those of other children at the center. Her childhood immunizations were current.
- 14. Case-2 • Temperature was 39.5°C, pulse 130/min, and respirations 24/min. Blood pressure was 110/60 mm Hg. • Physical examination showed a well-developed and well- nourished child of normal height and weight who was somnolent. • When her neck was passively flexed, her legs also flexed (positive Brudzinski sign, suggesting irritation of the meninges). • Ophthalmoscopic examination showed no papilledema, indicating that there had been no long-term increase in intracranial pressure. The remainder of her physical examination was normal.
- 15. Case-2 • The opening pressure was 350 mm of cerebrospinal fluid (CSF) (elevated). The fluid was cloudy. Several tubes of CSF were collected for culture, cell counts, and chemistry tests. • One tube was taken immediately to the laboratory for Gram staining. The stain showed many polymorphonuclear (PMN) cells with cell- associated (intracellular) gram-negative diplococcic. • Q- Name the etiological agent. Which antibiotic t/t should be taken?
- 17. • Suggestive of Neisseria meningitidis • t/t Intravenous cefotaxime therapy was started within 35–40 minutes of the patient’s arrival; dexamethasone was also given. The patient was treated with the antibiotic for 14 days and recovered without obvious sequelae. Further neurologic examinations and hearing tests were planned for the future. Rifampin prophylaxis was given to the other children who attended the day care center
- 18. Case-3 The patient was a 3½-week-old male who was born at term by cesarean section. At birth he had a left diaphragmatic hernia that was repaired soon thereafter. He required intubation at that time and continued to require respiratory support. Over a 24-hour period, the infant developed bulging anterior fontanelles, increased respiratory and heart rates, wide fluctuations in blood pressure, and difficulties maintaining adequate tissue perfusion, and his peripheral white blood cell (WBC) count increased from 6,300 to 13,700/μl. The child began to have focal seizures as well.
- 19. Case-3 A cerebrospinal fluid (CSF) examination showed 3,900 WBCs/μl with 92% neutrophils, a glucose level of 2 mg/dl, and a protein level of 350 mg/dl. A Gram stain of the child’s CSF is shown in Fig. The organism isolated from the CSF is shown in Fig. What is your diagnosis for this patient? What organism was most likely causing his infection? What other organism has similar Gram stain and colonial morphology? What simple, rapid test would you use to distinguish these two organisms?
- 20. Colonies on BA Gram Stain Appearance
- 21. • GBS (Gr B streptococcus) • Other- Listeria spp. • Catalase test
- 22. Case-4 • A 10-year-old female presented in August to the emergency department of a North Carolina hospital with a 3-day history of worsening headache and petechial rash. • She began feeling ill approximately 1 week prior to presentation, with increasing fatigue, intermittent chills, and lower back pain. She had 1 day of nausea, vomiting, and diarrhea, along with a yellowish nasal discharge. • Her headache, which began 3 days previously, was exacerbated by light and rapid movement. Over-the- counter medications had no effect on her headache. The patient stated that her “head hurts everywhere” and her neck felt stiff.
- 23. Case-4 • In addition to the headache and general malaise, she had a small pinpoint rash over her legs, trunk, and upper extremities. • The only known sick contacts were two younger cousins with fever and rash. She had a history of a tick bite earlier in the summer. • The patient’s physical exam was within normal limits with the exception of slight pain with neck flexion. She had negative Brudzinski’s and Kernig’s signs. Her laboratory tests, including a complete blood count, sedimentation rate, and urinalysis, were within normal limits.
- 24. Case-4 • Cerebrospinal fl uid (CSF) obtained by lumbar puncture showed <1 red blood cell/μl and 32 white blood cells/μl with 31% neutrophils, 36% lymphocytes, and 33% monocytes. CSF protein and glucose were both normal at 43 mg/dl and 54 mg/dl, respectively. • CSF Gram stain showed no neutrophils and no organisms. Bacterial cultures of blood and CSF were obtained, and a viral PCR was ordered on the CSF. While remaining laboratory results were pending, the patient was started on ceftriaxone and doxycycline. However, once the PCR test was reported as positive, all antibiotics were discontinued and the patient was discharged home. 1. Did this patient have meningitis? Explain your answer.
- 25. • Case of Viral meningitis • Enteroviruses include the coxsackieviruses (A and B), echoviruses, polioviruses, and the numbered enteroviruses (e.g., enterovirus 71). Recently, parechoviruses (formerly echoviruses 22 and 23) have been shown to be genetically distinct from the enteroviruses. Although parechoviruses are also associated with meningitis, it is important to note that most enteroviral PCR tests will not detect the parechoviruses. • Enteroviruses belong to the family Picornaviridae, along with rhinovirus and hepatitis A virus. The primary mode of enteroviral transmission is the fecal-oral route, but it can also spread via the respiratory route and by fomites. • Approximately 85% of viral meningitis cases in the United States are due to enteroviruses, although very few enteroviral infections result in meningitis. • In fact, most enteroviral infections are subclinical to mild. Similar to other childhood exanthems, enteroviral infections in children may present with only fever and rash, as was presumably the case for this patient’s cousins. Enteroviral infections typically peak in the spring to fall months in temperate regions.
- 26. Q -5 7. Can this organism causes meningitis? If yes, in which age group?
- 27. Answers 1. a 2. a 3. b 4. b
- 31. THANK YOU