CNS Syndromes
  • Meningitis:
    • Pearls
      • In a prospective nationwide cohort of 696 adults with culture-proven acute bacterial meningitis, the classic triad of fever, neck stiffness, and altered mental status was present in only 44% of episodes; however, 95% of episodes were characterised by at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status (as defined by a score below 14 on the Glasgow Coma Scale).Lancet 2012  NEJM 2006
      • Absence of neck stiffness, Kernig’s sign, and Brudzinski’s sign cannot rule out the diagnosis of community-acquired bacterial meningitisLancet 2012
      • Ear, sinus, or lung infections precede pneumococcal meningitis in 40% of patients 
      • DDx: Lancet 2012
        • viral meningitis (enteroviruses, HSV type 2, or mumps virus) 
        • fungal meningitis, 
        • tuberculous meningitis, 
        • drug-induced meningitis, 
        • carcinomatous or lymphomatous meningitis, 
        • meningitis associated with inflammatory diseases (eg, systemic lupus erythematosus, sarcoidosis, Behçet’s disease, or Sjögren’s syndrome), 
        • cerebral abscess, and 
        • subarachnoid haemorrhage (when the body temperature is normal or only moderately raised and the onset of headache is acute) 
      • CT before LP Indications Lancet 2012
        • New-onset seizures, 
        • an immunocompromised state patients with HIV/AIDS, those receiving immunosuppressive therapy, or those who have undergone transplantation), 
        • history of a CNS lesion (mass lesion, stroke, or focal infection), 
        • signs that suggest spaceoccupying lesions (papilloedema, focal neurological deficits, or evolving signs of brain tissue shift), or 
        • moderate-to-severe impairment of consciousness 
        • When none of these risk factors is present in adults, brain imaging before the lumbar puncture is not needed. 
        • Unanswered question: 
          • CT before LP caused SUBSTANTIAL delay in timing of antibiotic administration i.e unto 6 hrs in one study. If with modern days CT, where it takes 5=10 min, can CT be done before antibiotics  administration if CT and LP be done in 30 min, and abx administered soon after LP in 30 min. 
          • Do we wait for the lab (Platelets, PT/INR) to come back before LP
        • A normal CT scan on admission does not exclude the possibility that the patient will develop brain herniation during the meningitis episode.  
        • Other CI of LP
          • coagulation disorders such as disseminated intravascular coagulation, 
          • use of anticoagulant drugs, or 
          • significant thrombocytopenia in patients receiving chemotherapy or 
          • those with hematological diseases. 
          • If a patient presents with septic shock or respiratory failure, the lumbar puncture should be postponed until the patient has been stabilised. 
Original Research

  • Encephalitis 
    • AMS > 24 hr duration
    • C/F: AMS (Mild confusion to coma), Seizure, Hallucinations, Ataxia, Cranial Neuropathies, Focal Neurological manifestation
    • WNV Encephalitis
      • Vector: Culex mosquito (Late Summer, and early fall)
      • C/F: 
        • Asymptomatic (70-80%), 
        • Febrile illness (20%), (headache, body pain, fever, rash, joint pain)
          • Fatigue and weakness can last for weeks and months
        • WNND(West Nile Neuroinvasive disease (<1%)
          • Meningitis
          • Encephalitis
          • Myelitis
            • Focal weakness to flaccid paralysis (similar to Polio virus) to respiratory failure 
          • >60 yrs and patient with co-morbidities are at greater risk 
          • 10% case-fatality-ratio in WNND 
        • Rare Manifestations

      • Dx: 
        • IgM in CSF(present after 9 days of infection to year)
          • False Positive WN IgM: Due to cross reactivity to other flaviviruses i.e Saint Louis Encephalitis, Japanese Encephalitis, Dengue, Yellow fever virus)
        •  No role of Viral PCR due to very brief duration of viremia in WNND.
    • Reference:

ENT Infections: See ENT and Mono Syndrome

Clinical Question

59 yo M comes with 1 day of worsening headache, and worsening mental status. Menigitis is suspected. CT head is normal. LP is done. Below is the findings. What abx should be covered. 

1. Ceftriaxone 2 gm IV BID with Vanc 15-20 mg / kg BID
2. Ceftriaxone 2 gm IV BID with Vanc 25-30 mg / kg loading, and 15-20 mg / Kg BID 
3. 2 + Dexamethasone
4. 3 + Rifampin as Steroids decreases the penetration of Vancomycin. r

4 is the best answer. 
3 is correct as well. 

Clinical Question 
59 yo of W who had recently immigrated from India comes with AMS and is found to have  decreased oxygen saturation. CXR and CT chest shows the following. 

Given AMS, spinal tap is done and following is the finding. 


What is the DDx?


MTB PCR for Rifampin resistance done of bronch sample is positive. 

What treatment should be started? 

Case Based Studies 
62 yo M is seen for 3 months of dizziness that started during a trip to Europe. Also, has associated Headache, and gait instability. Associated symptoms include N and V. Physical Exam: Has tremors on b/l hand examination, that is present at rest but worsens with movement especially towards the target. Vertigo worsens on positional movement, but Epley does not help symptoms. 
PMHs; RA (treated with adalimumab, and infliximab), Pulmonary Sarcoidiosis, A fib (on anti-coat)
For this presentation, 2 months ago, patient was treated with high dose steroids, which initially helped with the symptoms, but symptoms persisted intermittently. MRI and EEG then were normal. 
MRI with contrast and repeat EEG were done. EEG was normal. MRI concerning for lesion in mammilary body consistent with Neurosarcoidosis. Pulse dose steroids were started. Patient improves, only to get worse 1 week later. LP is done,and is diagnostic for cryptococcal meningitis.