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Episode 45: Neurology Clerkship Shelf Review Part 2

CSF findings of meningitis

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HSV meningitis or HSV encephalitis
- CSF findings?
  - Elevated WBCs (lymphocytic predominance)
  - Lots of RBCs (but < 1000)
    - Note: If 4000-5000 RBCs → think SAH instead
  - Elevated protein
  - Normal glucose
- Location? Temporal lobe
- Dx? HSV PCR of CSF
- Tx? IV acyclovir
Young adult patient + fever + headache + neurologic deficits + no nuchal rigidity→ brain abscess
Headache + high fever + sudden-onset nuchal rigidity + → bacterial meningitis
- CSF findings?
  - Elevated WBCs (neutrophilic predominance)
    - Note: in contrast, Tb meningitis is the only bacterial meningitis with lymphocytic pleocytosis
  - HIGH protein
  - LOW glucose
#1 cause bacterial meningitis in children through middle-aged adults? Strep pneumo
- Tx for bacterial meningitis? Ceftriaxone + vancomycin + steroids
#1 cause bacterial meningitis in neonates? Group B Strep (Strep agalactiae)
- Tx for neonatal meningitis? Cefotaxime + vancomycin + ampicillin
  - Cefotaxime covers GBS
  - Vancomycin covers Staph aureus & resistant Strep pneumo
  - Ampicillin covers Listeria
Special bacterial cause of meningitis seen in neonates & elderly only? Listeria monocytogenes
- Tx? Add ampicillin to standard bacterial meningitis tx
What pathogen causes bacterial meningitis in young adult sxs of skin petechiae? Neisseria meningitidis
- Tx? Ceftriaxone
- PPX for close contacts? Rifampin, ciprofloxacin, or ceftriaxone (“RCC”)
- Prevention? Neisseria meningitidis vaccine
Pt with Neisseria meningitidis meningitis becomes profoundly hypotensive + hypoglycemic + hyperkalemic + bleeding from mucosal sites. Dx? → Waterhouse-Friedrichson syndrome
- Pathophys? adrenal hemorrhage → primary adrenal insufficiency
  - Cortisol production impaired → hypoglycemia & hypotension
  - Aldosterone production impaired → hyperkalemia & non-AG metabolic acidosis (can’t excrete H+)
  - Type 4 RTA
Populations at risk for Neisseria meningitis?
- Asplenic patients (e.g. sickle cell disease)
- Terminal complement deficiency or eculizumab use (tx for paroxysmal noctural hematuria)
  - Terminal complement = C5-C9
  - Eculizumab = C5 inhibitor