Neurology for AMC MCQ

A 19 year old university student is brought in with a 12-hour history of severe headache, fever, neck stiffness and photophobia. She is now drowsy and has a spreading non-blanching purpuric rash over her legs. Her blood pressure is 92/54 mmHg and her pulse is 124. A junior doctor wants to arrange a lumbar puncture before starting treatment. What is the most likely diagnosis?

1. Encephalitis Fever with strange behaviour, confusion, fits, or weakness on one side. This points to the brain itself as well as its lining. That does not match the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
2. Meningitis correct Correct. Fever, headache, a stiff neck, pain from light and a spotty rash that does not fade all point to meningococcal meningitis with infection in the blood.
3. Brain abscess Fever with weakness on one side and a lump seen on a brain scan. It does not fit the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
4. Viral meningitis A milder illness that looks like meningitis, with a certain type of white cell in the spinal fluid and a patient who still looks well. Here, the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure points elsewhere.
5. Sepsis A body-wide infection from another source, which can happen alongside meningitis or look like it. But the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure does not point to it.

The point: Bacterial meningitis is an infection of the tissue around the brain and spinal cord. It is a medical emergency that doctors must report. It causes fever, headache, a stiff neck, and pain from bright light (photophobia). The meningococcus germ can also cause a spotty rash that does not fade when you press on it (a non-blanching rash). Do not wait for test results. Give the antibiotic ceftriaxone into a vein right away. If the patient is still with a community doctor before reaching hospital, add the antibiotic benzylpenicillin too. Give a steroid called dexamethasone with the first antibiotic dose, or just before it. This lowers the chance of lasting nerve damage, especially with the pneumococcus germ. In older people, pregnant women, or people with a weak immune system, add benzylpenicillin. This covers a germ called Listeria. A lumbar puncture (a needle test that takes fluid from around the spine) proves the diagnosis. But if there are signs of high pressure inside the skull, weakness on one side, fits, or a lower level of alertness, do a CT scan of the head first. Never delay the antibiotics for the scan. Tell the public health team about the case. Give people who live with or are close to the patient a short course of antibiotics, such as ciprofloxacin, to protect them. Other illnesses that can look similar are viral meningitis, an infection of the brain itself (encephalitis), and bleeding around the brain (subarachnoid haemorrhage).

Source: Therapeutic Guidelines (Australia) — Antibiotic: acute bacterial meningitis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 19 year old university student is brought in with a 12-hour history of severe headache, fever, neck stiffness and photophobia. She is now drowsy and has a spreading non-blanching purpuric rash over her legs. Her blood pressure is 92/54 mmHg and her pulse is 124. A junior doctor wants to arrange a lumbar puncture before starting treatment. What is the most appropriate initial investigation?

1. Blood cultures and meningococcal PCR A blood sample taken before or alongside the antibiotics, to find the germ. That does not match the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
2. Blood glucose paired with cerebrospinal fluid glucose A low sugar level in the spinal fluid compared to the blood points to a bacterial cause. It does not fit the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
3. Lumbar puncture Proves the diagnosis and finds the germ, unless the pressure in the brain is too high for it to be safe. Here, the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure points elsewhere.
4. Notification to the public health unit Meningococcal disease must be reported, and this starts the search for other people who were close to the patient. But the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure does not point to it.
5. Immediate empirical antibiotics before investigations correct Correct. Antibiotics must not wait for a spinal fluid test. With shock and suspected meningococcal disease, any delay can cost her life.

The point: Bacterial meningitis is an infection of the tissue around the brain and spinal cord. It is a medical emergency that doctors must report. It causes fever, headache, a stiff neck, and pain from bright light (photophobia). The meningococcus germ can also cause a spotty rash that does not fade when you press on it (a non-blanching rash). Do not wait for test results. Give the antibiotic ceftriaxone into a vein right away. If the patient is still with a community doctor before reaching hospital, add the antibiotic benzylpenicillin too. Give a steroid called dexamethasone with the first antibiotic dose, or just before it. This lowers the chance of lasting nerve damage, especially with the pneumococcus germ. In older people, pregnant women, or people with a weak immune system, add benzylpenicillin. This covers a germ called Listeria. A lumbar puncture (a needle test that takes fluid from around the spine) proves the diagnosis. But if there are signs of high pressure inside the skull, weakness on one side, fits, or a lower level of alertness, do a CT scan of the head first. Never delay the antibiotics for the scan. Tell the public health team about the case. Give people who live with or are close to the patient a short course of antibiotics, such as ciprofloxacin, to protect them. Other illnesses that can look similar are viral meningitis, an infection of the brain itself (encephalitis), and bleeding around the brain (subarachnoid haemorrhage).

Source: Therapeutic Guidelines (Australia) — Antibiotic: acute bacterial meningitis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 19 year old university student is brought in with a 12-hour history of severe headache, fever, neck stiffness and photophobia. She is now drowsy and has a spreading non-blanching purpuric rash over her legs. Her blood pressure is 92/54 mmHg and her pulse is 124. A junior doctor wants to arrange a lumbar puncture before starting treatment. What is the most appropriate next step in management?

1. Add benzylpenicillin in the community before transfer Giving penicillin before the patient reaches hospital, for suspected meningococcal disease, saves lives. That does not match the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
2. Intensive care for a reduced conscious level or shock A higher level of care for the patient who is getting worse or going into shock. Here, the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure points elsewhere.
3. Add Listeria cover in the elderly, pregnant or immunocompromised Benzylpenicillin is added to cover the Listeria germ in these groups. But the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure does not point to it.
4. Clearance antibiotics for close contacts Ciprofloxacin or rifampicin for the household and close contacts of a person with meningococcal disease. It does not fit the combination of fever, a stiff neck and a spotty rash that does not fade, together with low blood pressure.
5. Intravenous ceftriaxone immediately correct Correct. The first antibiotic for bacterial meningitis, given at once rather than after the scan or the spinal fluid test.

The point: Bacterial meningitis is an infection of the tissue around the brain and spinal cord. It is a medical emergency that doctors must report. It causes fever, headache, a stiff neck, and pain from bright light (photophobia). The meningococcus germ can also cause a spotty rash that does not fade when you press on it (a non-blanching rash). Do not wait for test results. Give the antibiotic ceftriaxone into a vein right away. If the patient is still with a community doctor before reaching hospital, add the antibiotic benzylpenicillin too. Give a steroid called dexamethasone with the first antibiotic dose, or just before it. This lowers the chance of lasting nerve damage, especially with the pneumococcus germ. In older people, pregnant women, or people with a weak immune system, add benzylpenicillin. This covers a germ called Listeria. A lumbar puncture (a needle test that takes fluid from around the spine) proves the diagnosis. But if there are signs of high pressure inside the skull, weakness on one side, fits, or a lower level of alertness, do a CT scan of the head first. Never delay the antibiotics for the scan. Tell the public health team about the case. Give people who live with or are close to the patient a short course of antibiotics, such as ciprofloxacin, to protect them. Other illnesses that can look similar are viral meningitis, an infection of the brain itself (encephalitis), and bleeding around the brain (subarachnoid haemorrhage).

Source: Therapeutic Guidelines (Australia) — Antibiotic: acute bacterial meningitis Therapeutic Guidelines (Australia) · tier 3, national formulary