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You are working on 4th of July (god bless America) comes in with fever, AMS, hand tremors and flaccidity in legs with areflexia. What is the most likely diagnosis?
West Nile Virus encephalitis.
Arbovirus that spreads in summer by mosquitoes Culex.
Symptoms--> encephalitis and invades anterior horn cells.
Diagnosis--> IgM in CSF. MRI not helpful.
Treatment--> supportive
50, F, AIDS, not compliant with meds. Comes for seizure, right weakness, AMS. MRI brain showed three ring enhancing lesions. Brain biopsy done showed Bradyzoites. What is the diagnosis?
Toxoplasmosis (T. Gondii)
RF--> Immunosuppression (CD4 <100)
Diagnosis is clinical and biopsy is typically not done so DDX is CNS lymphoma, tuberculoma, abscess.
Treatment--> Sulfadiazine+ Pyrimethamine (give folate supplement). Alternative is Clindamycin! TMP SMX is for PPX
Patient with SAH and hydrocephalus gets EVD placed and few days after starts having fevers, CSF shows elevated WBC (neutrophilic), low glucose. Mention three possible organisms that caused this
Pseudomonas
Propionibacterium
S. Epidermidis
S. Aureus
S. PNA is not a common cause for hospital acquired meninigits
Patient with no PMH other than chronic sinusitis comes in with fever, AMS, weakness. MRI showed multiple ring enhancing lesions. What is a diagnosis you should keep in your differential?
Brain abscess.
Organism--> polymicrobial (staph. strept. enterobacter, anaerobes)
Spread--> hematogenous or contiguous (ear, teeth, sinus)
Treatment--> Drainages+ Abx (Vancomycin+ Ceftriaxone+ Metronidazole)
A 60 year old man brought in by his wife for rapidly progressive cognitive decline over 3 months. Also became paranoid, can't do maths anymore, has unsteady gait, ataxia, frequent falls. Wife also mentions that he "jerks" when you surprise him. What is the likely diagnosis?
CJD (prion disease due to protein misfolding leading to more Beta sheet content) (PrPC-->PrPSc)
MRI brain--> cortical ribboning, hockey stick sign, pulvinar sign
Diagnosis is clinical, CSF 14-3-3 is helpful but NOT SPECIFIC. RT QUIC is the way to go
EEG can show periodic sharp waves
No treatment, death is certain
A patient with DM comes in for DKA, destructive facial lesion (affecting nose, sinuses, right eye with proptosis). Eventually develops cavernous sinus thrombosis. What is the diagnosis?
Mucormycosis
Organisms--> mucor, rhizopus, rhizomucor fungus (septated/non-septated hyphae)
RF--> DM, iron chelation, immunosuppression
Symptoms--> facial/respiratory and CNS symptoms
Treatment--> Debridement and Amphotericin B
50, M, AIDS no medication. Comes for AMS, multiple neurologic deficits that developed over 4 months (LUE numbness, RLE weakness, aphasia, visual field deficit). MRI showed multiple coalescent non-enhancing white matter lesions in various locations. (show image here to help). What is the likely diagnosis?
PML (JC virus)
-Happens in late AIDS. Lot of population already have antibodies against JC so serum diagnosis is useless.
Symptoms--> multifocal deficits over months, visual symptoms common due to parieto-occipital involvement
Imaging--> non enhancing coalescing lesions in parieto-occipital
Diagnosis--> Clinical, positive CSF JC PCR, biopsy is gold standard (not needed if suspicion is good)
Treatment--> None :(
60, F, DM comes in for suspected meningitis. We are unsure if it is viral or bacterial yet. ID start her on an empiric regimen. What is does that regimen usually consist of?
Acyclovir (viral coverage HSV)
Vancomycin+ 3rd gen Cephalosporin (for S. PNA, N. Meningitis, H. Flu)
Ceftazidime and Cefepime (Pseudomonas)
If too old or too young or immunocompromised, add Ampicillin for Listeria coverage
In patients with mucormycosis, the cavernous sinus can be affected and have thrombosis in it. What are the structures in that sinus that are affected?
CN 3, 4, 6, V1 and V2
ICA
Sympathetic
25, F, comes in for fever, AMS, seizure. She had been having odd behavior for past week until two days ago when the other symptoms started. CSF looked "reddish" with 2500 RBC (LP done by LP king himself it cannot be a traumatic tap), elevated WBC (lymphocytic), elevated protein, normal glucose. What is the likely diagnosis and treatment of choice?
HSV Encephalitis
Likes to affect temporal and orbitofrontal
Symptoms and CSF as mentioned. MRI brain may show hyperintensity/diffusion restriction/hemorrhage in temporal region. CSF HSV PCR is best to test
Treatment is with Acyclovir 10mg/kg Q8hr minimum 14 days
20, M, comes for right Bell's palsy. He is given steroids and valacyclovir and sent home. Comes back few weeks later with left Bell's. Says he went hiking somewhere in Connecticut recently. Also has headache and arthralgias. What is the cause of his BL Bell's palsy?
Lyme disease (borrelia burgdorferi transmitted by the Ixodes/deer tick in NE USA)
Clinical diagnosis based on H+P, epidemiologic info, CSF/serum showing anti-borrelia). MRI may show leptomeningeal enhancement.
If CNS symptoms--> treat with IV Penicillin or Ceftriaxone 2-4 weeks.
If no CNS/cardiac symptoms--> oral Doxycycline
50, M, AIDS not on medication. Comes in aphasia and right weakness. MRI shows L. periventricular lesion with mild enhancement. CSF showed elevated protein and WBC (lymphocytic), normal glucose. EBV PCR positive in CSF. What is the diagnosis?
CNS lymphoma
Definitive diagnosis--> Biopsy
Treatment--> Steroids (try to biopsy first then steroids)
When TB affects the spine it causes Pott's disease. What part of the spine is most commonly affected?
T- spine
Symptoms--> constitutional, back pain/tenderness, compressive radiculopathy, myelopathy
30, F, multiple sexual partners, developed right weakness and aphasia. Brain MRI showing left infarct. RPR positive and CSF VDRL is positive. What's the diagnosis?
Meningovascular syphilis (spirochette treponema pallidum)
1ry--> painless chancre genital region
2ry--> 2-12 weeks after, constitutional sx, palms and soles rash. Meningitis and CNeuropathis may happen
3ry--> CNS and CV
CNS--> Tabes Dorsalis, meningovascular syphilis, parenchamtous syphilis
Treatment of CNS syphilis--> IV Penicillin
Argyll Robertson pupil
A patient with HSV encephalitis has an EEG done. What is a typical findings in these patients?
PLEDs in temporal regions
30, M, HIV positive not on medication comes in with headache, fever, flu like symptoms and neck stiffness. He is alert and cognition is normal. CSF analysis shows elevated WBC (lymphocytic) and protein, glucose normal. Stain and culture is negative. What is the likely diagnosis?
HIV aseptic meningitis (diagnosis of exclusion)
List three common common cause of bacterial meningitis in neonates (neonate is less than 1 month)?
E. Coli, Listeria, Group B strept.
Which bacteria is notorious for not wanting to show up on CSF gram stain?
Listeria (33%)
S. PNA (90%)
H. Flu (86%)
N. Meningitis (75%)
Gram negative (50%)
A patient from South America comes in for fever, AMS, neck stiffness, BL CN 6 palsies. CSF analysis shows elevated WBC (lymphocytic), elevated protein, low glucose. MRI brain showing leptomeningeal enhancement. What is the most likely diagnosis?
TB Meningitis (Mycobacterium tuberculosis)
Likes to affect the base of the brain--> cranial neuropathies. Can also cause tuberculomas and affect the spine (Pott's disease)
Diagnosis--> Best method is PCR, MRI may show leptomeningeal enhancement in basal area
Treatment--> combination 4 drugs: Isoniazid, Rifampin, Ethambutol, Streptomycin, Pyrazinamide
20, M, goes swimming with his friends in a lake and afterwards starts to become feverish, AMS, weak and comes to the hospital but dies 5 days after admission. What is the likely diagnosis based on the story?
Amebic meningoencephalitis (Naegleria Fowleri, Acanthomoeba)
Acquired by swimming in contaminated lakes/ponds and enter through the cribriform plate.
CSF analysis shows high WBC (neutrophilic), elevated protein, low glucose and high opening pressure. Stain can show Trophozoites
Patient has fevers, neck stiffness, AMS. CSF opening pressure 35, analysis shows elevated WBC (lymphocytic), elevated protein, low glucose. Diagnosis is officially confirmed with India Ink stain. What is the organism?
Cryptococcus Neoformans--> Cryptococcosis (THICC)
RF--> Immunocompromised
MRI--> may show cryptococcomas, hydrocephalus, infarcts
Diagnosis--> Cryptococcus antigen in CSF (fungal culture takes too long)
Treatment--> Amphotericin+ Flucytosine 2-3 weeks then if doing well--> Fluconazole 8- 10 weeks then long term maintenance is Fluconazole
List most common organisms for bacterial meningitis for patients age 1-23 months?
And for 2 years- 50?
Neurosurgical instrumentation?
Trauma?
Immunocompromised?
Up To Date table
A patient comes in from south America (yes he travelled all the way to see you) with well demarcated hypopigmented skin lesions, hair loss, anhidrosis, asymmetric peripheral nerve palsies and his ulnar nerves are thick and palpable at the groove. What is the diagnosis?
Leprosy/Hansen disease (Mycobacterium Leprae)
Loves cool areas in the body (ears, nose). Spread thru resp. tract but doesn't cause resp. illness
Two variants--> Lepromatous and tuberculoid
Lepromatous: maculopapular rash, demarcated skin lesions, sensory loss (ear, nose, dorsum hand, feet)
Tuberculoid: Skin lesions better localized, peripheral neuropathy asymmetric with thickened nerves (ulnar involvement common)
Diagnosis--> clinical + skin/nerve biopsy
Treatment--> Rifampin+ Dapsone+ Clofazimine
A patient comes in with abdominal pain, arthritis, diarrhea, weight loss that started 6 months ago. Now she has progressive dementia and abnormal eye movements that happen with rhythmic chewing movements of mouth and nose. Duodenal biopsy showed PAS positive. What the heck is this?
Whipple disease (Tropheryma Whippelii)
Symptoms as mentioned (oculomasticatory myorhythmia)
Treatment is IV Ceftriaxone followed by TMP SMX
40, M, comes for a new onset focal seizure. CTH showed multiple cystic lesions and some are calcified. What is the treatment of choice?
Neurocysticercosis (Pork Tapeworm Taenia Solium)
Human ingestion of uncooked pork meat
Variety of symptoms--> focal/generalized seizures, stroke, increased IC pressure, hydrocephalus, headache
Imaging will show multiple cyst that enhance and some may be calcified
Treatment--> Albendazole and alternative is Praziquantel