Neurology TOSCE 4

A 24 year old nursing student presented to his ED with a 1 day history of headache and
fever. He expressed a dislike for bright lights. On examination his vital signs were as
follows:

BP 110/68 mm/Hg, HR 104 bpm, Temp 38.6 degrees celcius and O2 Sats 98% R/A. He
was disorientated to place and time.

List 3 differential diagnoses:

Infectious Meningo-Encephalitis
Viral Illness
SAH

What is the most likely diagnosis?

Infectious Meningo-Encephalitis

What features would you look for on physical examination in support of the
suspected diagnosis?

Fever
Altered Mental Status
Rash
Cranial Nerve Palsies
Other Focal Neurological Signs
Nuchal Rigidity
Brudzinskis Sign
Kernigs Sign
Evidence of URTI- pharyngitis, otitis

What diagnostic test should be performed in this case?

Lumbar Puncture- CSF Analysis (cell count, microscopy, culture, sensitivity, protein,
glucose)

What other investigations would you perform?

FBC
Electrolytes: Renal Impairment, Hyponatraemia (mild)
Coagulation Screen (DIC)
Blood Cultures
ABG (raised anion gap metabolic acidosis)
Consider CT Brain prior to lumbar puncture if any of the following is present:
Immunocompromised state (organ transplant, HIV, immunosuppressive medications)
History of CNS Disease (mass lesion, stroke, focal infection)
New onset seizure (within the past 1 week)
Papilloedema
Abnormal level of consciousness
Focal Neurologic Deficit

Outline your management

ABC
IV high dose broad spectrum antibiotics initially
Cetriaxone 2g BD IV
Vancomycin 2g BD-QID IV (if high prevalence of cephalosporin resistant streptococcus
pneumoniae)
IV Dexamethasone 0.15mg/kg Q 6 hours x 4/7 (only if strep pneumo meningitis is
suspected. Must commence immediately before or at same time as first dose of
antibiotics)- shown to reduce mortality and neurological complications in streptococcal
pneumoniae meningitis (if alternative micro-organism is cultured, stop corticosteroids
immediately).
IV Hydration
Isolate
Change ABx based on sensitivities of culture
Contact tracing- chemoprophylaxis
Notify Public Health

CSF analysis reveals the following:

CSF Microscopy

Sample 1 2 3
RCC (/mm3) 5 3 2
WCC (/mm3) 1056 1023 1042 {90% neutrophils}

CSF Protein (mg/dL) 102 {15-45}

CSF Glucose (mmol/L) 2.4
Blood Glucose (mmol/L) 8.5

Comment on the Above Results:

CSF Microscopy-G positive cocci in chains, inflammatory cells
Elevated WCC- predominantly neutrophils
Elevated Protein
Low CSF Glucose (should be at least 2/3 blood glucose)

What is the most likely diagnosis?

Bacterial Meningoencephalitis

What is the most likely causative organism?

Streptococcus Pneumoniae

A patient with similar symptoms is admitted the following day. A lumbar puncture is
performed and the results of CSF analysis are as follows:

Sample 1 2 3

RCC (/mm3) 3 2 2
WCC (/mm3) 190 188 200 {predominantly
lymphocytes}

CSF Protein (mg/dL) 68 {15-45}

CSF Glucose (mmol/L) 4.0
Blood Glucose (mmol/L) 6.5

Comment on the results above:

Elevated WCC (usually less than 250/mm3 in viral meningitis)
Predominant elevation of lymphocytes (although within first 24 hours may see
predmominance of neutrophils in viral meningitis)
Mildly elevated protein ( usually less than 150 mg/dL)
Normal CSF glucose (may be slightly reduced)

What is the most likely diagnosis?

Viral meningitis

List 1 differential diagnosis:

TB Meningits