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Central Nervous System Infections
Published in Miriam Orcutt, Clare Shortall, Sarah Walpole, Aula Abbara, Sylvia Garry, Rita Issa, Alimuddin Zumla, Ibrahim Abubakar, Handbook of Refugee Health, 2021
In bacterial meningitis, symptoms progress rapidly, whereas tuberculous and fungal meningitis usually have a more insidious onset. Classic symptoms include fever, headache, neck stiffness, photophobia, lethargy, drowsiness and seizures. Clinical signs include meningism, petechial or purpuric non-blanching rash (meningococcal meningitis), reduced level of consciousness, cranial nerve palsies (tuberculosis [TB] meningitis, Lyme disease, ‘false-localising’ VIth nerve palsy in Cryptococcus) and papilloedema. Kernig’s sign involves pain and resistance on passive extension at knee with hip flexed. Brudinski’s sign involves forced flexion of the neck causing reflex flexion in the hips.
Medicine
Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
A 42-year-old man attends A&E complaining of the worst headache he has ever experienced. It came on suddenly 1 hour ago and affects the occipital region. He also complains of neck stiffness. He has been feeling well over this week and last saw his GP 1 year ago after having the coryzal symptoms. You suspect a subarachnoid haemorrhage (SAH). Is this an arterial or venous intracranial haemorrhage? (1)What is the type of aneurysm that commonly causes SAH? (1)Name a condition associated with this type of aneurysm. (1)Name four symptoms or signs the may patient experience other than a headache? (2)What is Kernig’s sign and what does it demonstrate? (2)What imaging would you request and what would it classically show you? (2)What further test would you perform if the imaging does not demonstrate any abnormality and what would you ask the laboratory to analyse for? (2)
Infectious diseases and tropical medicine
Published in Shibley Rahman, Avinash Sharma, MRCP Part 2 Best of Five Practice Questions, 2018
Shibley Rahman, Avinash Sharma
A 28-year-old woman was referred with jaundice, neck stiffness and headache. She also complained of red, gritty eyes. Her symptoms had started a week ago, as a ‘flu-like illness’, and had got progressively worse. She had just returned from a camping holiday in the USA in the Grand Canyon. There was no previous medical history and she was not on any medication apart from the oral contraceptive pill. She did not drink alcohol or smoke. She had, however, exactly three months previously been to a rather ethanolic leaving party for her best friend. On examination, she was jaundiced, and had bilateral suffuse conjunctivitis. Her temperature was 38.2°C, pulse 100 regular and blood pressure 120/90. Her JVP was not elevated, and her heart sounds and chest were clear to auscultation. There was some right upper quadrant tenderness, but no organomegaly. She was not encephalopathic. Kernig’s sign was positive, but the rest of the neurological examination was entirely normal. There was no skin rash.
Acute cerebellar ataxia: a rare Toscana Virus (TOSV) meningoencephalitis complication
Published in International Journal of Neuroscience, 2020
Lorenzo Roberto Suardi, Nicoletta Di Lauria, Marco Pozzi, Pier Giorgio Rogasi, Alessandro Barilaro, Federica Azzolini, Elio Prestipino, Maria Grazia Colao, Gian Maria Rossolini, Alessandro Bartoloni
Toscana Virus (TOSV) is an arthropod-borne virus belonging to Phlebovirus genus within the Bunyaviridae family, first identified in 1971, from Phlebotomus perniciosus and Phlebotomus perfiliewi in central Italy. It represents in Tuscany, from May to November, the most common responsible for aseptic meningitis or meningoencephalitis. Several studies have demonstrated its presence in most countries located on the northern border of the Mediterranean Sea (Portugal, Spain, France, Greece, Croatia, Cyprus and Turkey) [1, 2]. TOSV infection, when symptomatic, generally has rapid onset with high fever, severe headache, joint/muscle pain and vomiting. Central nervous system involvement occurs with neck rigidity and positive Kernig’s sign. Despite TOSV infection has usually favorable course without complications or sequelae [3], we report a case of acute cerebellar ataxia (ACA) evaluated in a young woman during TOSV meningoencephalitis.
Evaluating and managing severe headache in the emergency department
Published in Expert Review of Neurotherapeutics, 2021
Michelangelo Luciani, Andrea Negro, Valerio Spuntarelli, Enrico Bentivegna, Paolo Martelletti
Physical examination includes Kernig’s sign, Brudzinski’s sign and the ‘head jolt’ test to assess meningitis irritation. Although these signs are of low sensitivity for the diagnosis of meningitis, some studies have demonstrated their good specificity for predicting CSF pleocytosis.
Clinical presentation of a neuropsychiatric lupus patient with symmetrical basal ganglia lesions containing cytotoxic oedema cores surrounded by vasogenic oedema
Published in Modern Rheumatology Case Reports, 2020
Syoko Tsubouchi, Haeru Hayashi, Koichiro Tahara, Kayo Ishii, Takuya Yasuda, Yusuke Yamamoto, Takahiro Mizuuchi, Hiroaki Mori, Mayu Tago, Eri Kato, Tetsuji Sawada
On admission, she complained of slight fever (37.6 °C), headache, vertigo-like imbalance and a slight optical tilt in the visual field. The level of consciousness and cognition was slightly depressed and graded as I-1 on the Japan Coma Scale. There was neck stiffness, and Kernig’s sign was positive. Jolt accentuation of headache was also observed. There were no other neurological findings in her cranial nerves, motor system, deep tendon reflexes, plantar response or sensory system. Based on a presumptive diagnosis of ADEM, she was treated with intravenous administration of 1000 mg methylprednisolone on the day of admission (3-day course of corticosteroid pulse therapy). Before initiating systemic corticosteroid therapy, lumbar puncture was performed, which demonstrated slightly elevated levels of WBC in CSF (20 cells/ μL with 47% mononuclear cells). The glucose level in CSF (31 mg/dL) was decreased relative to the reference range (50–75 mg/dL) and simultaneous blood glucose level (97 mg/dL). Although the total protein level did not exhibit an increase (38 mg/dL), the interleukin (IL-6) level in CSF was remarkably elevated (1500 pg/mL, compared to the cut-off value for NPSLE: 4.3 pg/mL [17]). IgG index was slightly elevated (0.61 (reference value 0.60)), but myelin basic protein (MBP) was not detected in CSF. Table 1 summarizes the results of a complete blood count (CBC), serum biochemistry, immunological tests and urinalysis. CBC revealed leukocytopenia (1600/ μL) and lymphocytopenia (624/ μL). C-reactive protein (CRP) was within normal limits. Urinalysis showed mild proteinuria. Immunological examinations revealed the presence of anti-nuclear antibodies (ANA) at a titre of 1: 80 with a homogeneous, speckled and cytoplasmic pattern and anti-double stranded (ds)-DNA antibodies (Ab) at a titre of 341 IU/mL (normal value; ≤12). Anti-Smith Ab, Anti-ribosomal P Ab and anti-phospholipid Ab were negative. Serum haemolytic activity (CH50), complement 3 (C3) and complement 4 (C4) were decreased to <8.0 U/mL (normal value: 25–48 U/mL), 26 mg/dL (normal value: 86–160 mg/dL) and 3 mg/dL (normal value: 17–45 mg/dL), respectively. Although the patient received a tentative diagnosis of ADEM on admission, subsequent immunological test results indicated that she had SLE with central nervous system involvement. Consistent with the diagnosis of NPSLE, brain single photon emission computed tomography (SPECT) showed reduction of cerebral blood perfusion in the occipitoparietal regions (bilateral but left-hemisphere dominant), in addition to left basal ganglia and left thalamus regions, although to a lesser degree (Figure 3(A,B)).