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Category: Critical Care Medicine-Infections and Immunologic Disease--->CNS Infections
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Question 1# Print Question

A 55-year-old man with a history of well-controlled diabetes and hypertension presents to the emergency department (ED) with a 5- day history of worsening headache and fever. He requests that the light in his room to be turned off as it worsens his headache. Review of systems is otherwise significant only for cough productive of clear phlegm for the last 1 week and intermittent dizziness for 24 hours before presentation. His vital signs are:

  • T 102.4°F
  • heart rate (HR) 118 bpm
  • respiratory rate (RR) 24 bpm
  • blood pressure (BP) 106/60 mm Hg

He is alert and oriented to time, place, and person. Systemic examination, including a detailed neurological examination, is normal except for a 2/6 ejection systolic murmur in the aortic region and mild nuchal rigidity. Kernig signs are positive. Diagnostic lumbar puncture (LP) is planned.

Which of the following sequences of diagnostic and therapeutic steps is MOST appropriate for the care of this patient? 

A. Blood culture, empiric antibiotics, LP, transfer to intensive care unit (ICU), computed tomography (CT) head with contrast
B. Blood cultures, CT head without contrast, steroids, empiric antibiotics, LP
C. Blood cultures, LP, steroids, empiric antibiotic therapy
D. CT head without contrast, blood cultures, LP, empiric antibiotics, steroids
E. Blood cultures, LP, empiric antibiotic therapy, steroids, magnetic resonance imaging (MRI) of brain with gadolinium

Question 2# Print Question

A 66-year-old woman is brought to the ED after being found down in her home by her maid; no family member is reachable. On arrival, she has:

  • BP of 80/40 mm Hg
  • HR 128, RR 20
  • temperature 102°F
  • saturating 94% on room air (RA)

Her mental status is altered with a Glasgow Coma Scale (GCS) of 8, but her physical examination is otherwise normal including a nonfocal neurological examination. Soon after presentation, she has multiple emetic episodes and is intubated for airway protection. A head CT shows no signs of an acute intracranial process. A urine toxicology screen is negative. Empiric antimicrobial therapy with vancomycin and ceftriaxone is initiated after blood cultures are obtained, and she is transferred to the ICU for further care. Contact is finally established with her husband who reports that she had been having severe headaches, body aches, and fever for the past few days. He also reports that she has a history of osteoarthritis and well-controlled diabetes and was in a motor vehicle accident several years ago requiring emergent splenectomy. Her vaccination status is not known. An LP is performed approximately 13 hours after initial antibiotics administration, which shows:

  • cerebrospinal fluid (CSF) glucose 52 mg/dL
  • total protein 180 mg/dL
  • white blood cells (WBCs) 2000 cells/µL (90% neutrophils, 10% other forms)
  • red blood cells (RBCs) 2 cells/µL

CSF gram stain is negative, and cultures have no growth at 48 hours. Multiplex polymerase chain reaction (PCR) on CSF is positive for Neisseria meningitidis.

Which of the following interpretations of the CSF findings is MOST correct?

A. Prior antibiotics do not affect CSF glucose or CSF protein and do not alter the yield of CSF cultures
B. Prior antibiotics do not affect CSF glucose or CSF protein but do alter the yield of CSF cultures
C. Prior antibiotics decrease both CSF glucose and CSF protein and decrease the yield of CSF cultures within a few hours of initiation
D. Prior antibiotics alter both CSF glucose and protein and decrease the yield of CSF cultures within a few hours of initiation

Question 3# Print Question

A 42-year-old woman is admitted to the neurological ICU after presenting with worsening mentation and the finding of a new intracranial mass on MRI. She is intubated for airway protection and has a external ventricular drain (EVD) placed for management of obstructive hydrocephalus. On ICU day 1, she is afebrile and hemodynamically stable. Over the next 3 days, she has a low-grade fever (99.5-100°F), and on ICU day 5, she has a fever of 100.8°F. CSF drawn from the EVD on day 4 to day 6 shows the following results:

Based on the CSF results, what is the most appropriate next step in management?

A. Repeat the MRI to inform further management of the intracranial disease process
B. Defer any intervention unless CSF cultures show any growth
C. Start empiric intraventricular vancomycin and cefepime
D. Start empiric intravenous (IV) vancomycin and cefepime

Question 4# Print Question

A 42-year old woman is brought to the ED from home after she was difficult to arouse from sleep in the morning. She has no significant past medical history but had been complaining of malaise for 1 week as well as new onset headache and fever for 2 days before presentation. She has not had other symptoms except for cold sores, which she gets this time every year. She had also been taking care of her 7-year-old grandson who had fevers and a severe nonproductive cough. In the ED, her vital signs are:

  • T 103°F
  • BP 110/70 mm Hg
  • HR 110
  • RR 22
  • saturating 94% on RA

On examination, she is only responsive to noxious stimuli with eye opening and withdrawal of all four extremities. Her pupils are reactive to light bilaterally; there is no nuchal rigidity. Skin examination is normal with no visible rash. Heart, lung, and abdominal examination are unremarkable. During the examination, she has a generalized tonic-clonic seizure and is intubated for airway protection. A head CT is performed, which does not show any acute abnormality. An LP is performed, and results are pending. She is started on vancomycin, ceftriaxone, and dexamethasone for concern of bacterial meningitis. After that, a brain MRI is also performed, which shows altered signal in the left orbitofrontal cortex with enhancement on postgadolinium images.

What further diagnostic and therapeutic interventions are MOST appropriate at this time? 

A. Await results of the LP for further intervention
B. Add Herpes simplex virus (HSV) IgG to the CSF laboratory testing and begin empiric IV acyclovir
C. Add Varicella zoster virus (VZV) IgG to the CSF laboratory testing and begin empiric IV acyclovir
D. Add HSV PCR to the CSF laboratory testing and begin empiric IV acyclovir

Question 5# Print Question

A 66-year-old man is brought to the ED with a 3-week history of generalized malaise and worsening right-sided headaches not responding to acetaminophen or ibuprofen. He has a past medical history significant for hypertension, hyperlipidemia, moderate obesity, and recurrent otitis media and had an episode of pneumonia about 4 years ago. He is awake, alert, and well-oriented. Vital signs are within normal limits. Heart and lung sounds are normal, abdomen is soft and nontender, and neurological examination including cranial nerves is normal and symmetrical. Complete blood count and metabolic panel are within normal limits except for a mild leukocytosis and mild hyponatremia. Erythrocyte sedimentation rate (ESR) is 62 mm/h and a nasal swab for methicillin-resistant Staphylococcus aureus is negative by PCR. A CT of the head without contrast shows a single 2 cm lesion in the right temporal lobe with mild surrounding edema, which the radiologist reports as concerning for an abscess. Also seen are some microvascular ischemic changes and opacification of right mastoid air cells. The patient is started on vancomycin and piperacillin/tazobactam and transferred to the neurological ICU for further management.

Which of the following changes to the antibiotic regimen is MOST appropriate for this patient

A. Continue vancomycin and piperacillin/tazobactam. Start voriconazole
B. Continue vancomycin. Stop Piperacillin/Tazobactam. Start Cefriaxone and Metronidazole
C. Continue Vancomycin. Stop piperacillin/tazobactam. Start ceftriaxone, metronidazole, and amphotericin B
D. Stop vancomycin and piperacillin/tazobactam. Start ceftriaxone and metronidazole

Category: Critical Care Medicine-Infections and Immunologic Disease--->CNS Infections
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