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Category: Critical Care Medicine-Infections and Immunologic Disease--->CNS Infections
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Question 6#Print Question

A previously healthy 42-year-old man is brought to the ED by his wife who noticed that he was stumbling and almost fell down on two occasions over the past few hours. He had been having nausea and vomiting for the last few days followed by global headaches and subjective fevers. This morning he woke up complaining of double vision, and his wife noticed that he was limping when he got up from his bed. In the ED, his vital signs are:

  • BP 120/80 mm Hg
  • HR 120
  • RR 20
  • T 102.5°F
  • O2 saturation 92% on RA

On examination, he was alert and oriented. Cardiovascular, respiratory, and abdominal examination were normal. He did not have nuchal rigidity, but lateral gaze of the right eye was restricted; he had mild left-sided hemiparesis and decreased sensation on the left side of the body. Laboratory data included a hemoglobin of 12.3 g/dL, WBC count 16 000/dL (90% neutrophils), platelets 235 000/dL, sodium 126 mmol/L, creatinine 1.5 mg/dL (no prior data available), aspartate aminotransferase 37 U/L, alanine aminotransferase 26 U/L, and total bilirubin 1.0 mg/dL. A CT head without contrast was obtained, which did not show any acute abnormality. He was empirically started on vancomycin and ceftriaxone for community-acquired bacterial meningitis and transferred to the floor. Overnight, his level of consciousness decreased and respiratory status deteriorated resulting in the need for intubation before being transferred to the medical ICU. Bedside electroencephalography did not show any seizure activity. He continued to spike high-grade fevers and eventually underwent an LP, which showed mild neutrophilic pleocytosis and mildly elevated protein, suggestive of aseptic meningitis but was otherwise normal. A brain MRI with contrast was planned; however, before this could happen, the patient’s neurological status worsened with loss of cranial nerve reflexes and the family decided to withdraw care. Blood cultures from admission showed growth of gram-positive bacteria in two of two bottles at 48 hours, about 24 hours after the patient’s death. Final pathology from autopsy reported severe inflammation of the brainstem, which led to herniation.

Which of the following is true regarding the management of this patient?

A. Empiric therapy with acyclovir should have been started pending diagnostic workup
B. Empiric therapy with ampicillin would have decreased his risk of mortality
C. The brain stem inflammation was an autoimmune manifestation of an occult malignancy
D. Early initiation of dexamethasone may have prevented this poor outcome


Question 7#Print Question

A 76-year-old male with rheumatoid arthritis managed with rituximab infusions is brought in to the ED with altered mental status. Four days before presentation, he developed fevers up to 103°F and headaches about a week after he returned from a camping trip in rural Wyoming. He was seen in his primary care physician’s office 2 days ago for these symptoms and was noted to have a nonblanchable maculopapular rash over the left side of his trunk. He was managed symptomatically with antipyretics, but his headaches worsened and he was found to be confused this morning. On examination, he has limited ability to move his left lower extremity, which appears floppy. The rest of his examination is unremarkable, and no rash is seen. His complete blood profile and chemistry is normal. He has no risk factors for human immunodeficiency virus (HIV). Diagnostic workup is started for stroke, and he is empirically started on IV vancomycin, ceftriaxone, ampicillin, and acyclovir for possible meningoencephalitis. A CT head without contrast does not show an acute abnormality. An LP is performed, which reveals:

  • mildly elevated protein
  • normal glucose
  • no RBCs
  • WBCs 1000 cells/µL (80% neutrophils)

Gram stain is negative, and culture is pending. Brain MRI with gadolinium shows nonspecific enhancement of left basal ganglia. PCR for HSV on CSF is negative. Over the next 24 hours, his fevers persist, level of consciousness worsens, and he requires intubation for airway protection.

Which of the following laboratory tests is MOST likely to reveal the etiology of his presentation?

A. Echovirus PCR of CSF
B. Echovirus PCR of serum
C. West Nile virus PCR of CSF
D. West Nile virus IgG of serum


Question 8#Print Question

A 38-year-old male is brought to the ED when family noticed that he was confused. Per report, he was well until about 3 weeks ago when he developed generalized malaise and a dry cough followed by daily fevers of 100.6°F to 100.8°F. Over the last week, he had been feeling increasingly short of breath. His past medical history is significant for HIV for which he is receiving highly active antiretroviral therapy (HAART), untreated hepatitis C infection complicated by cirrhosis, and smoking-related chronic obstructive pulmonary disease (COPD) for which he has been receiving prednisone 40 mg daily for the last 2 weeks. His CD4 count 1 month ago was 640 cells/mL with an undetectable HIV viral load. He has no history of opportunistic infections. On physical examination, he has normal heart sounds, coarse crackles on the right lung base, his abdomen is soft and nontender without evidence of ascites, and his neurological examination is unremarkable except that he is not oriented to time, place, or person. In the ED, laboratory data are:

  • significant for a WBC count 14 000 cells/dL
  • platelets 165 000/dL
  • creatinine 1.1 mg/dL
  • spartate aminotransferase 56 U/L
  • alanine aminotransferase 48 U/L
  • alkaline phosphatase 110 U/L
  • total bilirubin 0.9 mg/dL

Chest x-ray shows a right lower lobar consolidation. Two sets of blood cultures are drawn, and he is started on vancomycin and piperacillin/tazobactam. Over the next 72 hours, his oxygen requirements increase to requiring 6 L via nasal cannula and he continues to spike fevers. His increasing confusion is attributed to delirium, and he is started on lactulose for possible hepatic encephalopathy. On day 5 of admission, he is transferred to the ICU with worsening hypoxia requiring intubation. He undergoes bronchoscopy for diagnostic bronchoalveolar lavage (BAL). The initial stain shows yeast with thick capsules, and the following day cultures show growth of pigmented colonies.

What is the next best step in management for this patient?

A. Check bacterial multiplex PCR on BAL fluid for identification of the causative organism
B. Check cytomegalovirus (CMV) PCR on BAL fluid and if positive, start ganciclovir
C. Start micafungin for Candida pneumonia
D. Perform an LP and if positive, start liposomal amphotericin B and flucytosine




Category: Critical Care Medicine-Infections and Immunologic Disease--->CNS Infections
Page: 2 of 2