Headache case 5

Headache case 5

A forty-year-old woman presents to the emergency department complaining of two days of severe headache, fever, and stiff neck. On examination, the patient displays nuchal rigidity and Brudzinski's sign.

Q1

Which of the following is the most likely diagnosis?
/ A. Embolic stroke
/ B. Guillain-Barré syndrome
/ C. Hemorrhagic stroke
/ D. Meningitis
/ E. Vascular headache

Q 2

Lumbar puncture is performed and the cerebrospinal fluid is examined. The fluid is turbid, and laboratory findings include elevated opening pressure, neutrophilic pleocytosis, markedly elevated protein, and decreased glucose. Which of the following is the most likely etiologic
agent?
/ A. Cryptococcus neoformans
/ B. Herpes simplex
/C. Listeria monocytogenes
/D. Mycobacterium tuberculosis
/E. Streptococcus pneumoniae

Q 3
Cerebrospinal fluid glucose concentration is normally approximately what fraction of serum glucose concentration?
/ A. 1/3
/ B. 1/2
/ C. 2/3
/ D. 1
/ E. 4/3

Q 4
Which of the following would be the most appropriate pharmacotherapy?
/ A. Acyclovir
/ B. Ceftriaxone
/ C. Cephazolin
/ D. Penicillin
/ E. Valicyclovir


Q 5
Which of the following best describes the order of meningeal layers from the skull to the cerebral cortex?
/ A. Arachnoid, dura mater, pia mater
/ B. Arachnoid, pia mater, dura mater
/ C. Dura mater, arachnoid, pia mater
/ D. Dura mater, pia mater, arachnoid
/ E. Pia mater, dura mater, arachnoid

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Headache case 5 answers
A1
The correct answer is D. Meningitis is characterized by fever, headache, nuchal rigidity, and CNS dysfunction including confusion, delirium, lethargy, coma, and cranial nerve dysfunction. Brudzinski's sign indicates meningeal irritation: as the patient's neck is flexed, the patient flexes the hip and knee.
Choices A and C are incorrect. A stroke is a vascular accident and would thus have an acute onset. Focal neurologic findings would be elicited. Fever would not be found in stroke.
Guillain-Barré syndrome (choice B) is a peripheral neuropathy, and thus peripheral, rather than central nervous system findings, would be present.
Vascular headache (choice E) presents as severe headache, often throbbing, which is accompanied by nausea and photophobia. Visual aura may precede the headache, and focal neurologic findings may complicate the course. Fever is not present.

A2
The correct answer is E. The CSF analysis greatly aids in finding the etiology of meningitis. In bacterial meningitis, the CSF has decreased glucose, elevated protein, and a proliferation of neutrophils. In addition, a Gram's stain should be performed and will often reveal and allow characterization of the bacteria. S. pneumoniae is a common bacterial pathogen seen in this patient's age group. Antibiotic therapy to cover this organism can now be started pending cultures and sensitivity.
Cryptococcus neoformans(choice A) is responsible for chronic fungal meningitis. The CSF would have lymphocytes with only a slight elevation in protein, with normal or slightly decreased glucose.
Viral meningitis, from e.g., Herpes simplex (choice B), would produce a slight elevation in CSF lymphocytes, normal glucose, and slightly elevated protein.
Listeria monocytogenes(choice C) is a bacterial pathogen, but it is found in the pediatric population, and thus would be extremely unlikely in this patient.
Tuberculous meningitis (choice D) has an indolent course and a delayed onset. The CSF in TB meningitis would have slight lymphocytic elevation, markedly elevated protein, and slightly decreased glucose.

A3
The correct answer is C. CSF glucose is derived from serum, and is a reflection of the serum concentration during the previous 2-4 hours. Glucose is often abnormally low in cases of bacterial meningitis. In normal-pressure hydrocephalus, CSF glucose is usually normal. Normally, CSF glucose is about 2/3 of the serum glucose concentration.

A4
The correct answer is B. When selecting an antimicrobial, it is important to select an agent that is effective against the likely organisms and will also penetrate the blood-brain barrier. Ceftriaxone will be effective against the likely organisms causing bacterial meningitis in a 40-year-old (Neisseria meningitidis and Streptococcus pneumoniae). In addition, it can cross the blood-brain barrier and access the CNS.
Acyclovir (choice A) and valicyclovir (choice E) are antivirals and would be inappropriate in bacterial meningitis.
Cephazolin (choice C) and penicillin (choice D) are effective against gram-positive organisms, but they do not cross the blood-brain barrier.

A5
The correct answer is C. The dura mater is the most substantial layer of the meninges and is the most distal from the brain. The next layer is the arachnoid layer. The pia is a thin tissue layer applied directly to the surface of the brain. Cerebrospinal fluid is found between the arachnoid and pia layers.