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Q1: A patient presents with fever, headache and neck stiffness. Talk me through your immediate approach. (2 min)
- Recognise the classic triad (fever + neck stiffness + altered mental status); two of three is enough to act. Suspect bacterial meningitis (or meningococcal septicaemia if there is a petechial rash) until proven otherwise.
- ABCDE, vitals (look for shock, raised ICP), GCS, examine for the petechial/purpuric rash (glass test), focal neurology, papilloedema, source (otitis, sinusitis, shunt).
- The non-negotiable rule: empirical IV antibiotics IMMEDIATELY on suspicion — before LP, blood cultures or CT. Adult empirical: ceftriaxone 2 g BD + vancomycin + ampicillin (Listeria if over 50/immunocompromised/pregnant) + aciclovir (HSV if encephalitis possible). Give adjunctive dexamethasone 0.15 mg/kg (10 mg) with or 15-20 min before the first antibiotic dose (pneumococcal benefit).
- Resuscitate shock with the Surviving Sepsis hour-1 bundle; isolate (droplets) 24 h.
Q2: When would you obtain a CT before lumbar puncture, and what does a normal CT exclude? (2 min)
Indications (do NOT delay antibiotics): immunocompromise, new-onset seizures, papilloedema, decreased GCS, focal neurology, head trauma within 1 week, prolonged coma, or a history of CNS disease. A normal CT does not fully exclude raised pressure — clinical criteria decide, and a contrast-enhanced CT adds sensitivity for abscess/empyema. If LP must be deferred, start antibiotics immediately and reconsider LP once the patient is stable; a delayed LP still helps with aetiology (cellular pattern and PCR persist for days after antibiotics).
Q3: What are the expected CSF findings in bacterial, viral and tuberculous meningitis? (2 min)
- Bacterial: cloudy; neutrophils high (100-5000), protein over 1 g/L, glucose under 40 mg/dL or under 40% of serum, high opening pressure, Gram stain/culture positive.
- Viral: clear; lymphocytes, protein normal/mildly raised, glucose normal, enterovirus/HSV PCR.
- Tuberculous: cobweb coagulum; lymphocytes, protein very high, glucose very low (under 20-40 mg/dL), AFB stain (low yield), GeneXpert/Xpert Ultra, culture (slow).
- (Cryptococcal: lymphocytes, low glucose, India ink + CrAg, very high opening pressure.)
Q4: Which groups need Listeria cover, and how does the regimen change? (2 min)
Cover Listeria monocytogenes (intrinsically resistant to all third-generation cephalosporins) when: age over 50, immunocompromised (HIV, transplant, anti-TNF, chemotherapy, malignancy), pregnant, neonate, or alcoholic. Add IV ampicillin 2 g every 4 hours (or amoxicillin), usually with gentamicin 5 mg/kg OD for the first week for synergy; treat for 21 days. Listeria can cause rhombencephalitis (cranial-nerve palsies, cerebellar signs). In the neonate, use ampicillin + cefotaxime — avoid ceftriaxone (bilirubin displacement → kernicterus, biliary sludging).
Q5: What are the complications of bacterial meningitis, and how do you reduce them? (2 min)
- Acute: septic shock, DIC/purpura fulminans, Waterhouse-Friderichsen (give stress-dose steroids), seizures, raised ICP with herniation, stroke (vasculitis/venous sinus thrombosis), subdural empyema/abscess, SIADH.
- Long-term: sensorineural hearing loss (commonest), cognitive impairment, epilepsy, focal deficits, hydrocephalus.
- Reducing them: early empirical antibiotics (the single biggest lever), adjunctive dexamethasone (reduces deafness and pneumococcal mortality), audiology follow-up at 6-8 weeks, vaccination, and chemoprophylaxis of contacts for meningococcal disease.