Resident Board Review: Neurology and Disorders of Cognition, Learning and Development

1. Resident Board Review:Neurology and Disorders of Cognition, Learning and Development May 13, 2011

2. Neurology

3. http://library.med.utah.edu/neurologicexam/html/home_exam.htmlhttp://library.med.utah.edu/neurologicexam/html/home_exam.html

4. 1 A 14-year-old boy who has epilepsy presents to the emergency department after a generalized tonic-clonic seizure that began on the playground at school. He continued to convulse en route in the ambulance, where he received 15 mg diazepam rectally and intravenous access was achieved. In the emergency department, he continues to be unresponsive, exhibiting tachycardia and nonsuppressable bilateral synchronous rhythmic clonic jerks.Of the following, the MOST appropriate medication to administer next is A. fosphenytoin 20 mg/kg intravenously B. pentobarbital 5 mg/kg intravenously C. phenobarbital 20 mg/kg intravenously D. phenytoin 7 mg/kg orally E. valproic acid 15 mg/kg intravenously

5. 1 A 14-year-old boy who has epilepsy presents to the emergency department after a generalized tonic-clonic seizure that began on the playground at school. He continued to convulse en route in the ambulance, where he received 15 mg diazepam rectally and intravenous access was achieved. In the emergency department, he continues to be unresponsive, exhibiting tachycardia and nonsuppressable bilateral synchronous rhythmic clonic jerks.Of the following, the MOST appropriate medication to administer next is A. fosphenytoin 20 mg/kg intravenously B. pentobarbital 5 mg/kg intravenously C. phenobarbital 20 mg/kg intravenously D. phenytoin 7 mg/kg orally E. valproic acid 15 mg/kg intravenously

6. Status Epilepticus

7. 2 • A mother brings her 8-year-old daughter to your office after the girl experiences a first unprovoked generalized tonic-clonic seizure at school. The child had been seen in an emergency department, and results of a head computed tomography scan performed there were normal. Her development, school performance, and results of physical examination are normal. You review safety concerns (no unsupervised time in bathtub or pools, wearing a bicycle helmet) and seizure first aid with the mother. Following published guidelines, you obtain routine electroencephalography (EEG), which a neurologist interprets as normal. The mother asks you about anticonvulsant therapy to prevent further seizures.Of the following, you are MOST likely to advise her that • A. repeat sleep-deprived EEG is needed to select medication • B. treatment with carbamazepine should be initiated • C. treatment with phenobarbital should be initiated • D. treatment with phenytoin should be initiated • E. treatment with seizure medication should be deferred

8. 2 • A mother brings her 8-year-old daughter to your office after the girl experiences a first unprovoked generalized tonic-clonic seizure at school. The child had been seen in an emergency department, and results of a head computed tomography scan performed there were normal. Her development, school performance, and results of physical examination are normal. You review safety concerns (no unsupervised time in bathtub or pools, wearing a bicycle helmet) and seizure first aid with the mother. Following published guidelines, you obtain routine electroencephalography (EEG), which a neurologist interprets as normal. The mother asks you about anticonvulsant therapy to prevent further seizures.Of the following, you are MOST likely to advise her that • A. repeat sleep-deprived EEG is needed to select medication • B. treatment with carbamazepine should be initiated • C. treatment with phenobarbital should be initiated • D. treatment with phenytoin should be initiated • E. treatment with seizure medication should be deferred

9. Management of new onset seizure activity First unprovoked seizure • Discuss safety concerns (no unsupervised time in bathtub or pools, wearing a helmet while on a bike or scooter) and seizure first aid • Obtaining an EEG is recommended by published practice guidelines. • Med treatment after a single seizure in childhood is not recommended • Neuroimaging • when the seizure occurs in the first year after birth, • if seizure is focal/asymmetric, or begins with focal features (including gaze deviation) and subsequently generalizes, • With focal physical examination • when postictal confusion is prolonged, particularly if the child is febrile (to rule out infectious encephalitis). Second seizure • Regardless of EEG results, two or more unprovoked seizures in a child are diagnostic of epilepsy and warrant treatment and referal to a neurologist. • Phenobarbital  sedation and cognitive and behavioral changes in young children (not first line) • Phenytoin  somewhat erratic absorption and can cause gingival hyperplasia in children, (not first line) • Carbamazepine  partial epilepsy (can worsen generalized epilepsy) • Valproic acid  both partial and generalized epilepsy in children older than age 2 years.

10. 3 • A 15-year-old boy presents to the emergency department after an apparent seizure. He had a sudden arrest of normal activity at school, with posturing on the left side, eye deviation, and loss of consciousness for about 1 minute, followed by confusion. On physical examination, he is fully oriented and answers questions appropriately. He is afebrile. Results of cranial nerve examination, motor examination, and gait evaluation are normal.Of the following, the procedure that is MOST likely to establish the cause of the seizure is • A. brain magnetic resonance imaging with contrast • B. electroencephalography • C. lumbar puncture • D. noncontrast head computed tomography scan • E. urine toxicology screen

11. A 15-year-old boy presents to the emergency department after an apparent seizure. He had a sudden arrest of normal activity at school, with posturing on the left side, eye deviation, and loss of consciousness for about 1 minute, followed by confusion. On physical examination, he is fully oriented and answers questions appropriately. He is afebrile. Results of cranial nerve examination, motor examination, and gait evaluation are normal.Of the following, the procedure that is MOST likely to establish the cause of the seizure is • A. brain magnetic resonance imaging with contrast • B. electroencephalography • C. lumbar puncture • D. noncontrast head computed tomography scan • E. urine toxicology screen

12. MRI is more sensitive to lesions that can be missed on CT scan. If child is clinically well and at baseline  defer emergent CT scan and schedule the more sensitive brain MRI. Low-grade glioma on MRI Not detected on CT

13. 4 • A 3-year-old child presents with 24 hours of episodes of inconsolable crying. His parents state that his sleep/wake pattern is altered and he seems uncharacteristically "out of it" at times. Physical examination shows fluctuation in attention and arousal, with diffuse hyperreflexia. Emergency head computed tomography scan shows no abnormalities. Laboratory testing documents markedly elevated serum transaminases.Of the following, the MOST likely cause for this child's mental status change is • A. acetaminophen ingestion • B. antiphospholipid antibody syndrome • C. carbon monoxide poisoning • D. diphenhydramine intoxication • E. lead poisoning

14. 4 • A 3-year-old child presents with 24 hours of episodes of inconsolable crying. His parents state that his sleep/wake pattern is altered and he seems uncharacteristically "out of it" at times. Physical examination shows fluctuation in attention and arousal, with diffuse hyperreflexia. Emergency head computed tomography scan shows no abnormalities. Laboratory testing documents markedly elevated serum transaminases.Of the following, the MOST likely cause for this child's mental status change is • A. acetaminophen ingestion • B. antiphospholipid antibody syndrome • C. carbon monoxide poisoning • D. diphenhydramine intoxication • E. lead poisoning

15. Encephalopathy • Acute confusional state/encephalopathy: • fluctuating arousal + inattention + irritability. • Create DDX using the mnemonic F-I-T • Focal trauma, abscess, and stroke. Look for localizing signs or symptoms, evaluate with emergent head CT. • Ictal/postictal, infection or inflammatory Postictal confusion can cause self-limited encephalopathy. Nonconvulsive status epilepticus is rare in child not known to have epilepsy. Consider meningo/encephalitis, abscess, cerebritis. • Toxic/metabolic. Evaluate with complete blood count, glucose, electrolytes, liver panel, and toxicology screen. • Hepatic encephelopathy - encephalopathy, irritability, and hyperreflexia. • Lead  elevated ICP, seizures, and possibly hemolytic anemia and multiorgan dysfunction. • Carbon monoxide  encephalopathy, headache, and flulike symptoms • Diphenhydramine  acute encephalopathy, seizures, and anticholinergic symptoms and signs. • Antiphospholipid antibody syndrome  one or more episodes of arterial or venous thrombosis  stroke and encephalopathy.

16. 5 • The parents of a 6-month-old previously well infant bring her to your office. She had been developing normally, but she stopped interacting with her parents over the last 24 hours. For several days prior to this development, she had had unusual spells during which her head and chin dropped to her chest. Now she is having clusters of these spells involving head drop and body flexion. On physical examination, there is no bruising. The infant is afebrile and alert, her tone is low, and she does not make persistent eye contact or track visually. You refer her to the emergency department, where results of a complete blood count, electrolyte panel, urinalysis, and a noncontrast head computed tomography scan are normal.Of the following, the test that is MOST likely to reveal the correct diagnosis is • A. electroencephalography • B. electroretinography • C. lumbar puncture • D. muscle biopsy • E. serum lactate measurement

17. The parents of a 6-month-old previously well infant bring her to your office. She had been developing normally, but she stopped interacting with her parents over the last 24 hours. For several days prior to this development, she had had unusual spells during which her head and chin dropped to her chest. Now she is having clusters of these spells involving head drop and body flexion. On physical examination, there is no bruising. The infant is afebrile and alert, her tone is low, and she does not make persistent eye contact or track visually. You refer her to the emergency department, where results of a complete blood count, electrolyte panel, urinalysis, and a noncontrast head computed tomography scan are normal.Of the following, the test that is MOST likely to reveal the correct diagnosis is • A. electroencephalography • B. electroretinography • C. lumbar puncture • D. muscle biopsy • E. serum lactate measurement

18. Encephalopathy secondary to ictal cause • Infantile spasms • epilepsy and encephalopathy in infancy • Cluster of body spasms combined with the loss of developmental milestones • Spasms range from subtle, quick movements involving just the head to dramatic "clasp-knife" full body spasms. • Infantile spasms can have a number of causes (structural, genetic, or metabolic) or can be idiopathic. • Peak onset at 6 months • The prognosis is often poor, particularly if the child's neurologic development was abnormal prior to the onset of spasms. • EEG with characteristic diffuse, slow, disorganized, and high-amplitude pattern is known as "hypsarrhythmia."

19. Who am I?

20. Who am I?

21. 6 • An 11-year-old boy presents for evaluation due to an episode of screaming and confusion at night. The boy's parents heard him scream in his room, and when they went to him, he exhibited rapid twitching of his left arm and hand, stiffening of his left leg, rolled back eyes, and some blinking of both eyes. He was incoherent and minimally responsive for 5 to 10 minutes. After the episode, he was weak on the left side of his body. By morning, he had returned to a normal status.Of the following, the MOST likely diagnosis is • A. benign rolandic epilepsy • B. juvenile myoclonic epilepsy • C. night terrors • D. nocturnal frontal lobe epilepsy • E. rapid eye movement sleep behavior disorder

22. 6 • An 11-year-old boy presents for evaluation due to an episode of screaming and confusion at night. The boy's parents heard him scream in his room, and when they went to him, he exhibited rapid twitching of his left arm and hand, stiffening of his left leg, rolled back eyes, and some blinking of both eyes. He was incoherent and minimally responsive for 5 to 10 minutes. After the episode, he was weak on the left side of his body. By morning, he had returned to a normal status.Of the following, the MOST likely diagnosis is • A. benign rolandic epilepsy • B. juvenile myoclonic epilepsy • C. night terrors • D. nocturnal frontal lobe epilepsy • E. rapid eye movement sleep behavior disorder

23. Benign rolandic epilepsy (centrotemporal epilepsy) • Partial, with vocalization, focal motor movements of lower face, extremities, followed by transient focal weakness • occurs between the ages of 3 and 13 years and resolves before adulthood. • Inheritance is autosomal dominant. • Interictal EEG shows characteristic centrotemporal spikes. • Treatment generally is not needed because the nocturnal seizures are infrequent and do not cause any problems the following day. Partial seizure medications such as carbamazepine are effective, if used. Some report cognitive deficits with untreated rolandic epilepsy • Juvenile myoclonic epilepsy • generalized epilepsy occuring most often in morning • characterized by one or more of the following: • myoclonic jerks, • generalized tonic-clonic seizures • absence seizures. • More often in teenage years

24. 7 • A 6-year-old boy presents with a sudden-onset loss of awareness characterized by staring, drooling, and chewing movements for more than 15 minutes, followed by confusion, then deep sleep. On physical examination in the emergency department, the child is afebrile and appears to be returning to normal. Vital signs and general examination findings are normal, and there are no focal findings. Head computed tomography scan shows a large, contrast-enhancing cerebral mass without edema or midline shift.Of the following, the MOST likely diagnosis is A. arteriovenous malformation B. brain damage from a seizure C. ependymoma D. glioblastoma multiforme E. herpes encephalitis

25. A 6-year-old boy presents with a sudden-onset loss of awareness characterized by staring, drooling, and chewing movements for more than 15 minutes, followed by confusion, then deep sleep. On physical examination in the emergency department, the child is afebrile and appears to be returning to normal. Vital signs and general examination findings are normal, and there are no focal findings. Head computed tomography scan shows a large, contrast-enhancing cerebral mass without edema or midline shift.Of the following, the MOST likely diagnosis is A. arteriovenous malformation B. brain damage from a seizure C. ependymoma D. glioblastoma multiforme E. herpes encephalitis

26. Most common cause of hemorrhagic stroke in children  vascular malformation, • Two types: arteriovenous malformations (AVMs) and cavernous malformations. • can present in childhood with hemorrhage that leads to headache and seizures • Glioblastoma multiforme • Can hemorrhage, usually surrounding edema.

27. 8 • A 13-year-old girl has had 5 days of unremitting headache that is relieved by vomiting but not sleep and 1 day of double vision. She was previously healthy and has no history of migraine headaches, but she was treated for otitis media 6 weeks ago. • Findings on physical examination are normal except for some tenderness over her left mastoid. On neurologic examination, you note normal mental status and normally reactive pupils and vision. Fundoscopic exam reveals the image on the next slide. She cannot abduct her right eye fully and has subjective double vision with both eyes open looking to the right but not looking to the left or with either eye covered. Facial sensation and movements are normally symmetric, and the rest of the findings are normal. • Head computed tomography scan yields normal results.

28. Of the following, the diagnostic test or procedure that is MOST likely to be helpful is • A. brain MRI • B. cerebral angiography • C. lumbar puncture with manometry • D. ocular nerve sheath fenestration • E. serum vitamin A measurement

29. Of the following, the diagnostic test or procedure that is MOST likely to be helpful is • A. brain MRI • B. cerebral angiography • C. lumbar puncture with manometry • D. ocular nerve sheath fenestration • E. serum vitamin A measurement

30. 6th nerve palsy seen in pseudotumor • Presence of facial weakness or facial sensory loss would suggest brainstem pathology • Causes of pseudotumor cerebri • obesity • minocycline, tetracycline, isotretinoin, steroids • hypervitaminosis A • venous sinus thrombosis (MRV) • Anemia • renal failure • hypercalcemia

31. 9 • A 4-year-old boy presents with headache and difficulty walking. On physical examination, he is afebrile, all growth parameters are within normal limits, and his mentation appears normal. The optic discs are clearly visible and appear normal. He has normal eye position in primary gaze but cannot abduct his right eye fully. He has normal tone, strength, and reflexes in his upper limbs, but has bilateral hyperreflexia at the knees and ankle clonus. On gait examination, he toe-walks.Of the following, the MOST important next step is to obtain • A. computed tomography scan of the head • B. electromyography/nerve conduction studies of the legs • C. lumbar puncture • D. magnetic resonance imaging of the thoracolumbar spine • E. visual evoked potentials

32. 9 • A 4-year-old boy presents with headache and difficulty walking. On physical examination, he is afebrile, all growth parameters are within normal limits, and his mentation appears normal. The optic discs are clearly visible and appear normal. He has normal eye position in primary gaze but cannot abduct his right eye fully. He has normal tone, strength, and reflexes in his upper limbs, but has bilateral hyperreflexia at the knees and ankle clonus. On gait examination, he toe-walks.Of the following, the MOST important next step is to obtain • A. computed tomography scan of the head • B. electromyography/nerve conduction studies of the legs • C. lumbar puncture • D. magnetic resonance imaging of the thoracolumbar spine • E. visual evoked potentials

33. Hydrocephalus is a neurosurgical emergency • Symptoms/signs of increased ICP • headache, vomiting, 3rd or 6th nerve palsy, papilledema, impairment of upward gaze, hypertension/bradycardia, or enlarging head circumference, bulging fontanelles if open • Spasticity of extremities • from stretching of periventricular upper motor neuron fibers (lower > upper ext) causing gait impairment • Mental status/personality changes Causes • Cerebellar neoplasm such as an astrocytoma, glioma, medulloblastoma, or ependymoma. • CNS malformation such as Dandy-Walker, Chiari malformation. • Acqueductal stenosis • Post-hemorrhagic hydrocephalus • Meningitis Evaluation • Emergent CT • MRI can document the brainstem/posterior fossa better

34. 10 • An 8-year-old girl who has intellectual disability and dysmorphic facial features presents to the emergency department with reduced alertness of 24 hours' duration. For the past hour, she has been crying inconsolably and holding her head. At triage she makes poor eye contact and is banging her head. Physical examination of the irritable child reveals dysmorphic features and abnormal head shape. On eye examination, her pupils are equally reactive and appear normally aligned. It is unclear whether her neck is supple, due to a lack of cooperation, but she has a subcutaneous tube connected to a shunt bulb over her right parietal skull.Of the following, the MOST appropriate next step is to • A. insert a needle into the shunt bulb • B. order brain magnetic resonance imaging with contrast • C. order head computed tomography scan without contrast • D. order stat electroencephalography • E. perform a lumbar puncture

35. 10 • An 8-year-old girl who has intellectual disability and dysmorphic facial features presents to the emergency department with reduced alertness of 24 hours' duration. For the past hour, she has been crying inconsolably and holding her head. At triage she makes poor eye contact and is banging her head. Physical examination of the irritable child reveals dysmorphic features and abnormal head shape. On eye examination, her pupils are equally reactive and appear normally aligned. It is unclear whether her neck is supple, due to a lack of cooperation, but she has a subcutaneous tube connected to a shunt bulb over her right parietal skull.Of the following, the MOST appropriate next step is to • A. insert a needle into the shunt bulb • B. order brain magnetic resonance imaging with contrast • C. order head computed tomography scan without contrast • D. order stat electroencephalography • E. perform a lumbar puncture

36. Elevated intracranial pressure secondary to shunt malfunction, resulting in acute hydrocephalus. • Emergent CT scan hydrocephalus • Routine radiographic shunt series  disconnections in tubing. Withdrawing fluid through the shunt generally is not performed before obtaining radiologic confirmation of the shunt malfunction.

37. 11 • A 15-year-old girl presents to the emergency department with a 4-week history of nasal drainage and face pain and a 2-week history of frontal headaches and fatigue. Her mother complains that her daughter has an "attitude" and has not been respectful or seemed to care about anything for the past 2 weeks. The daughter awoke this morning with a headache and vomited. On physical examination, the adolescent is afebrile and has normal vital signs. She responds slowly to questions and is not oriented to the date. She complains of pain to palpation of her cheeks and forehead. She has no nuchal rigidity and no focal weakness. The remainder of the physical examination findings are normal.Of the following, the BEST initial diagnostic procedure is • A. computed tomography scan of the head with intravenous contrast • B. emergent electroencephalography to rule out nonconvulsive status epilepticus • C. lumbar puncture to rule out meningitis • D. no procedure necessary; treat for bacterial sinusitis with appropriate antibiotic therapy • E. urine drug screen for barbiturates, amphetamines, and cocaine

38. 11 • A 15-year-old girl presents to the emergency department with a 4-week history of nasal drainage and face pain and a 2-week history of frontal headaches and fatigue. Her mother complains that her daughter has an "attitude" and has not been respectful or seemed to care about anything for the past 2 weeks. The daughter awoke this morning with a headache and vomited. On physical examination, the adolescent is afebrile and has normal vital signs. She responds slowly to questions and is not oriented to the date. She complains of pain to palpation of her cheeks and forehead. She has no nuchal rigidity and no focal weakness. The remainder of the physical examination findings are normal.Of the following, the BEST initial diagnostic procedure is • A. computed tomography scan of the head with intravenous contrast • B. emergent electroencephalography to rule out nonconvulsive status epilepticus • C. lumbar puncture to rule out meningitis • D. no procedure necessary; treat for bacterial sinusitis with appropriate antibiotic therapy • E. urine drug screen for barbiturates, amphetamines, and cocaine

40. Brain abscess • Often present only with severe headache of gradual or sudden onset, symptoms/signs of elevated ICP, mental status changes. • Less than 50% with fever • Cranial nerve deficits, papilledema, focal deficits develop later. • 25% develop seizures • Source • Preceding sinusitis, otitis media, mastoiditis, dental abscess • R  L shunting, i.e. cyanotic heart disease, AV malformations • Chronic pulm infections, i.e. cystic fibrosis • Diagnosis • Head CT with contrast initial study • MRI better sensitivity for small abscesses including satelitte lesions and early cerebritis • LP contraindicated if focal features before CT imaging

41. 12-meningitis • A term newborn is delivered to a mother who has had a 5-day history of a nonspecific gastroenteritis, some loose stools, generalized malaise, and low-grade fever. The infant had a seizure at 6 hours of age and is ill, with an inspired oxygen requirement of 0.40, some petechiae, and oozing from the umbilicus and phlebotomy sites. He is irritable on neurologic examination.Laboratory findings include: • White blood cell count, 7.5x103/mcL (7.5x109/L) • Platelet count, 90.0x103/mcL (90.0x109/L) • Hematocrit, 45% (0.45) • Aspartate aminotransferase, 240.0 U/L • Alanine aminotransferase, 300.0 U/L • Fibrinogen, 90.0 mg/dL (2.6 mcmol/L) • Prothrombin time, 20 seconds • Partial thromboplastin time, 60 seconds • Internationalized Normalized Ratio (INR), 1.80 • Serum glucose, 90.0 mg/dL (5.0 mmol/L) • A lumbar puncture reveals 35 white blood cells, with 50% polymorphonuclear cells and 50% mononuclear cells; 1 red blood cell; glucose of 60.0 mg/dL (3.3 mmol/L); and protein of 100 mg/dL (1,000 g/L). No organisms are seen on cerebrospinal fluid (CSF) Gram stain.Of the following, a TRUE statement about this patient's meningitis is that • A. gram-negative organisms are unlikely to be causative • B. group B streptococcal meningitis is likely to be the cause • C. infection likely is related to maternal enteroviral infection • D. the abnormal CSF glucose and protein values indicate bacterial meningitis • E. the abnormal liver function test results and CSF cell counts indicate herpes simplex virus infection

42. meningitis • A term newborn is delivered to a mother who has had a 5-day history of a nonspecific gastroenteritis, some loose stools, generalized malaise, and low-grade fever. The infant had a seizure at 6 hours of age and is ill, with an inspired oxygen requirement of 0.40, some petechiae, and oozing from the umbilicus and phlebotomy sites. He is irritable on neurologic examination.Laboratory findings include: • White blood cell count, 7.5x103/mcL (7.5x109/L) • Platelet count, 90.0x103/mcL (90.0x109/L) • Hematocrit, 45% (0.45) • Aspartate aminotransferase, 240.0 U/L • Alanine aminotransferase, 300.0 U/L • Fibrinogen, 90.0 mg/dL (2.6 mcmol/L) • Prothrombin time, 20 seconds • Partial thromboplastin time, 60 seconds • Internationalized Normalized Ratio (INR), 1.80 • Serum glucose, 90.0 mg/dL (5.0 mmol/L) • A lumbar puncture reveals 35 white blood cells, with 50% polymorphonuclear cells and 50% mononuclear cells; 1 red blood cell; glucose of 60.0 mg/dL (3.3 mmol/L); and protein of 100 mg/dL (1,000 g/L). No organisms are seen on cerebrospinal fluid (CSF) Gram stain.Of the following, a TRUE statement about this patient's meningitis is that • A. gram-negative organisms are unlikely to be causative • B. group B streptococcal meningitis is likely to be the cause • C. infection likely is related to maternal enteroviral infection • D. the abnormal CSF glucose and protein values indicate bacterial meningitis • E. the abnormal liver function test results and CSF cell counts indicate herpes simplex virus infection

43. Neonatal meningitis • Viral • Viral (aseptic) meningitis of the newborn may follow maternal infection, characteristically in the spring and summer seasons. • Herpes simplex viral meningoencephalitis is associated with a hemorrhagic pleocytosis, apnea, seizures, coagulopathy, and hepatic transaminase values generally greater than 1,000 U/L. • Bacterial more common than viral • Typically occurs in the face of a sepsis syndrome • known risk factors prenatally (maternal fever, chorioamnionitis, prolonged rupture of membranes) or postnatally (bacteremia, urinary tract infection, or respiratory distress), • Presents with apnea, lethargy, acidosis, hypoglycemia. • Physical examination findings can include a bulging or tense anterior fontanelle, irritability, fever, emesis, coma, seizures, increased or decreased neuromotor tone. • CSF values in bacterial meningitis: • protein > 150 mg/dL (1,500 g/L), • white blood cell count of more than 100 • glucose value < 50% of that measured in the blood. • Common bacterial pathogens include Group B Streptococcus, Escherichia coli, other gram-negative rods, and Listeria monocytogenes. Staphylococcal infections may be increasing. • S pneumoniae and Haemophilus influenzae are uncommon in newborn..

44. 13 • 6-year-old boy presents in late summer to the emergency department with a severe headache and muscle pains. He recently returned from a camping trip. On physical examination, he is febrile and has no focal weakness, but he suffers a prolonged tonic-clonic seizure and becomes unresponsive. Head computed tomography scan reveals no abnormalities. Acyclovir and fosphenytoin are administered. Magnetic resonance imaging shows subtle, diffuse signal change and thickening in the cerebral cortex, no signal changes in temporal lobes, and no meningeal enhancement.Of the following, the MOST likely cause of the boy's symptoms is • A. arbovirus • B. Borrelia burgdorferi • C. herpes simplex virus 1 • D. Listeria monocytogenes • E. Taenia solium

45. 6-year-old boy presents in late summer to the emergency department with a severe headache and muscle pains. He recently returned from a camping trip. On physical examination, he is febrile and has no focal weakness, but he suffers a prolonged tonic-clonic seizure and becomes unresponsive. Head computed tomography scan reveals no abnormalities. Acyclovir and fosphenytoin are administered. Magnetic resonance imaging shows subtle, diffuse signal change and thickening in the cerebral cortex, no signal changes in temporal lobes, and no meningeal enhancement.Of the following, the MOST likely cause of the boy's symptoms is • A. arbovirus • B. Borrelia burgdorferi • C. herpes simplex virus 1 • D. Listeria monocytogenes • E. Taenia solium

46. Infectious encephalitis • Suspected with neurologic dysfunction (eg, depressed or altered level of consciousness, lethargy, personality change, seizure, ataxia, focal neurologic findings) and CNS inflammation (+/- CSF pleocytosis; consistent neuroimaging or EEG findings). • Causes • Enterovirus (coxsackie, echovirus, poliovirus) • Arbovirus (WNV, LaCrosse virus) • more likely to occur in late summer, transmitted by mosquitoes. • More likely to cause generalized encephalitis • Herpes simplex • Childhood: • reactivation of the herpes simplex virus (usually HSV-1) in the trigeminal nerve • spreads directly into adjacent temporal lobe causing necrotizing focal encephalitis in the temporal lobes • Neonatal period: usually HSV-2. Enters via blood or from direct invasion. • EBV, VZV, HIV, CMV, Rabies • Empiric treatment • Acyclovir • Antibiotics, consider Doxycycline for RMSF or Ehrlichia