МОЗ УКРАИНЫ
MINISTRY OF PUBLIC HEALTH OF UKRAINE
Vinnitsya National Medical Pirogov Memorial University.
Department of infectious diseases
Ratified
on a methodical conference
“____” _____________ 20__
Chief of department, professor Moroz L.V.
M E T H O D I C A L M A T E R I A L S
Practical employment for students of the 5th year of medical faculties
(on the topic, which was included in the plan of classroom preparing)
Topic 2.3: MENINGEAL SYNDROME IN THE CLINIC OF INFECTIOUS DISEASES.
DIFFERENTIAL DIAGNOSIS OF SEROUS AND PURULENT MENINGITIS.
MENINGOCOCCAL INFECTION.
TOXIC SHOCK.
EDEMA-SWELLING OF THE BRAIN.
Prepared by: Nikituk N.P., assistant professor
2009
1. Relevance of the topic:
Involvement of the central nervous system in infectious diseases are associated with varying degrees of tropism of viruses, bacteria, toxins, and their aggressiveness to the nervous system. They may show up in various degrees of irritation that can occur with inflammatory meningism and morphological changes and the transition to a serous(aseptic) or purulent(septic) meningitis. There may be severe complications such as cerebral edema or cerebral compression with severe consequences such as hydrocephalus, paresis, paralysis, and others. These lesions are very common among adults as well as in children, which is important in the practical medicine and the development of medical science. The differential diagnosis is very important at the pre-hospital and the hospital stage to take decision about adequate therapy.
Meningismus - presence of meningeal syndrome caused by non-inflammatory lesions of the meninges and other causes. The main symptoms are headache, neck stiffness, Kernig-Brudzinsky sign mostly absent or mild, symptoms associated with irritation, no pleocytosis in CSF.
Causes of meningismus: impairment of CSF circulation in tumors, cerebral edema as a result of intoxication, allergies, hemorrhage, hydrocephalus. In the pathogenesis is the rapid increase in intracranial pressure.
Meningitis - inflammation of the meninges of the brain and spinal cord. Causes of meningitis may have different pathogenic microorganisms (Mycobacterium tuberculosis, staphylococcus, streptococcus, pneumococcus, meningococcus, viruses, etc.). In all forms of meningitis observed meningeal syndrome, which consists of local and cerebral symptoms and changes in the cerebrospinal fluid.
Main symptoms:
• Hyperthermia
• Headache
• Vomiting
• Stiffness of neck
• Kernig-Brudzinsky sign
• Seizures
• Paralysis and paresis
• Lesions of the cranial nerves
• Impairment of the sensitivity
• hypersensitivity
• Autonomic disorders, impaired swallowing, breathing, bradycardia, low blood pressure, anisocoria
• Mental disorders.
2. Learning Objectives of the lesson (indicating the level of learning that is planned):
2.1. The student must have an idea (learn): a-1
• have an idea: about the place of meningococcal disease in the structure of infectious diseases: definition, current views on the pathogenesis, classification, clinical diagnosis, principles of treatment, acute care of the patients in the pre-hospital setups, the history of the study, contribution of Russian scientists in the history of scientific research in this field .
• Learn: with statistical data of the prevalence of meningococcal disease, current mortality in Ukraine and in the world.
2.2. Student should know: a-2
• The etiology of meningitis, pathogenic factors of pathogens;
• Epidemiology of diseases of CNS;
• Pathogenesis of meningism and meningitis;
• Clinical manifestations of meningism and meningitis, primary and secondary meningitis;
• Laboratory diagnosis: routine and specific;
• Complications;
• Principles of treatment and prevention (prophylaxis);
• Measures in the emergency conditions;
• Prognosis;
• Rules of discharge (of patients) and the issue of rehabilitation in ambulatory conditions (OPD).
2.3. The student should be able to: a-3
• Follow the basic rules of work at the bedside of meningitis patient;
• Collect medical history to assess the epidemiological data;
• Examine the patient and find the main symptoms and syndromes, to make the clinical diagnosis;
• Analysis of meningeal symptoms;
• Analysis cerebral symptoms;
• Carry out a lumbar puncture (LP);
• Analysis of the cerebrospinal fluid (CSF);
• Make a differential diagnosis of meningitis;
• On the basis of clinical examination evaluate the potential complications of meningitis and emergency conditions;
• Issue the medical documentation establishing a preliminary diagnosis "MENINGITIS" (emergency message to the regional epidemiological center);
• Plan the laboratory and further examination of the patient;
• Interpret the results of laboratory tests;
• Make a treatment plan considering the syndromes of disease, presence of complications, severity, allergic history, co morbidities; provide emergency pre-hospital care;
• Make plan and prophylactic measures in the site of infection;
• Recommend about regimen, diet, examination, observation period of reconvalescence.
2.4. Creative level (for the most capable and prepared students): a-4
Develop the creative abilities of students in the course of clinical trials, analysis of scientific sources to engage the student in scientific section of the department; suggest topics for essays on the most relevant question on the topic.
3. Educational goals (goals of the individual development):
1. Develop deontological view. Follow the rules of conduct at the bedside, the principles of medical ethics. Master the ability to establish psychological contact with the patient and his family.
2. Develop understanding of the impact of anti-epidemic measures in the prevalence of meningococcal disease.
3. On the topic material develop a sense of responsibility for the timeliness and accuracy of professional activities.
4. Basic knowledge and skills necessary for studying the topic
(inter-disciplinary integration).
|subject |To know |Be able to |
|Microbiology |Properties of meningitis pathogens of different etiology, |Interpret the results of specific |
| |methods of their specific diagnostics. |diagnostic methods. |
|Physiology |The normal physiological parameters human organs and |To evaluate the data of laboratory |
| |systems, normal parameters of laboratory tests (routine |test. |
| |blood test, urine, blood biochemistry, the parameters of | |
| |acid-base balance, electrolytes, and likewise). | |
| |The mechanism of dysfunction of organs and systems |Interpret pathological changes on the basis |
|Pathological physiology |in pathological conditions of different genesis. |(result) of laboratory examination in dys |
| | |functions of organs and systems of different |
| | |genesis. |
|Histology |The structure of the meninges, the normal | |
| |composition of CSF | |
|Microbiology |Properties of pathogens of meningitis of different |Interpret the results of specific diagnostic |
| |etiology, methods of specific diagnostics. |methods. |
|Immunology and Allergology |The main issues the subject, the role of immunity |Estimate these immunological studies. |
| |in the infectious process. | |
|Epidemiology |Epidemiological process (source, mechanism of |Collect epidemiological history, conduct |
| |infection, modes of transmission), the prevalence |anti-epidemic and preventive measures in the |
| |of disease |site of infection. |
|Neurology |Meninges, liquor-dynamics, CSF study, meningeal |1.Investigate meningeal symptoms. |
| |syndrome |2.Carry out lumbar puncture. |
| | |3. Studies of CSF test. |
|Dermatology |Pathogenesis and characteristics of the rashes on |Recognize the rashes in the patient and |
| |the skin. |interpret it correctly. |
|Surgery |Necrosis, thrombosis, and likewise, and tactics of |Timely diagnosis of these complications and |
| |medical care. |provide necessary assistance. |
|Propaedeutics of Internal Medicine |Main steps and methods of clinical examination. |To collect anamnesis, conduct the clinical |
| | |examination of the patient to detect abnormal |
| | |symptoms, make syndromes. Analyze the data. |
|Clinical Pharmacology. |Pharmacokinetics and pharmacodynamics of antiviral |Prescribe treatment based on age, individual |
| |drugs, antibiotics, means of pathogenetic therapy. |characteristics of the patient, to choose the |
| | |best dose and mode of intake of prescribed |
| | |drug. |
|Intensive care |Emergencies: Acute respiratory failure, cerebral |To diagnose and provide first aid in case of |
| |edema. |emergency: Acute respiratory failure, cerebral |
| | |edema. |
5. Structural and logical schematic contents of the chapter.
6. Plan and organizational structure of the activity:
|The main stages of classes, functions|Learning objectives|Control methods, methods of study |Methodological support materials |Time |
|and content. |at the level of | | |(min) |
| |assimilation | | | |
|2 |3 |4 |5 |6 |
|1. Preparation stage: | | | | |
|anizational measures | | | | |
| | | | | |
| | | |See item 1 “relevance of the topic” | |
|2.Settings of educational goals and | | | | |
|motivation | |Interview. |See item 2 | |
| | | |"Learning Objectives" | |
| | |Individual quiz/question. | | |
|3. Control the level of knowledge | | |Questions for individual interviews. | |
|Content - see 2.1, 2.2, "Learning | |Test control. | | |
|Objectives" |ІІ | |Tests of Level 2 | |
| | | | | |
| | | | | |
|2. The main stage | |Practical |Curation of patients related to | |
| |III |professional training to solve the |topic. | |
|Formation of professional skills. | |different (typical and atypical) |Case history. | |
| | |clinical situations. |Discharge from hospital. | |
|Content - see 2.2, 2.3, "Learning | | |Archive of history. Situational | |
|Objectives" | | |problems of Level 2. | |
|3. The final stage | |Individual control of practical and | | |
|1. Control and correction of |III |professional skills of |Tests - Level 3. | |
|professional skills. | |the students. | | |
|2. Summarizing lessons | |Analysis of typical mistakes. |Case studies - 3rd levels. | |
|3.Homework: Reference Books (main and| |Test control. | | |
|supplementary) | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
7. Materials for practical classes.
7.1. Questions for self-control:
1. Pathogenic factors of meningitis.
2. Sensitivity of pathogens in the external environment.
3. Epidemiological features in meningitis of different etiologies.
4. Peculiar properties of pathogenesis.
5. Modes of transmission of diseases with meningeal symptoms.
6. Stage of clinical course.
7. Clinical forms:
• Typical
• Atypical
• Localized
• Generalized
8. Specific features of hemogram in different forms of meningitis.
9. Specific nature of CSF in various forms of meningitis.
10. Differential diagnosis of meningitis.
11. Bacteriological, virological and serological diagnostic methods
and rules for collection of the material.
12. Complications of meningitis.
13. Features of therapeutic approach in various forms of meningitis and treatment of complications.
14. Rules of discharge of convalescent and especially their rehabilitation at home.
7.2. Tests (MCQ) level – 2
Variant -1
9.1.1. Causes of meningitis are:
A Neisseria meningitides
B. herpes virus
C. encephalitis virus
D. polio virus
E. Brucella ovis
9.1.2. The source of infection in meningitis is:
A. meningitis patients
B. bacilli carriers
C. Rodents
D. Mites
E. Cattle
9.1.3. Which is/are non-characteristic signs for infectious-toxic shock?
A. metabolic alkalosis
B. leucopenia with decrease of poly nuclear cells and thrombocytopenia
C. leukocytosis with the increase number of mononuclear cells and thrombocytopenia
G. hypoxemia and hypokalemia
D. early and progressive azotemia
9.1.4. The normal chloride level in the blood is:
A. 50 mmol / L
B. 100 mmol / L
C. 150 mmol / l
D. 200 mmol / L
E. 300 mmol / L
9.1.5. Fluid therapy used in infectious toxic shock(ITS):
A. colloidal solutions (Rheopolyglukin)
B. crystalloid
B. control the hemo- dilution
G. forced diuresis
D. All of the above
9.1.6.Optimized parameter of antibiotic therapy in ITS :
A. verification of patient pathogen
B. optimal drug concentration in blood and in the lesion
C. Maintaining the optimal interval between the administration of medicines
D. Using antibiotics interactions with the physical, chemical and pharmacological
compatibility
E. All of the above
9.1.7.Metod of diagnosis of cerebral Edema and swelling of the brain :
A. blood culture
B. EEG
C. lumbar puncture
D. REG
E. biological method
9.1.8. Name the correct sequence of symptoms in cerebral edema and swelling of the brain:
A. somnolence, stupor, sopor, coma
B. somnolence, sopor, stupor, coma
C. stupor, somnolence, sopor, coma
D. Coma, somnolence, sopor, stupor
E. coma, stupor, sopor, somnolence
9.1.9. Material for bacteriological examination of suspected cerebral Edema and swelling of the brain is:
A. gastric lavage
B. blood
C. urine
D. feces
E. CSF
9.1.10.Main symptoms in cerebral Edema and swelling of the brain at the peak of the disease:
A disturbance of consciousness
B. Headache
C. severe abdominal pain
D. Cramps
9.1.11. In serous(aseptic) meningitis CSF is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%
protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O.
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes,
protein 1.0 g / l. Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/1 ml, 85% lymphocytes, neutrophils
15%, protein 0.3 g / l. Sedimentation test is negative. Pressure- 250 mm H2O .
D. colorless, transparent, cell count 1500 cells/1 ml, 2% lymphocytes, neutrophils,
98% protein 6.6 g / l. Sedimentation test is sharply positive. Pressure- 350 H2O
9.1.12. The normal CSF at macroscopic evaluation:
A. purulent, turbid
B. transparent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
Variant- 2
9.2.13. Typical clinical manifestations at the peak of
disease:
A. hepato-lienar syndrome
B. sore throat – nasopharyngitis
C. hemorrhagic rash
D. fever
E. intoxication
F. meningeal syndrome - inflammation of the meninges
9.2.14. Typical complications of meningitis:
A toxic shock
B. cerebral edema
C. thrombosis
D. myocarditis
E. pneumonia
F. damage of cranial meninges
9.2.15. Which is not characteristic of metabolic acidosis?
A. increase concentration of water ions
B. increase concentration of potassium in the cell
C. Changes in content of potassium in the cell
D. decrease potassium (K) in plasma
E. increase exchange of oxygen by tissues
9.2.16. Shock, which has the highest mortality rate?
A. hypovolemic
B. cardiogenic
C. ITS
D. traumatic
E. Anaphylactic
9.2.17. Normal potassium level in the blood is: unit?
A 2.25
B. 2.5
C. 3.35
D. 4.5
E. 9.5
9.2.18. For DIC in ITS characterized by all except:
A. activation fibrinolysin
B. decrease in plasma concentrations of antithrombin III
C. Reduction of prothrombin
D. The decline in blood concentrations of complexes fibrinomer and dehydration
products of fibrin
9.2.19. The main pathogenetic mechanisms of meningitis are:
A. inflammation and swelling of the meninges
B. disturbed blood circulation in cerebral and meningeal vessels
C. hypersecretion of CSF and delay its resorption
D. fibrosis and collagenation of arachnoid
E. dehydration of brain cells and the intercellular space
9.2.20. In purulent (septic) meningitis liquor is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%,
Protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes, protein 1.0 g / l.
Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/ml, 85% lymphocytes, neutrophils 15%,
protein 0.3 g / l. Sedimentation test is negative. Pressure of 300 mm H2O.
D. colorless, transparent, cell count 1500 cells/ml , 2% lymphocytes, neutrophils, 98%
protein, 6.6 g / l. Sediment samples sharply positive. Pressure of 350 mm H2O
9.2.21. In meningism typical liquor is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%,
Protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes, protein 1.0 g / l.
Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/ml, 85% lymphocytes, neutrophils 15%,
protein 0.3 g / l. Sedimentation test is negative. Pressure of 300 mm H2O.
D. colorless, transparent, cell count 1500 cells/ml , 2% lymphocytes, neutrophils, 98%
protein, 6.6 g / l. Sediment samples sharply positive. Pressure of 350 mm H2O
9.2.22. In meningeal form of tick-borne encephalitis, macroscopic evaluation of CSF
is:
A. purulent, turbid
B. transparent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.2.23. In tuberculous meningitis cerebrospinal fluid at the macroscopic evaluation:
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.2.24. Name the correct sequence of symptoms in cerebral edema and swelling of the brain:
A. somnolence, stupor, sopor, coma
B. somnolence, sopor, stupor, coma
C. stupor, somnolence, sopor, coma
D. coma, somnolence, sopor, stupor
E. coma, stupor, sopor, somnolence
Variant- 3
9.3.25. Bacteriological diagnosis of meningitis:
A. bacteriological examination of- cerebrospinal fluid, blood, swab of the oropharynx
B. virological examination of feces
C. serological diagnosis – IFA, Haemagglutination
D. urine culture
9.3.26. Types of fever in meningitis:
A. subcerebral
B. irregular
C. Botkin’s
D. Kildyushevsky’s
9.3.27. Standard values for arterial pH are:
A 7.0
B. 7.4
C. 7.6
D. 7.8
E. 7.2
9.3.28. The basic principles of pathogenetic therapy of ITS:
A. fluid therapy
B. corticosteroid therapy
C. correction of acid-base status
D. protease inhibitors
E. all of the above items
9.3.29. For ITS all are correct, except:
A. clinical and pathophysiological manifestations of ITS caused by gram negative
and gram positive bacteria are the same
B. in the early stages of shock there is an increase in stroke volume and cardiac output
C. in the early stages of shock there is hyperventilation of lungs
D. AD is not a reliable indicator of the severity
9.3.30. In shock increases the secretion of a number of substances, except:
A. antidiuretic hormone
B. catecholamines
B. rennin
G. Insulin
9.3.31. In meningococcal meningitis CSF is:
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.3.32. Cerebral edema and swelling may occur in:
A. diarrhea with significant water-electrolyte disbalance
B. Malaria
C. Meningitis
D. mumps
E. tuberculosis
9.3.33. In tuberculous meningitis cerebrospinal fluid at the macroscopic evaluation:
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.3.34. Methods of diagnosis in cerebral edema and swelling of the brain:
A blood culture
B. EEG
C. lumbar puncture
D. REG
E. biological method
9.3.35. . Name the correct sequence of symptoms in cerebral edema and swelling of the brain:
A. somnolence, stupor, sopor, coma
B. somnolence, sopor, stupor, coma
C. stupor, somnolence, sopor, coma
D. coma, somnolence, sopor, stupor
E. coma, stupor, sopor, somnolence
9.3.36. Fluid therapy used in infectious toxic shock(ITS):
A. colloidal solutions (Rheopolyglukin)
B. crystalloid
B. control the hemo- dilution
G. forced diuresis
D. All of the above
Varant-4
9.4.37. Types of fever in meningitis:
A. sub cerebral
B. irregular
C. Botkin’s
D. Kildyushevsky’s
9.4.38. Typical changes in the hemogram in meningitis:
A leukopenia
B. leukocytosis
B. shift to the left of the formula
D. shift to the right formula
9.4.39. Which one is not a physiological buffer?
A. lungs
B. kidney
C. liver
D. gastrointestinal tract
E. heart
9.4.40. Microcirculatory changes in shock:
A. vasodilatation
B. hyper coagulation
C. sludge syndrome
D. hypoxia of blood cells
E. all of the symptoms
9.4.41. In ITS to support normal volume and composition of the extracellular fluid, including circulating blood valume, to maintain homeostasis and blood rheology, macro-and microcirculation is used all solutions, other than:
A. polyglukine
B. gelatinol
C. rheopolyglukine
D. Ringer-Locke solution
9.4.42. For metabolic acidosis is characterized all except:
A. increase concentration of hydrogen ions
B. decrease concentration of hydrogen ions
C. decrease bicarbonate concentration in plasma
D. absolute or relative excess of acid
9.4.43. Lumbar puncture is performed:
A. on first day of illness
B. on the second day of illness
C. on the third day of illness
D. any day of sickness
E. on the fifth day of illness
9.4.44. In serous (aseptic) meningitis liquor is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%,
Protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes, protein 1.0 g / l.
Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/ml, 85% lymphocytes, neutrophils 15%,
protein 0.3 g / l. Sedimentation test is negative. Pressure of 300 mm H2O.
D. colorless, transparent, cell count 1500 cells/ml , 2% lymphocytes, neutrophils, 98%
protein, 6.6 g / l. Sediment samples sharply positive. Pressure of 350 mm H2O
9.4.45. In subarachnoid hemorrhage, cerebrospinal fluid is (at the macroscopic evaluation):
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.4.46. CNS symptoms of purulent (septic) meningitis:
A. hypersensitivity, nausea and vomiting of central origin, often loss of
consciousness, headache, arching pain in the parietal and occipital regions, positive
Kernig sign, stiffness of neck
B. euphoria, agitation, restless behavior, auditory and visual hallucinations, a constant
headache, bulbar symptoms
C. adynamia (weakness), confusion, stun, dull headache
D. dizziness, tinnitus, adynamia (weakness), headache, pain in the fronto-temporal
region
9.4.47. The clinical manifestations of edema-swelling of the brain are:
A. Severe headache
B. Diarrhea
B. Vomiting
G. Meningeal symptoms
D. Loss of consciousness
9.4.48. Name the correct sequence of symptoms in edema - swelling of the brain:
A. somnolence, stupor, sopor, coma
B. somnolence, sopor, stupor, coma
C. stupor, somnolence, sopor, coma
D. coma, somnolence, sopor, stupor
E. coma, stupor, sopor, somnolence
Variant- 5
9.5.49. Antibiotic therapy is completed:
A. after normalization of temperature
B. at the CSF cell count of 100 cells - neutrophils
C. at the CSF cell count 50 cells - lymphocytes
D. antibiotic therapy is not mandatory
E. 10 days after normalization of temperature
9.5.50. Antibiotic therapy is carried out:
A. bakterolom
B. penicillin
C. chloramphenicol
D. streptomycin
E. erythromycin
9.5.51. For the initial period ITS not typical:
A. decrease in pulse pressure
B. increase in cardiac output
C. decrease arterial-venous oxygen difference
D. moderate tachycardia
E. mild hypotension
9.5.52. If a patient with sepsis has developed ITS after antibiotics therapy, what is the tactic of a doctor?
A. proceed antibiotics therapy with the introduction of bacteriostatic
B. infusion of plasma substitutes
C. dopamine drip infusion to normalize blood pressure
D. Use of high doses of corticosteroids
E. all of the above
9.5.53. Types of shock that can be attributed to the circulatory?
A. endotoxic
B. exotoxic
C. ITS
D. septic
E. all of the above
9.5.54. In ITS develop all changes, except:
A breach of oxygen transport and utilization
B. fermentopathy
C. violations of membrane integrity
D. activation of peroxidation of lipid
E. sludge - Syndrome
F. excess loss of body fluids
9.5.55. In serous (aseptic) meningitis liquor is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%,
Protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes, protein 1.0 g / l.
Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/ml, 85% lymphocytes, neutrophils 15%,
protein 0.3 g / l. Sedimentation test is negative. Pressure of 300 mm H2O.
D. colorless, transparent, cell count 1500 cells/ml , 2% lymphocytes, neutrophils, 98%
protein, 6.6 g / l. Sediment samples sharply positive. Pressure of 350 mm H2O
9.5.56. The normal CSF at macroscopic evaluation:
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
9.5.57. Causes of meningitis are:
A Neisseria meningitidіs
B. herpes virus
C. encephalitis virus
D. polio virus
E. Brucella ovis
9.5.58. Fluid therapy used in ITS:
A. colloidal solutions
B. Crystalloid solutions
C. controlled hemodilution
D. forced diuresis
E. all of the above methods
9.5.59. The optimal parameters of antibiotic therapy in ITS:
A. verification of patient flora
B. optimal concentration of drug in the blood and in the lesion
C. Compliance with the optimal interval between the administrations of drugs
D. Use of antibiotics connection with the physical, chemical and pharmacological
compatibility
E. all of the above
9.5.60. Normal potassium level in the blood is:
A 2.25
B. 2.5
C.3.35
D. 4.5
E. 9.5
Variant-6
9.6.61. CNS symptoms of purulent (septic) meningitis:
A. hypersensitivity, nausea and vomiting of central origin, often loss of
consciousness, headache, arching pain in the parietal and occipital regions, positive
Kernig sign, stiffness of neck
B. euphoria, agitation, restless behavior, auditory and visual hallucinations, a constant
headache, bulbar symptoms
C. adynamia (weakness), confusion, stun, dull headache
D. dizziness, tinnitus, adynamia (weakness), headache, pain in the fronto-temporal
region
9.6.62. The clinical manifestations of edema-swelling of the brain are:
A. Severe headache
B. Diarrhea
C. Vomiting
D. Meningeal symptoms
E. Loss of consciousness
9.6.63. Name the correct sequence of symptoms in edema - swelling of the brain:
A. somnolence, stupor, sopor, coma
B. somnolence, sopor, stupor, coma
C. stupor, somnolence, sopor, coma
D. coma, somnolence, sopor, stupor
E. coma, stupor, sopor, somnolence
9.6.64. The optimal parameters of antibiotic therapy in ITS:
A. verification of patient flora
B. optimal concentration of drug in the blood and in the lesion
C. Compliance with the optimal interval between the administrations of drugs
D. Use of antibiotics connection with the physical, chemical and pharmacological
compatibility
E. all of the above
9.6.65. Normal potassium level in the blood is:
A 2.25
B. 2.5
C. 3.35
D. 4.5
E. 9.5
9.6.66. Causes of meningitis are:
A. Neisseria meningitides
B. The herpes virus
C. encephalitis virus
D. polio virus
E. Brucella ovis
9.6.67. Fluid therapy used in ITS:
A. colloidal solutions
B. Crystalloid solutions
C. controlled hemodilution
D. forced diuresis
E. all of the above methods
9.6.68. In serous (aseptic) meningitis liquor is:
A. colorless, transparent, cell count 3 cells/ml, 99% lymphocytes, neutrophils 1%,
Protein 0.33 g / l. Sedimentation test is negative. Pressure- 250 mm H2O
B. colorless, transparent, cell count 200 cells/ml, 80% lymphocytes, protein 1.0 g / l.
Sedimentation test is positive. Pressure- 300 mm H2O.
C. colorless, transparent, cell count 10 cells/ml, 85% lymphocytes, neutrophils 15%,
protein 0.3 g / l. Sedimentation test is negative. Pressure of 300 mm H2O.
D. colorless, transparent, cell count 1500 cells/ml , 2% lymphocytes, neutrophils, 98%
protein, 6.6 g / l. Sediment samples sharply positive. Pressure of 350 mm H2O
9.6.69. For the initial period of ITS not typical:
A. decrease pulse pressure
B. increase cardiac output
C. decrease arterial-venous oxygen difference
D. moderate tachycardia
E. mild hypotension
9.6.70. For metabolic acidosis it is characterized by all, except:
A. increase concentration of hydrogen ions
B. decrease concentration of hydrogen ions
C. decrease concentration of bicarbonate in plasma
D. absolute or relative excess acid
9.6.71. In meningeal form of tick-borne encephalitis, liquor is (at a macroscopic evaluation):
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
9.6.72. In tuberculous meningitis cerebrospinal fluid is ( at the macroscopic evaluation):
A. purulent, turbid
B. transparent, opalescent
C. hemorrhagic
D. xanthochromie
E. colorless, transparent
Correct answers to the tests on the topic: Meningococcal disease. Edema-swelling of the brain and ITS.
|Вариант 1 |Вариант 2 |Вариант 3 |Вариант 4 |Вариант 5 |Вариант 6 |
|9.1.1. |9.2.13. А,B,C,D,E,F |9.3.25. А,B,C |9.4.37. А,B |9.5.49. C |9.6.61. B |
|A,B,C,D,E | | | | | |
|9.1.2. A,B,C,D |9.2.14. A,B,C,D,E,F |9.3.26. А, B |9.4.38. А,В,C |9.5.50. B,C,D |9.6.62. C,D,E |
|9.1.3. А |9.2.15. B |9.3.27. B |9.4.39. E |9.5.51. А |9.6.63. А |
|9.1.4. B |9.2.16. C |9.3.28. E |9.4.40. E |9.5.52. E |9.6.64. E |
|9.1.5. E |9.2.17. D |9.3.29. А |9.4.41. D |9.5.53. E |9.6.65. D |
|9.1.6. E |9.2.18. А |9.3.30. D |9.4.42. B |9.5.54. F |9.6.66. А,B,C,D,E |
|9.1.7. B,C,D |9.2.19. А,B,C |9.3.31. А |9.4.43. D |9.5.55. B |9.6.67. E |
|9.1.8. B |9.2.20. D |9.3.32. B,C |9.4.44. B |9.5.56. E |9.6.68. B |
|9.1.9. E |9.2.21. А |9.3.33. D |9.4.45. C |9.5.57. А,B,C,D,E |9.6.69. А |
|9.1.10. А,B,D |9.2.22. B |9.3.34. B,C,D |9.4.46. А |9.5.58. E |9.6.70. B |
|9.1.11. B |9.2.23. D |9.3.35. B |9.4.47.C,D,E |9.5.59. E |9.6.71. А |
|9.1.12. E |9.2.24. B |9.3.36. E |9.4.48. B |9.5.60. D |9.6.72. B |
7.3. Algorithm with respect to the formation of professional skills and diagnosis of meningitis
of different etiologies
|№ |exercise |The sequence of execution |notes, warnings, self-control |
|1. | |1. Clarify complaints of the |Differentiates the complaints characterizing the syndromes: |
| |Master the technique of clinical |patient |• The overall toxicity |
| |examination of the meningitis | |• Organic problems |
| |patient with different genesis | |• Additional problems |
| | | | |
| | | | |
| | | | |
| | | |At the beginning pay attention to: the sequence of occurrence: |
| | |II. find out history: |• fever |
| | |1.Anamnesis of disease |• headache |
| | | |• impairment of consciousness |
| | | |• nausea and vomiting |
| | | |• skin rashes |
| | | |• related diseases |
| | | |• Other symptoms |
| |Conduct supervision of the | | |
| |patient | |Detect previous diseases, central nervous system injury. |
| | |2. Anamnesis vitae | |
|2. | | |Find data on the implementation of transmission factors of infection. |
| | | |Find data on the severity of the symptoms, prognosis, patient age, |
| | |3.epidemiological |comorbidities |
| | |Anamnesis | |
| | | | |
| | |III.Conduct an | |
| | |objective |Pay attention to: |
| | |examination |• Position the patient |
| | | |• body temperature |
| | |1. Overall patient survey |• The color of the skin, mucous membrane |
| | | |• The nature and localization of the rashes |
| | | |• Severity of neck muscle stiffness |
| | | |and Kernig Brudzinsky sign |
| | | |• Involvement of the central nerves |
| | | | |
| | | | |
| | | |Pay attention to: |
| | | |• tachycardia, bradycardia |
| | |2.Cardiovascular |• decrease BP |
| | |system: |• cardiac murmurs |
| | |• pulse | |
| | |• BP | |
| | |• auscultation of the | |
| | |heart | |
| | | |• The status of the oropharynx |
| | |3.Respiratory |• presence of bronchitis, pneumonia |
| | |System |• The status of ENT |
| | | | |
| | | |• meningeal syndrome |
| | |4. nervous system |• focal meningeal symptoms |
| | | |• condition of the fundus |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | |Pay attention to hyper leukocytosis, a shift to the left, the nature of |
| | | |the ESR |
| | |Laboratory studies: | |
| | |1. Complete blood count | |
| | | |No change in the typical course |
| | |2. urine (routine, microscopy) | |
| | | |• Nature |
| | |3. The study of the cerebrospinal |•Color |
| | |fluid: | |
| |Advise additional laboratory | | |
| |tests and other methods, their |microscopy |• cytosis |
| |interpretation | |• protein changes |
| | | |• bacteriological changes |
| | | |• sugar |
|3. | | |• presence of a film |
| | |4. blood sugar | |
| | | | |
| | |5.bacteriological studies | |
| | | | |
| | |6. bacterioscopic studies | |
| | | | |
| | |7.Serological methods: IHA, ELISA | |
| | | | |
| | | | |
| | | |Advise paired serum analysis at the intervals of 10 days: diagnostic |
| | | |titer at least 1:20 |
7.4. Case studies of the second level of assimilation ((= 2)
Case-1.
Patient A, 28 yrs., admitted for treatment (first day of illness) with complaints of a severe headache, frequent vomiting, not related to food intake, body temperature to 40 ° C.
The disease began acutely with severe chills. Epidemic anamnesis revealed that 5 days before the onset of the disease, 8-year-old son had nasopharyngitis.
The patient was irritative with neck muscle rigidity. Kernig Brudzinsky sign was strongly positive. There were petechial rashes over the skin of the trunk and limbs. Pulse rate 140 per minute, regular, thready. Heart sounds dramatically dull. In blood leukocytosis, rod nuclear cell - 15%, segmented nuclear cell - 79%, ESR - 46 mm / hour.
1. Formulate a preliminary diagnosis.
2. Name the complication and the cause.
3. Plan of investigation.
4. The principle of treatment.
Case-2
A patient 30 years old, builder admitted for treatment with complains of a severe headache, which is enhanced by changing the body position, dizziness, vomiting, not related to food intake, body temperature up to 37,4°C.
The patient became sick 7 days ago, when there were weakness and slight headache. Condition worsened, increased headache and vomiting started. Epidemic anamnesis revealed that the patient had contact with tuberculosis patients. The general condition of the patient severe stupor, neck stiffness, symptoms of Kernig Brudzinsky was strongly positive, right-sided ptosis, allocating the tongue towards right. The above mentioned complaints were without significant changes.
1. What is the preliminary diagnosis?
2. Plan of investigation.
3. The principle of treatment.
Case-3
A patient 28 years old, admitted with complaints of headache, body temperature up to
38 ° C, agitation, cough, convulsions, loss of consciousness.
Objectively: the patient was lying in the bed on her side. Flushed face, injected sclera. Pronounced muscle rigidity of the neck. Kernig Brudzinsky sign was strongly positive. Rales were present in the right lung. PR-106 per minute, regular, satisfactory. Epidemic anamnesis revealed that the mother had the flu. On day 4th the patient fell ill acutely with high grade fever and catarrhal symptoms. She was treated with antipyretic drugs. Due to the deteriorating condition, the patient was admitted to the intensive care unit (ICU).
1. Formulate a preliminary diagnosis.
2. What is the nature of complication?
3. Plan of investigation.
4. The principle of treatment.
7.5. Case studies of the 3rd level
Case-4
A patient has admitted on the 3rd day of his illness in serious condition with body temperature - 35,8 ° C. Lost of consciousness. Meningeal signs are positive. Multiple hemorrhagic elements are present over the skin. PR 132 per minute. HR – 28/min, AD - 60/40 mm Hg. At the onset of illness acute rise of temperature up to 40 °C, hemorrhagic rashes appeared over the limbs. Then - severe headache, vomiting, decreased temperature and blood pressure.
1. Find out the major complication of the disease:
A. ITS.
B. acute heart failure
C. respiratory insufficiency
D. cerebral coma
E. acute bleeding
2. Treatment.
Case-5
A patient 27 years old admitted on the 2nd day of the disease with complaints of severe headache, frequent vomiting. On examination: body T-37 ° C, the pulse rate120 / min, AD-80/50 mmHg. The condition was serious but concious. Adynamic. The position of the patient in the bed was forced with abandoned head. Over the skin of the lower extremities and buttocks hemorrhagic rashes with necrosis in the center. Pronounced neck stiffness with possitive Kernig Brudzinsky sign.
1. What is the cause of low BP?
A. ITS
B. DIC
C. Over production of immunoglobulin E
D. dehydration
E. Syndrome, edema-swelling of the brain.
2. Treatment.
Case-6
A patient has admitted on the 3rd day of his illness in serious condition with body temperature - 35,8 ° C. Lost of consciousness. Meningeal signs are positive. Multiple hemorrhagic elements are present over the skin. PR 132 per minute. HR – 28/min, AD - 60/40 mm Hg. At the onset of illness acute rise of temperature up to 40 °C, hemorrhagic rashes appeared over the limbs. Then - severe headache, vomiting, decreased temperature and blood pressure.
Identify the main complication of the disease.
1. Formulate a preliminary diagnosis.
2. Plan of investigation.
3. treatment
Case-7
Child, 8 years old, was admitted to the isolation (infection) hospital on February 10 at 22:00pm. From history we know that the child was ill a few days ago, when, after a nap in kindergarten there was a one-time vomiting, fever up to 38 ° C, the child became lethargic, refused to participate in the game. Around 17:00pm the mother took the child home, where she has repeated vomiting, increased body temperature up to 39 ° C, was capricious, and then there was a sharp weakness, refused to eat. After oral administration of amidopirin child fell asleep. At about 20:00 mother noticed the hemorrhagic rashes on the skin of the lower extremities and buttocks of child, which quickly began to spread to the trunk and upper extremities, and then appeared on his face.
On admission the general condition of the child was extremely severe, the body temperature 39,5°C. Consciousness is preserved, but the child comes into contact reluctantly slowed down, pronounced weakness. On the skin of the lower extremities, buttocks, trunk, upper limbs and face abundant dense hemorrhagic rashes of "stellate" character with targeted skin necrosis in the center. Moderately hyperemic pharyngeal mucosa with petechial hemorrhages. There were bleeding in the episclera of both eyes. Pronounced acrocyanosis. Breathing rate up to 40/minutes. harsh breathing in the lungs. Heart sounds considerably muted with regular rhythm. Pulse rate 160/min, thready. BP -40/20 mm Hg. Abdomen is soft and painless. The liver and spleen were not enlarged. Meningeal symptoms were negative. Regular bowl habbit. The patient did not pass urine since the onset of disease. Despite of the intensive care (antibacterial, detoxifying, anti shock with massive doses of parenteral corticosteroids, symptomatic agents, oxygen therapy, etc.), the child's condition rapidly deteriorated, hemodynamic stabilizing failed even after 8 hours after admission. The patient was died due to cardiovascular and respiratory arrest.
1. The clinical diagnosis of the disease.
2. Indicate a direct cause of death.
3. Named for the author's syndrome, which was the cause of death.
Case-8
The patient, 38 years old, was taken to the infectious diseases hospital in critical condition by ambulance doctor without attendants. Medical history is not known, however, according to neighbors, who found the patient's home in a state of unconsciousness, the last two days ago he felt good and did not consider himselves ill.
On examination: patient was unconscious. Increased motor activity with left side hemi paresis. There was an increase in muscle tone of the same side. Periodically observed clonic-tonic seizures in the right extremities. Pronounced asymmetry of the face, right eye gap narrowed, flattened right nasolabial fold, lowered the right corner of his mouth. Pronounced neck stiffness, bilateral positive Kernig sign, upper and lower Brudzinsky symptoms. On the skin of the upper and lower extremities, buttocks and body profuse haemorrhagic rashes of "stellate" character with necrosis in the center. Marked acrocyanosis. The body temperature of 38,8 ° C. Pharyngeal mucosa and the posterior pharyngeal wall is moderately hyperemic. Breathing rate up to 36/min., irregular, with a short apnea to 7-8 sec. In the lungs: vesicular breathing with hard tone. Heart sounds clean, muted, regular. Pulse rate 72/min, regular, weak filling. BP -80 / 50 mmHg. Tongue dry, coated with white bloom. Abdomen soft and palpable.
1. Preliminary diagnosis.
2. Specify the plan of diagnosis, with which diseases should be differentiated in this case?
3. Identify the key principles etiopathogenic and symptomatic therapy.
Case-9
Patient 20 years old, brought to the infectious diseases hospital with complaints of intense headache, fever, general aches, pain in the eyeballs, nausea, repeated vomiting, general weakness. She considers herself a patient for two days, when there were marked with the complaint. However, a careful anamnesis revealed that 3-4 days before the disease she had stuffy nose and slight pain in the throat when swallowing, but the patient did not give any significance and was not treated. Contact with infectious patients denied.
At the time of admission the general condition was moderate. Conscious. Sluggish. Skin color was normal, clean. The body temperature 38,5°C. Mucus membrane of the throat and back of the throat moderately hyperemic. Peripheral lymph nodes were not enlarged. Breathing through the nose was free, no discharge from the nose. Heart sounds slightly muffled, clean, rhythmic regular. Pulse rate 88 / min., satisfactory. BP -120/70 mmHg. Tongue moist, coated at the root of white bloom. The abdomen is soft and painless. The liver and spleen were not palpable. Significantly pronounced neck stiffness, positive Kernig on both sides, upper and lower symptoms Brudzinsky. Focal signs of CNS absent. Stool and flatus did not pass for two days. Urination was as usual.
Diagnostic lumber puncture was done: cerebrospinal fluid turbid, stream flowed; laboratory study: protein - 2,3 g / l, Pandy reaction + + + +; cytosis - 1475 leukocytes/mm3; microscopy draft - 97% neutrophils, lymphocytes - 3%.In hemogram - neutrophilic leukocytosis with a shift of band, moderately accelerated ESR.
When sowing nasopharyngeal swab culture is highlighted.
1. Explain the clinical diagnosis.
2. Specify the differential diagnosis in this case?
3. Treatment
.
Case-10
Patient A., 25years old, reffered by a doctor to isolation hospital with a diagnosis of meningococcal bacillicarriers. There was no complain at the time of admission. It is known that she was working in a kinder garden, 4 days ago had a contact with meningococcal disease (Before one week a boy had suffered with meningococcemia in the group).
Nasopharyngeal swab culture was positive for meningococcus, and therefore she was directed to the infectious diseases hospital. She felt on the day of investigation (as well as on the evening before one day and two days after the swab from the nasopharynx) malaise, stuffy nose, mild sore throat when swallowing, subfebrile fever, which she regarded as "common cold," and was treated with home remedies (drinking tea with raspberries, put mustard on his back).
On examination, the general condition satisfactory, the body temperature 36,8°C. Concious. Active. Normal skin color, clean. Pharynx and the posterior pharyngeal wall is moderately hyperemic. Breathing through the nose free, no runny nose. The internal organs abnormalities absent. Meningeal and focal signs of CNS absent.
1. Clinical diagnosis.
2. treatment.
3. Conditions of discharge.
7.6. Tests Level - 3 (=3
The levels of destruction of the nervous system in infectious diseases
|nature of |nosological form |Meningitis |Meningoencephal|Encephalitis|The damage of the |The damage of the |The damage of |
|inflammation | | |itis | |brain structures |peripheral nervs |the cerebral |
| | | | | | | |vessels |
|Serous |lymphocytic choriomeningitis | |± |+ |+ | | |
|inflamation | | | | | | | |
| |epidemic encephalitis |+ |+ |+ |+ | |+ |
| |Tick borne encephalitis |+ |+ |+ |+ |± |± |
| |mosquito encephalitis | |± |+ |+ | | |
| |influenzal | |± |+ |+ |+ |± |
| |Para-influenzal | |± |+ |+ | | |
| |measle | |± |+ |+ | | |
| |rubella | | |+ |+ | | |
| |chickenpox | |± |+ |+ | | |
| |CMV | |+ |+ |+ |+ |± |
| |Enterovirus | | |+ |+ | | |
| |Herpes virus | |± |+ |+ | | |
| |Mumps | | |+ |+ | | |
| |Rinosintitsial | | |+ |+ | | |
| |Tuberculosis | |± |+ |+ | | |
| |Toxoplasma | |± |+ |+ |+ | |
| |Mycoplasma |+ |± |± |± | | |
| |Psittacosis/ | |± | |± | | |
| |parrot disease | | | | | | |
| |Typhous | | |+ |+ | |+ |
| |Malaria | | |± |± | |+ |
The levels of destruction of the nervous system in infectious diseases
|nature of |nosological form |Meningitis |Meningoencephal|Encephalitis|The damage of the |The damage of the |The damage of |
|inflammation | | |itis | |brain structures |peripheral nervs |the cerebral |
| | | | | | | |vessels |
|Purulent |Meningococcal |+ |+ | |+ | | |
|(septic) | | | | | | | |
|inflamation | | | | | | | |
| |Amoebic | |+ |+ |+ | | |
| |Pneumococcal |+ |+ |+ |+ | | |
| |Influenza meningitis |+ |+ | |± | | |
| |Staphylococcal |+ |± | | | | |
| |Streptococcal |+ |± | | | | |
| |Leptospiral |+ |+ | |+ | |+ |
| |Listerial |+ |+ |± |± |+ |+ |
| |Syphilitic |± |± |+ |+ | | |
| |Proteaceae |+ |± | |± | | |
| |Pseudomonas |+ |± | |± | | |
| |Klebsiella |+ |± | |± | | |
| |Brucellosis | | |+ |+ |± | |
| |Anthrax |± |+ | |± | | |
Literature:
Basic (Main):
Возианова Ж.И. Инфекционные и паразитарные болезни – Киев: Здоровье, 2001. – Т.3 –С. 605-644.
Инфекционные болези / Под ред. Титова М.Б. – Киев: Высшая школа,1995. – С.311-325.
Руководство по инфекционным болезням / Под ред. Лобзина Ю.В. – Санкт-Петербург: Фолиант, 2003.- 567 с.
Шувалова Е.П. Инфекционные болезни. – Ростов н/Д.: Феникс, 2001. – 959 с.
Supplementary references:
Гавришева Н.А., Антонова Т.В. Инфекционный процесс. Клинические и патофизиологические аспекты. – Спб.: Специальная литература, 1999. – 255 с.
Иммунология инфекционного процесса: Руководство для врачей / Под ред. Покровского В.И., Гордиенко С.П., Литвинова В.И. – М.: РАМН, 1994. – 305 с.
Клинико-лабораторная диагностика инфекционных болезней: Руководство для врачей. – Спб.:Фолиант,2001. –384 с.
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planned
Depending upon epidemiological indications
Specific
Non-specific
Prophylaxis
Symptomatic treatment
Steroids
deintoxication
Etiological
Treatment
laboratory diagnosis
CSF study
Bacteriological test
Serological test
Macro-logical test
Sign and symptoms
Throat pain
Fever, intoxication
meningeal syndrome
hyperesthesia
convulsions
blood count
Low blood pressure
The status of other systems
consciousness
complications
Carrier formation
Complications
Formation of immunity
Elimination of pathogens
Toxemia
Bacteremia
Main diseases
Nasopharyngitis
Penetration
Pathogenesis
Recovery
Source - the sick persom, bacillicarriers. The mechanism of transmission: airborne, contact.
Epidemiology
Etiology
Viruses, bacteria, protozoa, meningococcus, mycobacterium tuberculosis, etc.
Meningeal syndrome. Meningism and meningitis. Their etiology, clinical and laboratory diagnosis. Serous(aseptic) and purulent(septic) meningitis. Treatment and prevention.
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