DIP Episode 88 - USMLE Step 3/Medicine ITE/ABIM Review Series 3 (Meningitis)

Okay, welcome. My name is Devine. I am a PGY1 transitional year resident that's going into radiology. Into this podcast I'm going to be, so this is our 88th episode. I'm going to be talking about a step three topic and something that's also relevant for like the medicine board and the medicine training exam. I think I've got in some feedback from people and it sounds like for step three and the medicine training and whatnot because these are mostly residents taking this, they profess your other podcasts. So I'm just going to make many more podcasts for step three slasher, the medicine IT and the medicine boards, but they're going to be like short and sweet podcasts. So they'll focus on like one particular topic, but I'll still make them case presentation. So let's jump right into it. So what if you get a question about a patient that you know, let's say they're they end the military, they just, they were in basic training and had to be pulled and brought to the hospital because over the last like 12 to 24 hours, they've been sort of having like pretty bad headaches. They've been having like fever's, I mean their T-max is like 102.9 and when you see them, their blood pressure is kind of low, right? It's like 90 over 60 and you observe like PTKI on their skin, right? And then on your physical exam, right? Let's say the heart sounds fine, their long sound fine, I mean they're kind of tacky, cardiac and a little too kipnic, but they're long so the most part sound fine.

And then when you try to flex their head towards their, basically like bring their chin towards their chest, they can't do it. It's like impossible for them to do it. So hopefully with all these close-up giving you, I really hope you're thinking about a meningitis. And really on exams, if you see a person that has meningitis and they have skin findings, really the only bug you should think about is my seramine inciditis, right? So the classic demographic, right? It's like military, recruits, college students, basically any situation where a lot of people, especially young people, sort of get together in a group, you really want to think about a meningitis on the little circumstances, right? And the classic physical exam finding on these exams is the local rigidity, right? And really if you're trying to think, okay, what are the bugs that cause meningitis? Again, like I said, if you see skin findings or dimension like a gram-negative diplococcus, think about a my seramine inciditis, right? But if you see, if they say, oh, the fun gram positives or whatever, think about strep pneumo, right? So the, in fact, think of your shin organisms, right? Like strep pneumo, H flow, my seria, um, the tend to cause a lot of meningitis, a herpes can also cause meningitis. So it's just one of those weird things you want to keep in mind.

And then if a person is like immunocompromised or like C has HIV or is like greater than the age of 50, you also sort of kind of want to think about, um, um, uh, Listeria monocyte, uh, I'm just touching it, right? Remember, that's the one you have to cover with, um, insulin. So basically, if you, if you see meningitis, right? Like I said, the two most common causes are strep pneumo and H, uh, end on my seria. So strep pneumo and I seria, they cause about 80% of cases of meningitis, right? And again, fever, no coregidity, sodium acute onset, that's your cue to meningitis. And the thing is, how do you work up meningitis, right? So basically the first question you ask yourself on examples is this person, um, altered or do they have, um, so are they kind of like confused or do they have like signs of increased ICP, right? So do they have like papilladema on exam, right? Or do they have like any like neurological deficits? If you see any of those things, then you don't want to jump straight to a lumbar puncture. You want to do a CT of the head just to make sure they don't have like, um, uh, like high IC Ps because if you do a lumbar puncture and relieve that pressure, they will hurt you and die. And you don't want that, right?

So, um, if you see like if the patient is like confused, they are altered, they have like neuro deficits or they have like other like direct physical exam signs of, uh, increasing trocranial pressures like, like, bulginized, like papilladema and all that stuff. Um, you really want to think about, um, getting a CT scan for it before you do an LP. But if you don't see any of those signs and you're like, yeah, it looks a lot of meningitis, go ahead and do the lumbar puncture, okay? And remember the lumbar puncture when you send that off for results that will basically help you differentiate between like viral, but, but, uh, I mean, between a viral bacterial and a fungal meningitis, the thing is for the most part, if you're dealing with like, but, you're meningitis, um, you have a, uh, very high opening pressures, uh, I would not necessarily memorize these values, but I'll just say that usually they'll give you like a key on the exam. So, you know, they're dealing with high pressures, right? So, in bacterial meningitis, your opening pressures will be super high. You'll see a lot of white blood cells in the CSF and it will be neutrophils that you'll see. It will be predominantly neutrophils. There'll be low glucose, there'll be high protein because the bacteria consume all the glucose and with all the inflammation that's happening, right? All those dead and deep-red cells, you have a ton of protein and then you can also obviously send it off for gramsthane and culture.

And usually that will help you identify the organism in like 70% of your cases, right? Versus viral meningitis, things for the most part are normal. It's like, oh, the opening pressure is not too high. The white count is not super high, usually less than a thousand. And instead of seeing neutrophils as the predominant cells, you actually have lymphocytes for the most part, okay? And your glucose will be fairly normal. Your protein will be fairly normal, right? And usually the gramsthane and culture will not bring anything, right? Versus fungal infections, fungal infections usually, the opening pressure is high, the white count will be relatively high, but again, you'll also be lymphocytes, not neutrophils, that you'll find out predominantly. So basically fungal, I will just tell you this so that you don't have to remember a bunch of crap. If you're dealing with bacteria and meningitis, and fungal meningitis, fungal meningitis basically has essentially all the same findings as bacteria and meningitis, but in fungal meningitis, the cells that are elevated in the CSF are lymphocytes, non-neutrophils, viral meningitis, for the most part, things are normal. If you see like, relatively like normal, like everything, normal glucose, normal protein, we see lymphocytes, that's a viral meningitis. And then if they do the lumbar puncture, you see like a crap ton of ribloxels, like 500, 600, crap like that.

I mean, again, there are many causes of this thing like traumatic type, whatever, but really on exams, the number one thing you should think about is HSV, usually HSV1. So you do a lumbar puncture and you're like, okay, how do we treat this person? Right? Basically, I'll tell you this, if you're thinking about treatment, you want to think in terms of, is the person like a guiding, basically, in fact, let me put it this way for you. There are three groups of people you want to sort of deal with, or how do I treat them in any diseases on these exams? You ask yourself, are they less than 50 and okay, for the most part, basically they don't have like chronic medical problems or are they greater than 50 or do they have other problems in play, right? So for example, are they people that are like, have HIV, or they have some kind of like, where do you mean your deficiency disease? And then the third group of people, the people that have been in the hospital or have been around the OR in some way, shape of form, especially for their brains, right? So let's say the person has been in the hospital for a while, or the person has had like a VP Cion place, right? Because they had like high IC Ps for some other indication, right? If you see any of those things, then your treatment plans change, right?

So if for example, you are less than 50, okay, you don't have any like, let's say like the classic like college students and all that crap, you want to go ahead and give them basically the bugs you want to cover, right? You want to cover MRSA, and you want to cover like, uh, strep pneumonia in ICR, right? So, and then also sort of helps with strep pneumonia in a sense, but that's a very weak association. I would even bother memorizing that. But basically, you give a third generation cephalosporing so you can give like, uh, so again, less than 50 years old normal person, you can give strep triaxone, that's what's called strep fin, or you can give us strep toxin. So you can do either of those strep triaxone, I think of strep toxin as like baby strep triaxone, but it works pretty well as well, works pretty well in adults, although it's used strep toxin is used mostly in the pediatric world, right? So you can use either IV strep triaxone or cephotaxine, and then you add vent, that's literally all you need to do. But if the person is more than 50 years old, or they're, um, they have like HIV or whatever, then in addition to giving those drugs, you give to the people that are less than 50, you begin to worry about a stearia, right? And if you're worried about a stearia, you go ahead and give them pysilin, okay? You go ahead and give them pysilin, uh, for those circumstances. However, if the person is in the hospital, right?

They've been in the hospital and then the development in Gides, or if someone has been working around in their brain, you basically want to cover the two nasty, nasty bogus, right? So mersand pseudomonas. So you can give any drug that covers pseudomonas like the third genersion cephalosporin, cepatazidine, or the fourth genersion cephalosporin, um, cephepine, right? Or the remember cephepine causes a lot of stomach upset. And then you can also give meropenem, right? Meropenem also covers a pseudomonas. And then to cover mersand, obviously you do use vent, okay? But if they want it to be particularly evil on these exams and start talking about like, oh, what if the person is allergic to a bit of lactam, right? Like the allergic to like cephalosporins and all that crap. For the cephalosporin, so like for the septraax, or the cephutaxine, you can basically sub, sub that out with the fluoroquinolodermoxyfloxacin. It works well for, it can basically sub out for the cephalosporin. But pysilin, right? And pysilin, like, there are very few occasions where you will not give a person an pysilin. There's not many people that are allergic to an pysilin. But again, if they want it to be evil on the exam and the patient was allergic to an pysilin, you can solve that out with like a back trim, like IV back trim, right? So like TMPSMX.

And I mean, like if it's like strep pneumo that's causing the problem, you treat for two weeks, like, be there like two weeks, if it's like H-fluin like Syria, you treat for like a week. And then if it's like, um, if it's like a mersemininjitis or like Listeria or like some gram-negative bug like pseudomonas, you want to cover for like three weeks, right? So I just remember like the one, two, and three. So for one week, you, one week you use that for my Syria and H-flu for strep pneumo is two weeks. And then for like mersemin, amigram-negative bug, Listeria, go ahead and give for, for three weeks. And don't forget, if a person has my serum in in jidis, you want to treat close contacts, right? So you can treat close contacts with like rifampin or sipro like sef-trax, so just remember that the rifampin is the preferred agent on exams. So if you see all three of those answer choices, pick rifampin. But if the person is pregnant, you obviously don't want to do rifampin or sipro, right? And under those circumstances, go with sef-trax, where rifampin is the preferred agent. Now, one thing you want to think about, if you're suspecting herpes, right, don't forget to give a cyclover, IV cyclover for like three weeks. But if it's like a weird virus like Westnell or whatever crap, there's no tremendous Westnell virus, just supportive care, just watch the patient, maybe keep them in the ICU, whatever.

And the thing is, you can empirically, if you suspect that this may be herpes, or you get like an MRI and you see like a temporal lobe, like the mesiotemporal lobe, like enhancing or whatever, you're like, oh crap, this is herpes, right? You can empirically, especially if you have high slowspecions, can empirically add a cyclover to the person's treatment regimen, and then you can always withdraw it later, okay? Because herpes, like herpes meningitis is almost like a hundred percent fetal, if it's not treated, and I remember it classically affects the temporal lobe of the brain. And then, sort of as a complication of meningitis, right? You should just maybe try to recognize this triad. Those are always presented between the real world, but in exams, this is how it almost always presents, right? So high temperatures, right? So like fever, headache, neuro deficits, if you see that, you're thinking about a brain abscess. And really, the way you want to go ahead and do your work that up is go ahead and do an MRI, an MRI is the best test to help you detect a brain abscess. And really, these people need to be on like IV antibiotics for like, these are people you've probably sent to a sniff or whatever, you need like one to two months of IV antibiotics. And I mean, if it's a particular large abscess, if it's like two and a half centimeters or whatever, you can go ahead and sort of call your surgery and the old drain, the old drain that abscess, we'll assume it's in the right spot.

Now, here's one thing you absolutely do not want to do for a brain abscess. If a patient has a brain abscess, please never, ever, ever do a lumbar puncture. If you do a lumbar puncture again, that can relieve pressures and the patient can hurt you and die, right? And again, you certainly do not want to, you certainly do not want that. So I think that's all I'll say about herpies, about meningitis. I mean, for herpies again, the thing is herpies usually doesn't grow very well in CSF. So the thing you can try to do for herpies is just to do the PCR, doing like the HSV PCR is what you should do as a CSF study for suspect herpies. And then for like West now, West now, you can try to find like the IGM antibodies against the West now. You really do not want to start doing like a culture or whatever. It will basically not grow. So don't waste your time. Now, last thing I want to talk about, right? So what if you get a question about a patient, right, that has like, you know, like a large ovarian mass. And then they tell you that this patient starts acting confused, sort of acts altered and he's been going on for like three, four days, right? And then let's say they show you like the ovarian mass and you see like on imaging, let's say it has like like, you see like hyperdense things that are consumed like teeth. And then they say, oh, they analyze it up a thology. They see like hair, they see like thyroid, they see like neurons and all that crap.

But I really hope you're thinking about a teratoma. And in this patient, it's kind of acting crazy. You really want to think about something called an anti-nng receptor in cephalitis. This is something some people call it autoimmune and cephalitis. But basically, the classic association is that these people have a teratomas. And the thing is teratomas, right, they contain many tissue types, including neurons, right? So those neurons, remember, if a person has like a tumor or whatever, your body tries to fight against it. So the thing is, as your body is fighting against a tumor, you can actually like have like a failure of immune tolerance. And then you basically have those antibodies sort of crossing the blood brim barrier, especially if you have like blood brim barrier that has lost its integrity. So let's say you had like an infection or whatever, right? Those antibodies crossing to the brain and then they begin to literally like nuke the person's a central nervous system. So again, these people will have like weird symptoms. They will be like depressed. Sometimes they can be psychotic. They can have seizures. The blood pressures can keep going like up and down like superly, by blood pressures. Or they may have like weird like choriform movements of the upper extremities. If you see that again, in a patient that has a teratoma, you really want to think about anti-nng receptor in cephalitis. Really the way you treat this is you get rid of the tumor if it's there.

If you have a tumor like a teratoma, get rid of it. And then you want to sort of like suppress the immune system. Usually you've started like a steroid or you can start with IVIG. If that's not caught in it, you can jump to retox them up. I mean, there's actually some famous people that have had this that have sort of had this problem in the past. There's this player that will see is a fairly famous story like the Dallas Cowboys. They had like this person is he's actually a Nigerian mobile coi. And this guy basically he had to be like intubated for like a super long time. It was like three, four months, something crazy. And then he lost a ton of weight during that period. But thankfully it was actually able to come back. So some people actually do recover from this. But it's usually not a good thing to have right. So that's just the classic as a surgeon, teratoma, patient acting crazy. Think about, think about anti-NMD receptors, ethylitis. And then as I always do at the end of my podcasts, I do offer tutoring for step one, two CK, two CES, step three. And then if you're a resident applying, if you're a medicine applying to residency, so like ERAS or college student applying to a med school that's like Amkaz, I do offer application advising. I mean, I've been on the admissions committee for top three med school. Just hit me up, send me an email through the website. I can give you more details on this. So just let me know if you need help with any of those things.

Or if you need tutoring with your pre-clinical exams or your 30-ish-elf exams or weirdly like O-CAM for some reason, just let me know I do offer tutoring for all these things. So I'll see you in the next podcast. Have a wonderful day and try to keep this short. God bless. See you next time.

Young people in close quarters (military recruits, college students).

Neisseria meningitidis.

If the patient is altered, confused, or shows signs of increased ICP (e.g., papilledema).

High opening pressure, high neutrophils, low glucose, and high protein.

Listeria monocytogenes (or fungal infections generally).

Rifampin.

1) <50 years old/normal; 2) >50 years old or immunocompromised (HIV); 3) Hospitalized/Neuro-surgery patient.

Third-generation cephalosporin (e.g., ceftriaxone) plus vancomycin.

Ampicillin (to cover Listeria monocytogenes).

Fever, headache, and focal neurological deficits.

PCR (Polymerase Chain Reaction).

Three weeks.

1) <50 years old/normal; 2) >50 years old or immunocompromised (HIV); 3) Hospitalized/Neuro-surgery patient.

Third-generation cephalosporin (e.g., ceftriaxone) plus vancomycin.

Ampicillin (to cover Listeria monocytogenes).

Fever, headache, and focal neurological deficits.

PCR (Polymerase Chain Reaction).

Three weeks.