Meningitis and Encephalitis — MCQs
Which organism is most commonly associated with causing bacterial meningitis in adults?
Complications of tubercular meningitis include all except
Most common organism causing bacterial meningitis between 6 months and 2 years in vaccinated populations.
An appropriate single antibiotic for the empiric treatment of presumed bacterial meningitis in a six month old child would be:
Meningitis with rash is seen in -
Neurological complications of meningitis include all of the following except:
Child with generalized petechiae. CSF shows gram-negative diplococci. Treatment -
The most common cause of meningitis in children aged 5 yrs is-
Which virus is most commonly recognized as a prototypical viral hemorrhagic fever in endemic regions of West Africa?
A 10-year-old girl presented with fever, convulsions, and neck rigidity. CSF findings are protein 150 mg/dL, sugar 40 mg/dL with lymphocytic pleocytosis –
Meningitis and Encephalitis Indian Medical PG Practice Questions and MCQs
Question 1: Which organism is most commonly associated with causing bacterial meningitis in adults?
- A. Streptococcus agalactiae (Group B Strep)
- B. Staphylococcus aureus
- C. Mycoplasma pneumoniae
- D. Streptococcus pneumoniae (Pneumococcus) (Correct Answer)
Explanation: ***Streptococcus pneumoniae (Pneumococcus)*** - *Streptococcus pneumoniae* is the most common bacterial cause of **meningitis** in adults and children worldwide. - It often follows a primary infection like **otitis media**, sinusitis, or pneumonia. *Staphylococcus aureus* - While *S. aureus* can certainly cause meningitis, it is more commonly associated with **post-neurosurgical**, **post-traumatic**, or **hematogenous meningitis** from distant foci. - It is not the most frequent cause of community-acquired meningitis in the general population. *Streptococcus agalactiae (Group B Strep)* - *Streptococcus agalactiae* is a leading cause of **neonatal meningitis** (in newborns). - It is an important pathogen in infants but much less common in older children and adults. *Mycoplasma pneumoniae* - *Mycoplasma pneumoniae* is primarily known for causing **atypical pneumonia** and tracheobronchitis. - While neurological complications can occur, such as encephalitis or Guillain-Barré syndrome, it is a very rare cause of meningitis itself.
Question 2: Complications of tubercular meningitis include all except
- A. Hydrocephalus
- B. Cerebral Artery Thrombosis
- C. Cortical venous thrombosis (Correct Answer)
- D. Cranial Nerve Palsy
Explanation: ***Cortical venous thrombosis*** - While TB meningitis can cause vascular complications, **isolated cortical venous thrombosis** is a rare and atypical complication. - The inflammatory exudate in TB meningitis typically affects arteries and basal cisterns, leading to problems like arteritis and communicating or obstructive hydrocephalus [1]. *Hydrocephalus* - This is a common complication due to the inflammatory exudate in the **basal cisterns**, which obstructs the flow of cerebrospinal fluid (CSF) [2]. - It can be either **communicating** (impaired absorption) or **non-communicating** (obstructive due to blockage) [2]. *Cerebral Artery Thrombosis* - The **inflammatory exudate** surrounding basal cisterns in TB meningitis can lead to vasculitis and thrombosis of nearby arteries, especially the large cerebral arteries. - This can result in **ischemic strokes** and focal neurological deficits [3]. *Cranial Nerve Palsy* - The inflamed meninges and exudate can directly compress or damage **cranial nerves** as they exit the brainstem and travel through the basal cisterns. - Cranial nerves III, IV, VI, VII, and VIII are particularly susceptible to this complication.
Question 3: Most common organism causing bacterial meningitis between 6 months and 2 years in vaccinated populations.
- A. E. coli
- B. Pneumococcus (Correct Answer)
- C. H. influenzae
- D. N. meningitidis
Explanation: ***Pneumococcus*** - **Pneumococcus (Streptococcus pneumoniae)** is now the most common cause of bacterial meningitis in children aged 6 months to 2 years in countries with high vaccination rates for *H. influenzae type b (Hib)* and *N. meningitidis*. - The introduction of the **pneumococcal conjugate vaccine (PCV)** has significantly reduced the incidence of pneumococcal meningitis, but it still remains the leading cause among the remaining cases in this age group. *E. coli* - **E. coli meningitis** is primarily a concern in **neonates** (birth to 1 month of age), often acquired during passage through the birth canal. - Its incidence significantly decreases after the neonatal period, making it a much less common cause in children aged 6 months to 2 years. *H. influenzae* - Before routine vaccination, **Haemophilus influenzae type b (Hib)** was the leading cause of bacterial meningitis in children under 5 years old. - The widespread use of the **Hib vaccine** has drastically reduced its incidence, making it a rare cause in vaccinated populations. *N. meningitidis* - **Neisseria meningitidis** (meningococcus) is a significant cause of bacterial meningitis, especially in older children, adolescents, and young adults. - While it can occur in children aged 6 months to 2 years, widespread **meningococcal vaccination** in many regions has reduced its overall prevalence, making *Pneumococcus* a more frequent cause in this specific vaccinated age group.
Question 4: An appropriate single antibiotic for the empiric treatment of presumed bacterial meningitis in a six month old child would be:
- A. Cefotaxime (Correct Answer)
- B. Ampicillin
- C. Cefadroxil
- D. Cefuroxime
Explanation: ***Cefotaxime*** - As a **third-generation cephalosporin**, cefotaxime has excellent penetration into the **cerebrospinal fluid (CSF)** and provides broad-spectrum coverage against common bacterial meningitis pathogens in young children, including *Streptococcus pneumoniae*, *Neisseria meningitidis*, and *Haemophilus influenzae*. - In a 6-month-old child, cefotaxime is an excellent choice for empiric therapy. While both cefotaxime and ceftriaxone are appropriate at this age, cefotaxime is specifically preferred over ceftriaxone in **neonates younger than 28 days** due to concerns about biliary pseudolithiasis and bilirubin displacement, which can worsen jaundice and increase the risk of kernicterus. *Ampicillin* - While effective against *Listeria monocytogenes* (particularly important in neonates and infants <3 months) and Group B *Streptococcus*, ampicillin provides **insufficient coverage** for many other common causes of bacterial meningitis in this age group, particularly penicillin-resistant *Streptococcus pneumoniae* and *Haemophilus influenzae*. - Its use alone as empiric therapy for bacterial meningitis in a 6-month-old would be inadequate, often warranting combination therapy with a third-generation cephalosporin in younger infants. *Cefadroxil* - Cefadroxil is a **first-generation cephalosporin** primarily used for skin, soft tissue, and urinary tract infections. - It has **poor penetration into the CSF** and therefore is not an appropriate choice for treating meningitis. *Cefuroxime* - Cefuroxime is a **second-generation cephalosporin** with limited activity against *Streptococcus pneumoniae* and certain **Gram-negative bacteria** compared to third-generation cephalosporins. - While it has some central nervous system penetration, its efficacy is **inferior to third-generation cephalosporins** like cefotaxime or ceftriaxone for treating bacterial meningitis, especially considering the potential for resistant strains.
Question 5: Meningitis with rash is seen in -
- A. Neisseria meningitidis (Correct Answer)
- B. H. influenzae
- C. Strepto. agalactae
- D. Pneumococcus
Explanation: **Neisseria meningitidis** - **Meningococcal meningitis** is classically associated with an acute onset of fever, headache, stiff neck, and a characteristic **petechial or purpuric rash** [1]. - The rash is due to widespread **vasculitis** and disseminated intravascular coagulation (DIC) caused by the bacteria. *H. influenzae* - While *H. influenzae* type b (Hib) was a major cause of bacterial meningitis before vaccination, it typically does not cause a *rash*. - Meningitis caused by *H. influenzae* presents with fever, headache, stiff neck, and altered mental status without dermatological manifestations. *Strepto. agalactiae* - *Streptococcus agalactiae* (Group B Strep) is a common cause of meningitis in **neonates** and infants. - It usually presents with non-specific symptoms like fever, lethargy, and poor feeding, and a rash is not a typical feature of GBS meningitis. *Pneumococcus* - *Streptococcus pneumoniae* (Pneumococcus) is another leading cause of bacterial meningitis in adults and children [1]. - Symptoms include fever, headache, stiff neck, and altered mental status, but a cutaneous rash is not characteristic of pneumococcal meningitis [1].
Question 6: Neurological complications of meningitis include all of the following except:
- A. Increased intracranial pressure
- B. Brain abscess
- C. Subdural effusions
- D. Cerebral hamartoma (Correct Answer)
Explanation: Cerebral hamartoma - A cerebral hamartoma is a benign, tumor-like malformation of abnormally organized mature brain tissue; it is a developmental anomaly and not a complication of meningitis. - Unlike the other options, it does not represent an inflammatory, infectious, or pressure-related sequela of meningeal infection. Increased intracranial pressure - Increased intracranial pressure (ICP) is a common and serious complication of meningitis due to cerebral edema, hydrocephalus, or vasodilation. - Elevated ICP can lead to herniation, neurological deficits, and even death if not managed promptly. Brain abscess - A brain abscess is a localized collection of pus within the brain parenchyma that can develop as a focal complication of bacterial meningitis, particularly in cases of hematogenous spread or direct extension of infection [1]. - This serious condition causes focal neurological deficits and requires aggressive treatment. Subdural effusions - Subdural effusions are accumulations of sterile or infected fluid in the subdural space, most commonly seen in infants and young children with bacterial meningitis. - While they can be asymptomatic, large effusions may cause increased ICP or focal neurological signs requiring drainage.
Question 7: Child with generalized petechiae. CSF shows gram-negative diplococci. Treatment -
- A. IV Penicillin G
- B. Oral Penicillin V
- C. IV Ceftriaxone (Correct Answer)
- D. IV Cefotaxime
Explanation: ***IV Ceftriaxone*** - The presence of **generalized petechiae** and **gram-negative diplococci** in the CSF strongly suggests **meningococcal meningitis**, which is a severe infection requiring prompt and effective antibiotic treatment. - **Ceftriaxone** is a third-generation cephalosporin that has excellent penetration into the CSF and is a first-line treatment for bacterial meningitis caused by *Neisseria meningitidis*. *IV Penicillin G* - While **Penicillin G** can be effective against penicillin-susceptible strains of *Neisseria meningitidis*, there is increasing concern about penicillin resistance. - **Ceftriaxone** is generally preferred empirically due to its broader coverage and reliable efficacy against penicillin-resistant strains. *IV Penicillin V* - **Penicillin V** is an oral penicillin, and it is not suitable for the treatment of severe, invasive infections like **meningitis** due to inadequate systemic and CSF concentrations. - It is typically used for less severe infections like pharyngitis. *IV Cefotaxime* - **Cefotaxime** is also a third-generation cephalosporin with good CSF penetration and is an effective treatment for bacterial meningitis. - However, in many guidelines, **ceftriaxone** is often listed as the preferred agent due to its longer half-life, allowing for once-daily or twice-daily dosing, which is more convenient.
Question 8: The most common cause of meningitis in children aged 5 yrs is-
- A. Staphylococcus
- B. E.coli
- C. H. influenzae
- D. S. pneumoniae (Correct Answer)
Explanation: ***S. pneumoniae*** - **_Streptococcus pneumoniae_** (Pneumococcus) is the **most common cause of bacterial meningitis** in children aged 5 years and older, as well as in adults. - Widespread vaccination has reduced its incidence but it remains a significant pathogen. *H. influenzae* - **_Haemophilus influenzae_ type b (Hib)** was a major cause of meningitis in young children, but its incidence has **drastically decreased** due to the routine **Hib vaccine**. - Without vaccination, it would still be a significant cause in this age group, but with high vaccine coverage, it is less common than _S. pneumoniae_. *Staphylococcus* - **_Staphylococcus aureus_** and other staphylococcal species are **less common causes of meningitis** in otherwise healthy children. - They are more typically associated with meningitis following **neurosurgery**, trauma, or in immunocompromised patients. *E.coli* - **_Escherichia coli_** is a common cause of **neonatal meningitis** (in infants less than 3 months old), often acquired during passage through the birth canal. - It is **rarely a cause of meningitis** in children aged 5 years.
Question 9: Which virus is most commonly recognized as a prototypical viral hemorrhagic fever in endemic regions of West Africa?
- A. Lassa fever virus (Correct Answer)
- B. West Nile virus
- C. Yellow fever virus
- D. Crimean-Congo hemorrhagic fever virus
Explanation: ***Lassa fever virus*** - Lassa fever is a prototypical **viral hemorrhagic fever (VHF)** endemic to West Africa, caused by an **Arenavirus** transmitted through contact with rodent (Mastomys) excreta. - Characterized by fever, hemorrhagic manifestations in severe cases (15-20%), and multi-organ involvement with high mortality in hospitalized patients. - Represents one of the most important VHFs due to its **endemic nature** affecting millions annually in West Africa. *Yellow fever virus* - Yellow fever causes hemorrhagic fever with prominent **jaundice** and **hepatic necrosis**, transmitted by *Aedes* mosquitoes. - A **Flavivirus** causing "yellow" fever due to liver damage, but vaccine-preventable and less commonly seen in modern practice in endemic regions. *West Nile virus* - A **Flavivirus** primarily causing **neuroinvasive disease** (meningitis, encephalitis) rather than hemorrhagic fever. - Hemorrhagic manifestations are **extremely rare** and not characteristic of West Nile virus infection. *Crimean-Congo hemorrhagic fever virus* - CCHF is a severe **tick-borne VHF** (Nairovirus) with prominent hemorrhagic features and high mortality (10-40%). - Endemic to **Africa, Asia, Eastern Europe, and Middle East** but NOT West Africa, distinguishing its geographic distribution from Lassa fever.
Question 10: A 10-year-old girl presented with fever, convulsions, and neck rigidity. CSF findings are protein 150 mg/dL, sugar 40 mg/dL with lymphocytic pleocytosis –
- A. Viral meningitis
- B. Pyogenic meningitis
- C. Tuberculous meningitis (Correct Answer)
- D. Cryptococcal meningitis
Explanation: ***Tuberculous meningitis*** - The combination of **fever, convulsions, neck rigidity** (suggesting meningitis), elevated **CSF protein (150 mg/dL)**, **low CSF sugar (40 mg/dL)**, and **lymphocytic pleocytosis** is highly characteristic of tuberculous meningitis. - Tuberculous meningitis typically presents with a **subacute** or **chronic** course and CSF analysis reveals **elevated protein**, **low glucose**, and a **lymphocytic pleocytosis**. *Viral meningitis* - While viral meningitis presents with fever and meningeal signs, the **CSF protein** is usually mildly elevated (<100 mg/dL), and **CSF glucose** is typically normal. - Often has a **benign and self-limiting course** with predominantly lymphocytic pleocytosis. *Pyogenic meningitis* - Characterized by very high **CSF protein (>100 mg/dL)**, very low **CSF glucose (<40 mg/dL)**, and a predominant **neutrophilic pleocytosis**. - Symptoms are usually **acute and severe**, rapidly progressing over hours to days. *Cryptococcal meningitis* - This is more common in **immunocompromised individuals**, such as those with HIV/AIDS, and the clinical picture in a 10-year-old girl without immune compromise makes it less likely. - While it can cause elevated CSF protein and low glucose, the presence of **lymphocytic pleocytosis** is less specific for cryptococcal infection compared to tuberculous meningitis in this clinical context.
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