19-§1-Symmetrical Neurological Signs (+/-Headache)
(Symmetrical neurological signs
means that muscle strength, deep tendon reflexes, Babinski reflex, sensation
(...) are equal on both sides of the body. (E.g. paraplegia is
"symmetrical" but hemiplegia is not...)
- "NORMAL" BACTERIAL MENINGITIS?
Uncommon but we have to consider it because it is easy to treat.
- Diagnosis: acute+++; stiff neck +++; Kernig's
sign +; headache; high fever; +/- petechia (pxx021)
- Treatment: ampicillin IM 1g 4x/day until no signs, then
amoxycillin 500mg 1-2tabs 4x/day for 1 week.
(If IV drug addict and/or a few unclear focal signs, add gentamycin
- Diagnosis: "sub acute"; fever;
stiff neck is common (present in nearly all patients); level of
consciousness usually good/lucid (more rarely, unconscious (=final
stage)); 10% of patients have convulsions; the headache is typically
symmetrical, severe in temporal region and does not respond
to Paracetamol, diclofenac…
- Treatment: Fluconazole 200mg 1tab 2x/day for 6-10weeks
then fluconazole 200mg 1-2tabs per
day for life (see "25-Prophylaxis"). For severe cases, we prefer
to treat first with fluconazole 200mg 1tab 3x/day for 5 days and
after 1tab 2x/day. Resistance is rare or as we discovered
too late there is no cross-resistance between fluconazole
and itraconazole but itraconazole
is less active on crypto (but still active!). To know if treatment
is active: stop all painkillers on the 7thday to observe the level
of pain compared to pre-treatment levels. Stiff neck can stay
longer even if treatment is active.
- If a patient survives a severe infection, alertness may be reduced
("slow brain"), the pronunciation of words can be strange
(strong and not fluid), which is similar to after sever toxo infection.
- CEREBRAL TB? Common!!! 80% of
patients have symmetrical neuro signs. (For the other 20% see
- Diagnosis: "chronic";
characteristic TB signs such as irregular low fever, loss of weight,
typical gray copper skin color... sometimes confusion; +/- convulsion;
patients often have a stiff neck...
- Treatment See "31-Tuberculosis"
- CMV? Rare without ophthalmologic problems
(decrease of visual acuity)! Delirium; psy/cogn problems; lethargy;
photophobia; stiff neck… No treatment is available/affordable
in a poor hospice.
- HIV DEMENTIA?
No fever. Can be the first manifestation of HIV! Often
begins similar to Alzheimer's or chronic depression (memory loss,
loss of concentration...); confusion/delirium; behavior troubles;
aphasia; lack of motor coordination; trembling; etc. and sometimes
paraplegia! No curative treatment is available (but often a
TOXO treatment test is indicated before making the diagnosis!)
Symptomatic care as for psychological diseases: haloperidol,
diazepam (Attention!!! Those
patients have an increased sensitivity to the side effect of neuroleptic
drugs). Death usually comes in weeks or months...
Common, but only 20% of patients have symmetrical neuro exams! (For the other 80%,
- INFLAMMATORY DEMYELINATING POLYNEUROPATHIES, POLYRADICULITIS & VACUOLAR MYELOPATHY?