1. Case 1

2. Case Background A 7 year old healthy child went camping with his scouting team at a lake, where he swam for a long time. 7 days later, he developed a severe headache, high fever, nausea, vomiting, photophobia and meningismus.

3. What will be your next step? A.Empiric broad spectrum antibiotics + Anti epilepticsEmpiric broad spectrum antibiotics + Anti epileptics B.Acyclovir + Anti epilepticsAcyclovir + Anti epileptics C.Send for immediate Blood cultureSend for immediate Blood culture D.Lumbar punctureLumbar puncture E.Wait and watch + Careful Mannitol InfusionWait and watch + Careful Mannitol Infusion F.Order CT ScanOrder CT Scan

4. A. No response after days 2 and 3, patient becomes comatose, has seizures, needs airway protection: – Continue Antibiotic therapy for days 4 and 5 Continue Antibiotic therapy for days 4 and 5 – Go back to do list and restart! Go back to do list and restart! + 5

5. B. No Response after days 2 and 3, patient becomes comatose, has seizures, needs airway protection : – Continue Anti Virals for Days 4 and 5 Continue Anti Virals for Days 4 and 5 – Go back to first step and restart! Go back to first step and restart! - 5

6. C. Methicillin Resistant, Coagulase Negative Staphylococcus cultured. Start: – IV Cefepime IV Cefepime – IV Quinupristine/Dalfopristine IV Quinupristine/Dalfopristine – IV Vancomycin IV Vancomycin – IV Linezolid IV Linezolid – Resend blood for culture Resend blood for culture - 5

7. Resend Culture No growth Go back to starting list + 5

8. IV Drugs. No response after days 2 and 3: – Continue Antibiotic therapy for days 4 and 5 Continue Antibiotic therapy for days 4 and 5 – Go back to do list and restart! Go back to do list and restart! - 5

9. D. High intracranial pressure observed during LP WBC = 15,000/microlit Protein = (very high) Glucose = (very low) More Slides Provisional Diagnosis Next step + 10

10. More Slides

11. Next step Start: – Amphotericin B Amphotericin B – Fluconazole Fluconazole – Anti TB drugs Anti TB drugs – Albendazole + Ivermectin Albendazole + Ivermectin – Piperacillin/Tazobactam Piperacillin/Tazobactam – Meropenem or Imipenem/Cilastatin Meropenem or Imipenem/Cilastatin

12. Amphotericin B. CORRECT drug choice Patient becomes comatose Respiratory failure Intubated and put on ventilator No response to empirical antibiotic/antiviral/antifungal therapy Death on day 3! Provisional diagnosis? + 10

13. Other Drugs. INCORRECT drug choice Patient becomes comatose Respiratory failure Intubated and put on ventilator No response to empirical antibiotic/antiviral/antifungal therapy Death on day 3! Provisional diagnosis? - 5

14. E. Patient becomes comatose Respiratory failure Intubated and put on ventilator No response to empirical antibiotic/antiviral/antifungal therapy Death on day 5! Provisional diagnosis? - 5

15. F. Back to List of options + 5

16. Continuing Drugs On Day 6 patient has severe seizures, becomes comatose. Transferred to ICU. Further deterioration  Death! - 5

17. Provisional Diagnosis Correct Incorrect Back to work up

18. Incorrect Incorrect Diagnosis: You missed, he hit! - 10

19. Correct Early Diagnosis! Patient may have a chance if properly treated! Choose treatment + 15