Headache Answers 363analysis is helpful in diagnosing TA, but waiting for serum analysis inap-
propriately delays treatment. The confirmatory diagnostic test of choice is a
temporal artery biopsy.
330.The answer is c.(Rosen, pp 1716-1719.)The normal number of WBCs
in the CSF is 5 or fewer with 1 or less polymorphonuclear neutrophils
(PMN).Numbers greater than these should be taken as evidence for CNS infec-
tion. In cases of acute bacterial meningitis,cell counts of 1000/μL to
20,000/μL WBCs are observed, often with neutrophil predominance. In cases of
aseptic (viral) meningitis, cell counts are generally lower with lymphocyte pre-
dominance. Initial treatment with antibiotics prior to LP is unlikely to affect the
cell count, after 6 hours though, the culture is less likely to return positive. It
should be noted that a subset of patients with bacterial meningitis may present
with lymphocytic predominance. Therefore, lymphocytic predominance does
not rule out bacterial meningitis and antibiotics should be given.
The classic clinical presentation of bacterial meningitis includes photo-
phobia, headache, fever, and nuchal rigidity. None of these symptoms are spe-
cific(a)and an LP must be obtained. The classic clinical presentation is altered
in states of immunocompromised (HIV, corticosteroid use), so clinical suspi-
cion should be higher in these patients. Fevers (b)are generally thought to be
high in bacterial meningitis, but there is no number that is specific for its diag-
nosis. CSF protein level (d)generally ranges from 15 to 45 mg/dL. Levels
greater than 150 mg/dL are often seen in acute bacterial meningitis, but can
result from many other conditions including CNS abscesses, encephalitis, and
fungal infections. Fungal infections often have CSF proteins that are markedly
elevated, often greater than 1000 mg/dL. Glucose levels are generally depressed
(e)in cases of bacterial meningitis.
331.The answer is c.(Goetz, pp 1192-1194. Rosen, pp 1456-1459.)
Dystonic reactionsmay occur with the use of dopamine blocking agents.
Medications classically associated with dystonic reactions are typical
antipsychotics (eg, haloperidol) but can also occur with the antiemetics
used to treat migraines. They are generally not life-threatening and respond
almost immediately to administration of diphenhydramine (Benadryl) given
intravenously or intramuscularly or benzodiazepines. Common dystonic
reactions include oculogyric crises (eyes deviating in different directions),
torticollis, tongue protrusion, facial grimacing, and difficulty speaking.
Morphine sulfate (a)has the principal side effect of respiratory depres-
sion. This effect and the drug’s analgesic properties are reversed by naloxone.