Central Nervous System Infections and Inflammatory Disorders — WACS Viva & Clinical Scenarios (Neurology)

Exam-style central nervous system infections and inflammatory disorders viva scenarios with examiner probes and model answers for Internal Medicine candidates.

Scenarios covered

• SCENARIO 1: A 28-year-old male presents to the emergency unit with a 2-day history of high-grade fever, severe throbbing headache, neck stiffness, and progressive photophobia. On examination, he is febrile at 39.2°C, has a Glasgow Coma Scale of 13/15, marked nuchal rigidity, and positive Kernig and Brudzinski signs. There are no focal cranial nerve deficits or papilloedema on fundoscopy. Formulate the urgent diagnostic workup, prioritize empiric antimicrobial and adjunctive corticosteroid therapy, and state the indications for neuroimaging prior to lumbar puncture.
• SCENARIO 2: A 34-year-old woman living with advanced HIV disease (CD4 count 42 cells/microliter) presents with a 3-week history of dull, continuous headache, low-grade fever, intermittent confusion, and horizontal diplopia due to an isolated right sixth cranial nerve palsy. Lumbar puncture reveals an opening pressure of 320 mm H2O. Detail the definitive diagnostic steps, outline the induction antifungal regimen, describe the management of raised intracranial pressure, and state the optimal timing for initiating antiretroviral therapy.
• SCENARIO 3: A 45-year-old male presents with a 4-week history of insidious malaise, intermittent low-grade fever, weight loss, progressive lethargy, and bilateral sixth nerve palsies. Brain magnetic resonance imaging demonstrates marked basal meningeal enhancement and hydrocephalus. Cerebrospinal fluid analysis reveals a lymphocytic pleocytosis, protein of 2.8 g/L, and a CSF-to-blood glucose ratio of 0.22. Outline the clinical staging of tuberculous meningitis, interpret the CSF parameters, and detail the complete therapeutic protocol including anti-tuberculosis medications, adjunctive corticosteroids, an
• SCENARIO 4: A 22-year-old woman presents with rapid-onset bilateral visual loss over 4 days, preceded by severe orbital pain on eye movement, followed 1 week later by acute paraparesis, a sensory level at T4, and urinary retention. Spine MRI demonstrates contiguous hyperintensity on T2-weighted images extending from C5 to T6. Contrast the pathophysiology, diagnostic biomarkers, imaging hallmarks, and therapeutic approach of Neuromyelitis Optica Spectrum Disorder with classic Multiple Sclerosis.
• SCENARIO 5: A 52-year-old male with chronic right-sided suppurative otitis media presents with worsening left-sided hemiparesis, lethargy, fever, and papilloedema. Contrast-enhanced cranial CT demonstrates a ring-enhancing lesion with surrounding perilesional vasogenic edema in the right temporal lobe measuring 3.5 cm in diameter. Describe the microbial etiology, pathophysiological stages of brain abscess formation, indications for surgical aspiration versus conservative medical therapy, and the empiric intravenous antibiotic regimen.