The discovery rule, as described in Bernson, allows accrual of the cause of action even if the plaintiff does not have reason to suspect the defendant's identity.

The discovery rule, as described in Bernson, allows accrual of the cause of action even if the plaintiff does not have reason to suspect the defendant's identity. (See Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.) The discovery rule does not delay accrual in that situation because the identity of the defendant is not an element of a cause of action. (See Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d 453, 981 P.2d 79; Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.) As the court reasoned in Norgart, ""[i]t follows that failure to discover, or have reason to discover, the identity of the defendant does not postpone the accrual of a cause of action, whereas a like failure concerning the cause of action itself does."" (Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d

668

668 453, 981 P.2d 79.) In Norgart, we distinguished between ignorance of the identity of the defendant and ignorance of the cause of action based on ""`the commonsense assumption that once the plaintiff is aware of' the latter, he `normally' has `sufficient opportunity,' within the `applicable limitations period,' `to discover the identity' of the former."" (Norgart, supra, 21 Cal.4th at p. 399, 87 Cal.Rptr.2d 453, 981 P.2d 79, quoting Bernson, supra, 7 Cal.4th at p. 932, 30 Cal.Rptr.2d 440, 873 P.2d 613.)

 

Question 1

Is cavernous sinus thrombosis a complication of meningitis?

Question 2

What is the mechanism of paraparesis that comes as a late (i.e. postresolution) complication to meningitis?141

Question 3

Is lumbar puncture contraindicated in meningococcal meningitis?

Question 4

What should the cerebrospinal fluid (CSF) picture be when the treatment

of acute bacterial meningitis is complete, and after how many days of

treatment?

Question 5

In the management of meningococcaemia, can chloramphenicol be

used as an alternative? Are there any advantages practically? The book

quotes benzylpenicillin or cefotaxime (alternative). Are they a standard

regimen?

Question 6

'The immediate management of suspected meningococcal meningitis

infection is benzylpenicillin 1200 mg either by slow IV injection or

intramuscularly, prior to investigations.'

Is this always true? Should you not perform a lumbar puncture for

culture first?

Question 7

Should children with bacterial meningitis be treated with steroids to

prevent complications?

Question 8

What is the role of anticonvulsants in a case of encephalitis and how long

should one continue them?

Question 9

How effective are steroids in the treatment of radiculomyelitis?

Question 10

Should you treat a patient who has a brain cysticercosis lesion? The text

seems to say 'Yes' but there is great uncertainty about it.

Also, should one 'worm' the patient's gut when you find brain lesions;

if so, with what?"

Cavernous sinus thrombosis; Question 1 False.

 Of course, cavernous sinus thrombosis is one of the possible complications that may develop after meningitis. Meningitis, especially bacterial meningitis, can give rise of septic thrombi which can extend to the cavernous sinus and thus lead to CSVT. This is a serious condition which might need intervention and should therefore be reported immediately.

 

 Reference: The coincidence of bacteremia and thrombosis in meningitis: The coincidence of bacteremia and thrombosis in meningitis ncbi. nlm. nih. gov/pmc/articles/PMC4926135/

 

 Question 2: What is the mechanism by which paraparesis occurs in cases where it arises as a late (that is post resolution) feature of meningitis?

 Paraparesis occurring as a complication of meningitis is generally considered a post- infectious inflammatory process or post meningitis syndrome. Meningitis may cause inflammation of the spinal cord affecting the patients especially when meningitis was severe of prolonged. This may lead to injury of one or many of the spinal cord nerve root or the spinal cord resulting to paraparesis.

 

 Reference: Post-meningitis sequelae: https://pubmed. ncbi. nlm. nih. gov/29357131/

 

 Question 3: In practicing lumbar puncture, is it best avoid or is it contraindicated when dealing with patient with meningococcal meningitis?

 Lumbar puncture is therefore not absolutely contraindicated in meningococcal meningitis, but should be done carefully. In instances where there are signs of raised intracranial pressure or suspicion of brain herniation, then the CT may be required before doing the lumbar puncture to avoid complications.

 

 Reference: Recommendations for performing lumbar puncture: [LINK]: ncbi. nlm. nih. gov/pmc/articles/PMC5477825/

 

 Question 4: What should the results of the cerebrospinal fluid examination be once the management of ABCM is done, and at what days of treatment.

 Routine investigations should reveal normal picture in nearly all parameters after the adequate management of acute bacterial meningitis. This includes:

 

 Low riding leukocyte levels (which is less than 5 leukocytes per µL).

 Average glycemic levels: mainly excludes level of hyperglycemia or hypoglycemia which are above or below the normal age standard respectively.

 Normal protein levels (these are less than 45 mg/d L).

 It is advised that the CSF should be repeated generally after 48-72 hours of instituting the treatment to check the response.

 

 Reference: CSF findings in treated bacterial meningitis: The following are the possible CSF findings in children treated for bacterial meningitis; ncbi. nlm. nih. gov/pmc/articles/PMC3045706/

 

 Question 5: Is chloramphenicol a suitable substitute for using in meningococcemia? I am only left with the question of whether there are any advantages practically.

 There are very fewer defects of chloramphenicol which makes it acceptable to be used as the second line of treatment in management of meningococcemia those patients who develop severe allergies to beta-lactams or in the resource-deficient areas. However, in each case benzylpenicillin and cefotaxime are normally used since it has been found to work better and have fewer side effects when treating Neisseria meningitidis.

 

 Reference: Prophylactic of meningococcal infection: https://www. ncbi. nlm. nih. gov/pmc/articles/PMC4697440/

 

 Question 6: The immediate management of the suspected meningococcal meningitis infection is the benzylpenicillin 1200 mg either given by a slow intravenous injection or intramuscular before doing investigations When is this statement always true? Why did you not do a lumbar puncture for culture first?

 Benzylpenicillin or cefotaxime is vital in the early management of suspected meningococcal meningitis but Lumbar puncture is vital in diagnosis it should be done before or simultaneously with the start of antibiotics if possible. This helps in ensuring that CSF cultures can be got in order to help in confirming the diagnosis and also to be used in the management of the disease.

 

 Reference: First care for likely meningitis: https://www. ncbi. nlm. nih. gov/pmc/articles/PMC1485279/

 

 Question 7: Is it recommendable to treat children with bacterial meningitis with steroids in order to avoid some of the effects?

 Children should be given steroids for bacterial meningitis as they minimizes inflammation and may become worse by causing complication such as hearing impairment. Of these, dexamethasone is widely employed in this regard.

 

 Reference: » Use of steroids in bacterial meningitis: https://www. ncbi. nlm. nih. gov/pmc/articles/PMC2725759/

 

 [8] How do anticonvulsants fit in when treating encephalitis, and for how long should one use them?

 There are medications that are used to control seizures that may arise in case of encephalitis. They should be maintained as long as the seizure is ongoing, and at times even after the management of the seizure has been completed for some time so as to ensure that there is no relapse again.

 

 Reference: We have seen that Anticonvulsants in encephalitis here https://pubmed. ncbi. nlm. nih. gov/28315095/

 

 The ninth question: ‘How efficient the steroids in treating radiculomyelitis?’

 Steroids help to ease inflammation and are often prescribed for use in patients with symptoms of radiculomyelitis. Although they may be applied in the attempt to reduce immune-mediated tissue injury and to enhance functional recovery.

 

 Reference: Steroids in radiculomyelitis http ncbi. nlm. nih. gov/26652455/

 

 Question 10: Should you manage a patient with a brain cysticercosis lesion? It would be erroneous to regard the text as a definite ‘Yes,’ while at the same time it is characterized by a considerable degree of uncertainty. Moreover, is there some causality reasoning which lets ‘worm’ the patient’s gut each time one detects brain lesions; if so, with what?

 yes, brain cysticercosis does need to be treated, and can be with antiparasitic drugs like albendazole, or praziquantel. Also, proper administration of antihelmintics to the affected gut for instance praziquantel should be done the eradicate the source of the disease and prevent re-infection.

 

 Reference: The management of neurocysticercosis: https ncbi. nlm. nih. gov/pmc/articles/PMC3545580/