The discovery rule, as described in Bernson

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?"

On Meningitis and Other Such Diseases.

 1. Can it be said that cavernous sinus thrombosis is a complication of meningitis?

 

 Yes, CS thrombosis can be a complication of meningitis and most especially bacterial meningitis. Cerebral venous sinus thrombosis can be a complication of meningitis, including septic thrombophlebitis of the cavernous sinus. This condition is characterised by the extension of the infection to the venous sinuses with the formation of thrombi and possible severe neurological complications. The symptoms of the presentation may be proptosis, ophthalmoplegia and visual disturbances.

 

 2. What is the pathogenesis of the paraparesis that occurs as a late (i. e. postresolution) feature of the meningitis?

 

 Paraparesis is a late complication of meningitis which is characterised by the partial paralysis of the lower limbs, this could be due to post infectious sequelae such as damage caused by residual inflammation or it could be due to complications such as arachnoiditis or spinal cord injury. Inflammation and infection can cause fibrosis or scarring of the meninges which can then involve the spinal cord and nerve roots. Disorders which can cause motor deficits include chronic inflammation or direct infection related damage to the spinal cord which can lead to paraparesis.

 

 3. Is the performance of lumbar puncture relative to meningococcal meningitis safe?

 

 Lumbar puncture is not absolute contraindication in meningococcal meningitis. It should be done carefully especial in those patients who have features of elevated ICP or neurological impairment. In such a situation, there may be a danger of the so-called brain herniation caused by rapid changes in the cerebrospinal fluid pressure. Clinical assessment of the patient and neuroradiological imaging can help in determining the risk and then go for a lumbar puncture.

 

 4. What should be the cerebrospinal fluid (CSF) profile at the end of the management of acute bacterial meningitis, and by what duration of therapy?

 

 After completing treatment for acute bacterial meningitis, the CSF should typically show normalization of the following parameters:After completing treatment for acute bacterial meningitis, the CSF should typically show normalization of the following parameters:

 

 Appearance: Clear and colorless

 Cell Count: The normal level (is when it is less than 5 white blood cells per microliter).

 Protein: Low levels (Most often <45 mg/dL)

 Glucose: Average ranges (which are about two third of the blood sugar levels).

 Such alterations very often develop within the first 2 to 3 days of administering efficacious antibiotics, though the precise period may depend on the pathogens and the patient’s condition.

 

 5. Can chloramphenicol be used in the management of meningococcemia? Is there any gain in real use?

 

 Chloramphenicol may also be used in treating meningococcemia in case of penicillin or cephalosporin allergies. Chloramphenicol has activity against Neisseria meningitidis and has good penetration into the CNS. It is not frequently employed owing to its side effects including bone marrow suppression and because of more frequently employed antibiotics such as benzylpenicillin or cefotaxime which are preferred owing to their efficacy and safety.

 

 6. In management of suspected meningococcal meningitis, benzylpenicillin 1200mg should be given by slow intravenous injection or intramuscularly before investigations. Is this always true? Why didn’t you do a lumbar puncture for culture first?

 

 For suspected meningococcal meningitis, benzylpenicillin should be given without delay if meningococci are highly suspected to be the cause of the disease; a lumbar puncture to culture and analyse the CSF should be done if it is safe to do so. In severe illness or where one suspects complication such as increased intracranial pressure, imaging studies may be necessary prior to lumbar puncture to avoid complications. The principal problem is to begin the antibiotics as soon as possible, yet not harm the diagnostic process at the same time.

 

 7. Is the use of steroids in children with bacterial meningitis to prevent complications advisable?

 

 The administration of steroids in bacterial meningitis particularly in children is still a subject of debate but they are generally advised for particular forms of bacterial meningitis including Haemophilus influenzae type b (Hib) meningitis. It is also useful in preventing complications of the condition including hearing impairment and neurological dysfunction. The standard therapy is dexamethasone; it is given for 2 to 4 days starting from the first dose immediately after the diagnosis is made.

 

 8. What is the part played by anticonvulsants in encephalitis and how long should these be continued?

 

 Anticonvulsants are useful in the management of encephalitis to prevent seizures which are one of the features of the disease. It should be given if the patient develops seizures or at high risk of developing seizures because of the encephalitis. The duration of anticonvulsant therapy is manifold and is usually influenced by the clinical features of the patient and his/her seizures. Most anticonvulsants should be continued for a period of weeks to several months after the risk of seizures is considered to be low.

 

 9. This paper aims at explaining the efficacy of steroids in the management of radiculomyelitis.

 

 There is evidence that steroids may be useful in the management of radiculomyelitis, particularly if there is an inflammatory element to the pathology. They have the ability to decrease inflammation and oedema and may be used to relieve symptoms and enhance the patient’s recovery. There is evidence that the response to steroids may depend on the type of radiculomyelitis, but steroids are widely employed in the treatment of the condition.

 

 10. Do you operate on a patient with a brain cysticercosis lesion? The answer is presumably ‘Yes’, although this is not very clear, and there are many uncertainties. Also, should one ‘worm’ the patient’s gut when you find brain lesions; if so, with what?

 

 Treatment for brain cysticercosis is usually advised if the patient has symptomatic lesions or if there is substantial mass effect or neurological dysfunction. The management is pharmacological with the use of antiparasitic drugs including albendazole or praziquantel. Besides antiparasitic therapy supportive care and possibly corticosteroids may be utilized for inflammation. As for deworming the gut, it is also necessary to treat the intestinal cysticercosis to avoid re-infection and worsening of the condition. Most of the time this entails administration of anthelmintic drugs such as praziquantel or albendazole.