Sepsis, Meningitis, Encephalitis, Tetanus, Rabies and COVID-19 for NEET PG Medicine

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🎯 Exam priority: High. Expect: septic shock definition and first-hour care, meningitis organisms and empirical cover, dexamethasone timing, CSF patterns, HSV encephalitis, tetanus signs and treatment, tetanus prophylaxis for wounds, rabies categories and schedules, RIG dose, re-exposure, and COVID-19 treatment by severity.

CBME mapping: GM 26.1–26.35. Malaria, dengue, typhoid and fevers are in article 9; HIV in article 10; TB in article 7. Immunisation schedules are in Community Medicine.

Rabies categories and schedules, sepsis, meningitis, tetanus and COVID-19. Drawn by TrackNation.

Sepsis and Septic Shock

• Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.

• Septic shock: sepsis needing vasopressors to keep MAP ≥ 65 mm Hg with lactate > 2 mmol/L despite adequate fluids. Mortality is about 40–60%.

• qSOFA uses blood pressure, respiratory rate and GCS — no lab tests needed; best outside the ICU.

• Resuscitation: crystalloid, usually at least 30 mL/kg in the first 3 hours; then norepinephrine or vasopressin to MAP ≥ 65. Early antibiotics and source control (drain abscesses, remove infected catheters).

Meningitis and Encephalitis

• Headache, fever and neck stiffness; petechiae or purpura suggest meningococcaemia. Meningococcal sepsis can cause bilateral adrenal haemorrhage (Waterhouse–Friderichsen).

• Do not delay treatment: give antibiotics and dexamethasone (before or with the first antibiotic dose, every 6 h for 4 days; best evidence in pneumococcal meningitis) — before CT if the lumbar puncture will be delayed.

• Bacterial CSF: turbid, raised pressure, neutrophils, high protein, low glucose (CSF:blood ratio < 0.23 strongly suggests bacteria).

• Meningococcal contacts: rifampicin 600 mg 12-hourly × 4 doses, or one dose of ceftriaxone 250 mg IM.

• HSV encephalitis: olfactory auras (temporal lobe), MRI oedema in orbitofrontal and temporal areas, CSF PCR for HSV; treat with acyclovir.

• ICMR: intubate if GCS < 8.

Tetanus and Botulism

• Clostridium tetani toxin (tetanospasmin) binds nerve endings irreversibly and travels retrograde to the CNS. Incubation 2–50 days (average 5–10).

• Jaw stiffness is the most frequent first symptom, then trismus, risus sardonicus, opisthotonos and spasms; autonomic instability. Neonatal tetanus starts from a poorly cleaned umbilical stump in babies of unimmunised mothers.

• Treatment: human tetanus immune globulin (TIG 500 units IM), wound debridement, metronidazole, benzodiazepines for spasms, magnesium sulfate for autonomic instability, ventilation if needed. The disease gives no immunity — complete the vaccine series.

• Wound prophylaxis: unknown or < 3 doses → toxoid for any wound plus TIG for dirty wounds; ≥ 3 doses → toxoid if ≥ 10 years (clean) or ≥ 5 years (dirty) since the last dose, no TIG.

• Botulism: symmetric cranial nerve palsies with descending flaccid paralysis and no sensory loss.

Rabies

• Incubation averages 1–2 months (can exceed a year). Furious form (80%) with hydrophobia; paralytic form (20%). Almost always fatal once symptoms start.

• Wound care first: wash with soap and running water; avoid suturing; no irritants.

• RIG for all category III (and category II in the immunocompromised): ERIG 40 IU/kg or HRIG 20 IU/kg, infiltrated into and around the wounds.

• Vaccine: IM Essen days 0, 3, 7, 14, 28 in the deltoid (never gluteal); or intradermal updated Thai Red Cross 2-2-2-0-2 (two sites on days 0, 3, 7, 28).

• Start PEP at once; the 10-day observation applies only to dogs and cats. Pregnancy and infancy are not contraindications. Previously vaccinated: two boosters on days 0 and 3, no RIG.

COVID-19

• Incubation typically 2–10 days; diagnosis by RT-PCR/NAAT or antigen test; imaging shows ground-glass opacities and consolidation.

• High-risk mild–moderate: nirmatrelvir/ritonavir (preferred) or molnupiravir, started within 5 days of symptoms.

• Dexamethasone only when supplemental oxygen is needed — not for patients who do not need oxygen.

• MIS-C: post-infectious inflammatory syndrome in children resembling Kawasaki disease.

Traps the Examiner Sets

• Septic shock needs BOTH vasopressor-dependent MAP ≥ 65 and lactate > 2.

• Over 50 with meningitis → add ampicillin for Listeria.

• Dexamethasone goes with or before the first antibiotic dose, not after.

• Rabies: lick on broken skin = category III; previously vaccinated = 2 boosters, no RIG.

• Tetanus: descending paralysis is botulism, not tetanus.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 Septic shock '65/2': MAP 65 on pressors, lactate above 2 — septic shock

• 🧠 Meningitis over fifty → add 'A for Aged' Ampicillin (Listeria) — meningitis > 50

• 🧠 HSV loves the Temporal lobe: smells and memory — HSV encephalitis

• 🧠 Tetanus: 'Lockjaw, Laugh (risus), Leaning back (opisthotonos)' — tetanus signs

• 🧠 Rabies Essen '0-3-7-14-28'; ID Thai '2-2-2-0-2' — rabies schedules

• 🧠 ERIG 40, HRIG 20 — Horse needs double — RIG dose

Rapid-Revision Cards

• Sepsis

  Organ dysfunction from dysregulated host response.

• Septic shock

  Vasopressor for MAP ≥ 65 + lactate > 2 mmol/L.

• Sepsis fluids

  ≥ 30 mL/kg crystalloid in 3 h.

• qSOFA

  BP, RR, GCS.

• Meningitis 18–50

  Ceftriaxone + vancomycin.

• Meningitis > 50

  Add ampicillin (Listeria).

• Dexamethasone in meningitis

  Before/with first antibiotic; q6h × 4 d.

• Bacterial CSF

  Neutrophils, protein ↑, glucose ratio < 0.23.

• Waterhouse–Friderichsen

  Meningococcal sepsis + bilateral adrenal haemorrhage.

• Meningococcal contacts

  Rifampicin 600 mg q12h × 4, or ceftriaxone 250 mg IM.

• HSV encephalitis

  Temporal lobe, olfactory aura; acyclovir.

• Tetanus toxin

  Tetanospasmin; irreversible binding, retrograde.

• Tetanus signs

  Jaw stiffness → trismus, risus sardonicus, opisthotonos.

• Tetanus Rx

  TIG 500 U IM, debride, metronidazole, benzodiazepines, MgSO4.

• Tetanus immunity

  Disease gives none — vaccinate.

• Dirty wound, ≥ 3 doses

  Toxoid if ≥ 5 years; no TIG.

• Botulism

  Descending flaccid paralysis, no sensory loss.

• Rabies forms

  Furious 80% (hydrophobia), paralytic 20%.

• Rabies Cat III

  Transdermal bite, lick on broken skin, wild animal → RIG + vaccine.

• RIG dose

  ERIG 40 IU/kg, HRIG 20 IU/kg, into wound.

• Essen IM

  Days 0, 3, 7, 14, 28 (deltoid).

• ID Thai Red Cross

  2-2-2-0-2: days 0, 3, 7, 28.

• Rabies re-exposure

  Boosters days 0 and 3; no RIG.

• COVID dexamethasone

  Only if oxygen needed.

Sources

Facts in this article were checked against these documents.

• National Guidelines on Rabies Prophylaxis — National Centre for Disease Control (National Rabies Control Programme), MoHFW, 2015 (link)

• Standard Treatment Workflow: Neuroinfections — Indian Council of Medical Research, DHR, 2019 (link)

• MSD Manual Professional: Sepsis and Septic Shock; Acute Bacterial Meningitis; Encephalitis; Tetanus; Rabies; Botulism; COVID-19 — Merck & Co. (MSD Manuals), reviewed 2025–26 (link)

• Competency Based Undergraduate Curriculum, General Medicine (GM 26) — National Medical Commission, 2024

Test Yourself: Practice Questions

Thirty questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. Sepsis is currently defined as

• (a) two SIRS criteria with infection

• (b) bacteraemia with fever

• (c) life-threatening organ dysfunction caused by a dysregulated host response to infection

• (d) any positive blood culture

Q2. A patient with pneumonia remains hypotensive after adequate fluids and needs norepinephrine to keep MAP at 65 mm Hg. Septic shock also requires

• (a) positive blood culture

• (b) temperature > 39 °C

• (c) WBC > 12,000

• (d) serum lactate > 2 mmol/L

Q3. In sepsis-induced hypotension, most patients need crystalloid of at least

• (a) 100 mL/kg in 1 hour

• (b) no fluids

• (c) 30 mL/kg in the first 3 hours

• (d) 5 mL/kg over 24 hours

Q4. A septic patient remains hypotensive despite fluid resuscitation. The drug used to raise MAP to at least 65 mm Hg is

• (a) nitroglycerin

• (b) norepinephrine (or vasopressin)

• (c) propranolol

• (d) furosemide

Q5. The qSOFA score uses

• (a) platelets and PaO2

• (b) temperature and WBC

• (c) lactate, creatinine and bilirubin

• (d) blood pressure, respiratory rate and Glasgow Coma Scale

Q6. A septic ICU patient's likely source is an infected central venous catheter. Besides antibiotics, the key step is

• (a) leave it and add steroids

• (b) start heparin

• (c) remove the catheter (source control)

• (d) flush it with saline

Q7. A young adult has fever, headache, neck stiffness and a petechial rash. The most likely organism is

• (a) Streptococcus agalactiae

• (b) Listeria monocytogenes

• (c) Cryptococcus

• (d) Neisseria meningitidis

Q8. A 68-year-old has acute bacterial meningitis. Compared with a younger adult, the empirical regimen adds

• (a) doxycycline

• (b) metronidazole

• (c) azithromycin

• (d) ampicillin to cover Listeria

Q9. Per the ICMR neuroinfection workflow, empirical antibiotics in suspected pyogenic meningitis should be given

• (a) only after MRI

• (b) within 30 minutes of arrival — ceftriaxone 2 g + vancomycin

• (c) after CSF culture results

• (d) after 24 hours of observation

Q10. In suspected bacterial meningitis, dexamethasone should be given

• (a) after 3 days of antibiotics

• (b) immediately before or with the first antibiotic dose

• (c) only if cultures grow S. aureus

• (d) never

Q11. A patient with suspected bacterial meningitis needs a CT before lumbar puncture, which will take an hour. Antibiotics should be

• (a) started before neuroimaging

• (b) withheld until CT is reported

• (c) given only orally

• (d) withheld until the CSF is obtained

Q12. CSF in acute bacterial meningitis typically shows

• (a) eosinophils only

• (b) normal cells and protein

• (c) lymphocytes with normal glucose

• (d) neutrophils, raised protein and low CSF:blood glucose ratio

Q13. A patient with meningococcal sepsis develops shock with bilateral adrenal haemorrhage. This is

• (a) Addison disease from TB

• (b) Nelson syndrome

• (c) Sheehan syndrome

• (d) Waterhouse–Friderichsen syndrome

Q14. A household contact of a meningococcal meningitis patient should receive

• (a) penicillin for 2 weeks

• (b) vancomycin

• (c) no prophylaxis

• (d) rifampicin 600 mg 12-hourly for 4 doses (or single-dose ceftriaxone 250 mg IM)

Q15. A patient with fever and confusion reports auras of smelling burnt meat; MRI shows temporal and orbitofrontal oedema. The drug to start is

• (a) acyclovir

• (b) amphotericin B

• (c) praziquantel

• (d) ceftriaxone alone

Q16. Tetanus toxin causes disease by

• (a) destroying motor neurons by bacterial invasion

• (b) blocking acetylcholine release at the neuromuscular junction

• (c) binding nerve endings irreversibly and travelling retrograde to the CNS

• (d) invading muscle directly

Q17. A man with an untreated deep puncture wound has jaw stiffness, a fixed smile with raised eyebrows and painful spasms. The facial sign is

• (a) mask facies

• (b) Bell palsy

• (c) myasthenic snarl

• (d) risus sardonicus

Q18. The most frequent early symptom of generalised tetanus is

• (a) hydrophobia

• (b) descending paralysis

• (c) jaw stiffness

• (d) sensory loss

Q19. In a patient with tetanus, the antibiotic of choice is

• (a) ciprofloxacin

• (b) chloramphenicol

• (c) gentamicin

• (d) metronidazole

Q20. Human tetanus immune globulin in tetanus

• (a) replaces vaccination

• (b) reverses toxin already bound to nerves

• (c) is given orally

• (d) neutralises only unbound toxin; 500 units IM once is effective

Q21. In tetanus, magnesium sulfate infusion is used mainly to

• (a) neutralise toxin

• (b) prevent hypoglycaemia

• (c) control autonomic instability (catecholamine surges)

• (d) treat infection

Q22. A patient recovering from tetanus asks whether they are now immune. The answer is

• (a) yes, for 10 years

• (b) yes, for life

• (c) only if TIG was given

• (d) no — tetanus infection gives no immunity; complete the vaccine series

Q23. An adult with a dirty wound had a full primary tetanus series; the last dose was 7 years ago. Management is

• (a) toxoid + TIG

• (b) TIG only

• (c) tetanus toxoid booster, no TIG

• (d) nothing

Q24. A patient has symmetric cranial nerve palsies with descending flaccid paralysis and no sensory loss after eating home-canned food. The diagnosis is

• (a) Guillain–Barré syndrome

• (b) botulism

• (c) tetanus

• (d) rabies

Q25. A stray dog licks a child's abraded (broken) skin. Under the national guidelines this is

• (a) no exposure

• (b) category II — vaccine only

• (c) category III — wound care, rabies immunoglobulin and vaccine

• (d) category I — no treatment

Q26. A man has a minor scratch without bleeding from a dog. The prophylaxis is

• (a) no treatment

• (b) RIG only

• (c) wound care + RIG + vaccine

• (d) wound care + anti-rabies vaccine

Q27. The dose of equine rabies immunoglobulin is

• (a) 40 IU/kg infiltrated into and around the wounds

• (b) 10 IU/kg IV

• (c) 1 mL per wound regardless of weight

• (d) 20 IU/kg into the gluteus

Q28. The intramuscular Essen schedule of anti-rabies vaccine is given on days

• (a) 0, 7, 21 in the gluteus

• (b) 0 and 28 only

• (c) 0, 1, 2, 3, 4

• (d) 0, 3, 7, 14 and 28 in the deltoid

Q29. A veterinarian who completed full rabies vaccination 2 years ago is bitten by a dog. Management is

• (a) RIG only

• (b) full course plus RIG

• (c) no treatment

• (d) wound care and two booster doses on days 0 and 3, no RIG

Q30. A patient with COVID-19 has a normal oxygen saturation on room air. Regarding dexamethasone,

• (a) give a high dose for 3 weeks

• (b) it is not recommended unless supplemental oxygen is needed

• (c) it replaces antivirals

• (d) give to all patients

Active Recall

From memory: define sepsis and septic shock and outline resuscitation; give meningitis organisms, empirical antibiotics by age, dexamethasone timing and CSF findings; describe HSV encephalitis; describe tetanus signs, treatment and wound prophylaxis; give rabies categories, RIG dose, vaccine schedules and re-exposure; and state when dexamethasone is used in COVID-19.