Meningitis, Bacterial

MENINGITIS, BACTERIAL 59A

A 19-year-old freshman living in a college dormitory presents to the emergency department with 1 day of fever and headache. On presentation, she complains of anorexia, lethargy, nausea, and vomiting, as well as muscle aches and neck stiffness. On physical examination, her temperature is 39.1°C and heart rate is 124 beats/min. She appears toxic. Her neck is stiff, and there are small, purple, nonblanching petechiae on both legs. She is slightly confused about the day’s events. Lumbar puncture is performed, and the opening pressure is elevated. Cerebrospinal fluid (CSF) examination shows elevated protein, pleocytosis, low glucose, and intracellular gram-negative diplococci on gram-stained smear.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Young adult living in a crowded situation; headache, confusion, muscle aches; meningismus; fever and tachycardia; toxic appearance; petechial rash; CSF with elevated opening pressure, pleocytosis, elevated protein, low glucose, and intracellular organisms consistent with meningococcus on smear

How to think through: Fever, headache, nausea, and myalgias are common nonspecific symptoms, usually caused by a viral infection. The challenge is to identify patients with a more serious infection, such as bacterial endocarditis or meningitis. Clinicians should always ask patients with acute headache about neck stiffness or pain and photophobia. On physical examination, the Kernig and Brudzinski signs are not sensitive tests; the jolt test, in which headache worsens with rapid horizontal rotation, may be more sensitive. This patient’s heart rate is commensurate with fever but could also indicate the onset of shock. Her petechial rash is a crucial physical finding. Where should the examiner search for petechiae? (The entire skin and mucosa of the soft palate.) Although there is a broad differential diagnosis for a petechial rash, meningococcal meningitis is an emergency, so this finding should spur rapid evaluation and treatment. She should be placed on isolation precautions. What complications could occur? (Shock, disseminated intravascular coagulation, altered mental status, seizures, coma, death.) How should she be managed? (Rapid initiation of antibiotics. Corticosteroids improve outcomes in pneumococcal meningitis, so dexamethasone is also often given in bacterial meningitis. But meningococcus is seen on Gram stain, so corticosteroid treatment is not indicated. Fluid resuscitation is important.)