HPI
Exam
Actions
Labs
HPI
HPI: 22 y.o. lethargic and ill-appearing man brought in by friends from his college dormitory presents with fever, headache, photophobia and neck pain.
BP: 120/80 HR: 110 RR: 14 T: 39.3˚C Sat: 100% on RA FS: 90
Exam
General: mildly lethargic but arousable
Eyes: pale conjunctivae, + photophobia
Neck: pain and stiffness with flexion
Neuro: CN 2-12 intact. Normal sensation, strength; normal reflexes and gait
Skin: Diffuse petechial rash over complete trunk
Actions
Medications
- Antibiotics: Ceftriaxone & Vancomycin
- Steroids: Dexamethasone
Work-up
- CT Head
- Chest x-ray
- Lumbar puncture
- Admit to ICU, isolation bed
Public Health
- Prophylaxis for friends
- Prophylaxis for exposed health care providers
- Contact college dean due to public health concern
- Report case to Department of Public Health
Labs
- Lumbar Puncture CSF: WBC: 1600, RBC: 20, PMNs: 95%, Glucose: 34, Protein: 198. Gram stain: GN diplococci
- CT Head: unremarkable
Key Points
Differential Diagnosis
- Encephalitis
- Brain, spinal, epidural abscess
- Febrile seizure
- CNS/systemic lupus erythematosus cerebritis
- Intracranial bleed
- Primary or metastatic CNS malignancy
- Stroke
- Venous sinus thrombophlebitis
- Trauma
- Toxic/metabolic
Signs & Symptoms
- Fever
- Nuchal rigidity:
- Kernig: Flexed knee resists extension (bilateral).
- Brudzinski: Flexion of neck produces flexion at hips.
- Kernig and Brudzinski signs are neither sensitive nor specific for meningitis.
- Altered mental state, headache
- Photophobia
- Papilledema
- Focal CNS abnormalities
- Seizure, nonsimple
- Petechial and palpable purpuric rash (meningococcal infection)
- Associated infections: Sinusitis, otitis media, pneumonia
- Elderly and immune compromised: Confusion with or without fever, Less-striking symptoms overall
Labs
Blood
- CBC with differential and platelets
- BMP: electrolytes/glucose
- Assess for metabolic acidosis, SIADH
- Calculate CSF glucose to serum glucose ratio
- BUN/creatinine for medication dosing
- Coags: particularly in patients with petechiae or purpura
- Obtain before LP in severe sepsis or disseminated intravascular coagulation
- Blood cultures (2 sets) before antibiotics
- Toxicology studies as needed
Urine
- Urinalysis, Urine culture
- Urine Pregnancy
- Urine Tox
Lumbar Puncture/CSF
- Tube 1: Cell count and differential
- Tube 2: Protein and glucose
- Tube 3: Gram stain, culture, and sensitivity. May add acid-fast bacillus smear, TB culture, India ink and fungal cultures, VDRL, cryptococcal antigen as needed
- Tube 4: Repeat cell count or save for additional tests.
Imaging
CT Head
CXR: Pneumonia, TB if suspected
Consults
- Neurology
- Medical ICU
- Infectious Disease
Management
- Antibiotics
- Steroids
- Droplet precautions
- ICU Admission
- Prophylaxis for people exposed
Critical Actions
▢ Appropriate antibiotic therapy before imaging or lumbar puncture
▢ Lumbar puncture
▢ Admission to isolation bed and ICU
▢ Assessment of public health concerns
Most Common Bacterial Pathogens According to Age
| Predisposing Factor | Common bacterial pathogens | Antimicrobial therapy |
|---|---|---|
| <1 month | Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes | Ampicillin plus cefotaxime; OR ampicillin plus an aminoglycoside |
| 1 to 23 months | Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli | Vancomycin plus a third-generation cephalosporin |
| 2 to 50 years | N. meningitidis, S. pneumoniae | Vancomycin plus a third-generation cephalosporin |
| >50 years | S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli | Vancomycin plus ampicillin plus a third-generation cephalosporin |
Meningococcal Prophylaxis
| Drug | Age group | Dose | Duration and route of administration |
|---|---|---|---|
| Rifampin | Infants age <1 month | 5 mg/kg/dose every 12 hours | 2 days (4 doses) of oral therapy |
| Rifampin | Infants and children age ≥1 month | 10 mg/kg/dose(maximum: 600 mg) every 12 hours | 2 days (4 doses) of oral therapy |
| Rifampin | Adults | 600 mg every 12 hours | 2 days (4 doses) of oral therapy |
| Ciprofloxacin | Infants and children age ≥1 month | 20 mg/kg (maximum 500 mg) | Single oral dose |
| Ciprofloxacin | Adults | 500 mg | Single oral dose |
| Ceftriaxone | Children age <15 years | 125 mg | Single IM dose |
| Ceftriaxone | Adults and adolescents age ≥15 years | 250 mg | Single IM dose |
