Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Bacterial Meningitis - The Febrile Patient with Headache

Patient Demographics

  • Age: 22 years
  • Sex: Female
  • Occupation: College student

Chief Complaint

"Worst headache of my life and I can't stand the light."

History of Present Illness

A 22-year-old college student presents with severe headache for 12 hours, progressively worsening. She reports fever, neck stiffness, and photophobia. Roommate states patient has been "out of it" for the past few hours. Patient lives in dormitory; two other students on her floor recently had "bad colds."

Initial Assessment

ESI Level: 1 - Immediate intervention required

First Impression:

  • Appearance: Toxic-appearing, lying still with eyes closed
  • Work of breathing: Mildly tachypneic
  • Circulation: Flushed appearance

Vital Signs:

  • Heart rate: 118 bpm
  • Blood pressure: 102/68 mmHg
  • Respiratory rate: 22 breaths/min
  • SpO2: 96% on room air
  • Temperature: 39.8C (103.6F)
  • GCS: 13 (E3V4M6)

Primary Survey

Airway: Patent, speaking in short sentences Breathing: Tachypneic, clear lungs Circulation: Tachycardic, warm peripheries, capillary refill 2 seconds Disability: Lethargic, oriented to person only; photophobic Exposure: Petechial rash on trunk and lower extremities

Neurological Assessment

Mental Status:

  • Lethargic but arousable
  • Oriented to person only
  • Following simple commands

Meningeal Signs:

  • Nuchal rigidity: Present
  • Kernig sign: Positive
  • Brudzinski sign: Positive

Cranial Nerves: Intact Motor: Moving all extremities, withdraws to pain Pupils: 3mm, reactive, photophobic

Secondary Survey

SAMPLE History:

  • Symptoms: Headache, fever, neck stiffness, photophobia, nausea/vomiting
  • Allergies: None
  • Medications: Oral contraceptives
  • PMH: Healthy, immunizations up to date (including MenACWY but not MenB)
  • Last Meal: Yesterday evening
  • Events: Gradual onset headache, progressive lethargy

Clinical Decision - Lumbar Puncture Timing

CT Before LP? Risk factors for herniation (need CT first):

  • Immunocompromised: No
  • History of CNS disease: No
  • New-onset seizure: No
  • Papilledema: Unable to assess (photophobia)
  • Altered consciousness: YES
  • Focal neurologic deficit: No

Decision: CT head before LP due to altered mental status, BUT antibiotics given BEFORE CT

Diagnostic Testing

Point-of-Care:

  • Glucose: 98 mg/dL
  • Lactate: 3.8 mmol/L

CT Head: No mass effect, no herniation risk

Lumbar Puncture Results:

  • Opening pressure: 32 cm H2O (elevated)
  • WBC: 2,400 cells/μL (95% neutrophils)
  • RBC: 12 cells/μL
  • Glucose: 28 mg/dL (serum 98) - ratio 0.29
  • Protein: 280 mg/dL
  • Gram stain: Gram-positive diplococci

Labs:

  • WBC: 18,500 with 88% neutrophils, 8% bands
  • Procalcitonin: 8.4 ng/mL
  • Blood cultures: Pending

Diagnosis

Acute Bacterial Meningitis - presumed Streptococcus pneumoniae based on Gram stain

Management

Immediate Treatment (given BEFORE CT):

  1. Dexamethasone 0.15 mg/kg IV (before or with first antibiotic dose)
  2. Ceftriaxone 2g IV
  3. Vancomycin 25 mg/kg IV (for possible resistant pneumococcus)
  4. IV fluid resuscitation

Timing:

  • Door-to-antibiotic: 18 minutes (goal <60 minutes)
  • Steroids given with antibiotics

Additional Measures:

  • Droplet precautions until N. meningitidis ruled out
  • Close contact prophylaxis notification to public health
  • ICU admission for monitoring

Disposition

  • ICU admission
  • Continued antibiotics (narrowed based on culture)
  • Dexamethasone x 4 days
  • Hearing evaluation prior to discharge
  • Public health notification

Teaching Points

  1. Classic triad rarely complete: Fever, neck stiffness, and altered mental status all present in only 44% of cases
  2. Don't delay antibiotics: If LP will be delayed for CT, give antibiotics first
  3. Dexamethasone timing: Must be given before or with first antibiotic dose; reduces mortality in pneumococcal meningitis
  4. Petechial rash: Suggests meningococcemia - requires immediate isolation and treatment
  5. CSF interpretation: Low glucose ratio (<0.4), elevated protein, neutrophilic pleocytosis suggest bacterial etiology
  6. Chemoprophylaxis: Close contacts of meningococcal meningitis need rifampin, ciprofloxacin, or ceftriaxone

Clinical Image

Image Description: Photograph showing petechial and purpuric rash on the lower extremities, characteristic of meningococcal septicemia. The rash is non-blanching and can rapidly progress to purpura fulminans.

Attribution: Image from Wikimedia Commons, Meningococcal rash. Public domain. Source: https://commons.wikimedia.org/wiki/File:Meningococcemia.jpg

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