Cases on meningitis
Case (1):
A 65-year-old man presents to the emergency department with a two-day history of fever,
headache, altered mental status and vomiting. His past medical history is significant for renal
transplantation secondary to polycystic kidney disease, hypertension, and diabetes. He takes
aspirin, insulin, nifedipine, cyclosporine and prednisone. He has no known drug allergies. His
temperature is 39 .2C (1 02 .5F), pulse is 1 02/min. respirations are 18/min. and blood pressure is
120/75 mm Hg. He is alert but confused. Fundoscopy does not show any abnormalities. His neck
is stiff. Lungs are clear to auscultation. He has a normal S1 and S2 with a II/IV systolic ejection
murmur heard best in the right infraclavicular area. Complete blood count shows a WBC count
of 17 OOO/cm3 with neutrophilic leukocytosis. His blood is drawn and sent for culture. Lumbar
puncture is performed and the results are pending. Which of the following is the most
appropriate empiric antibiotic therapy for this patient?
A. Ceftriaxone
B. Ceftriaxone and vancomycin
C. Cefotaxime and ampicillin
D. Ceftriaxone, vancomycin and ampicillin
E. Ceftazidime and vancomycin
Explanation:
Empiric treatment of meningitis is tailored to the patient's age group and the clinical situation,
since the most likely causative organisms vary in different settings. The above patient has signs
and symptoms of meningitis, appears sick, and has an elevated white count with a predominance
of neutrophils. The presentation is acute; therefore, he most likely has acute bacterial meningitis.
The most appropriate empiric antibiotic regimen is vancomycin. ceftriaxone. and ampicillin.
Vancomycin + ceftriaxone are ideal for community-acquired bacterial meningitis in adults and
children since it covers the three most frequent etiologic agents: Sfrepfococcus pneumoniae.
Haemophi/us inf/uenzae, and Neisseria meningifidis. Many pneumococcal strains have become
resistant to penicillin and cephalosporins; thus. vancomycin is needed in addition to ceftriaxone.
Vancomycin alone does not sufficiently penetrate the blood-brain barrier.
Ampicillin is included in the empiric regimen to cover Listeria monocyfogenes, which is also an
important cause of meningitis in patients older than 55. Other patients who are at risk for Listeria
meningitis include immunocompromised patients, patients with malignancies (especially
lymphoma). and patients taking corticosteroids.
So the answer is D
Case (2):
An 18-year-old woman comes to the emergency department because of acute onset of headache,
muscle pains, and nausea. She has had these symptoms for one day, soon after returning from a
college camping trip. The illness started with fever and muscle pains that progressed to include
headache and nausea over the next several hours. She says that she went hiking twice during the
trip and participated in many outdoor activities with her friends. She has no other medical
problems. Her temperature is 38 .9•c ( 1 02.F), blood pressure is 90/60 mm Hg, pulse is 120/min,
and respirations are 18/min. Physical examination shows a stiff neck with pain to passive flexion.
Careful inspection reveals few purpuric lesions on both legs. Examination of the cerebrospinal
fluid ( CSF) reveals
Glucose 20 mg/dl Protein 175 mg/dl WBC 2000/cmm
Which of the following is the most likely cause of this patient's condition?
A. Neurosyphilis
B. Pneumococcal meningitis
C. Rocky Mountain spotted fever
D. Meningococcal infection
Explanation:
This otherwise healthy patient presents with sudden onset of fever, stiff neck, headache, nausea,
and myalgias, worrisome for bacterial meningitis. The hypotension, tachycardia, myalgias, and
purpuric skin lesions suggest meningococcal meningitis with meningococcemia, which can
develop within several hours of the initial meningitis. Myalgias more commonly occur in
meningococcal meningitis than other bacterial causes and can be more intense and painful than
the myalgias caused by viral influenza.
The CSF findings of elevated white blood cell (WBC) count, elevated protein level, and
decreased glucose level are indicative of bacterial meningitis. Viral meningitis may present with
similar symptoms but is usually not associated with purpura. The CSF findings also tend to show
normal glucose, mild elevation of protein (usually < 150 mg/dl), and WBC count <250/cmm.
This patient has CSF findings consistent with bacterial meninaitis and the hvootension and skin
lesions most consistent with disseminated meninaococcemia.
This otherwise healthy patient presents with sudden onset of fever, stiff neck, headache, nausea,
and myalgias, worrisome for bacterial meningitis. The hypotension, tachycardia, myalgias, and
purpuric skin lesions suggest meningococcal meningitis with meningococcemia, which can
develop within several hours of the initial meningitis. Myalgias more commonly occur in
meningococcal meningitis than other bacterial causes and can be more intense and painful than
the myalgias caused by viral influenza.
The CSF findings of elevated white blood cell (WBC) count, elevated protein level, and
decreased glucose level are indicative of bacterial meningitis. Viral meningitis may present with
similar symptoms but is usually not associated with purpura. The CSF findings also tend to show
normal glucose, mild elevation of protein (usually < 150 mg/dL), and WBC count <250/cmm.
This patient has CSF findings consistent with bacterial meningitis and the hypotension and skin
lesions most consistent with disseminated meningococcemia.
So the answer is D