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Case
Report -
A middle aged woman with confusion
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Mitra
Abessi, MD
A 50+ year old woman with a past medical history significant
for hypertension was admitted to the hospital because of
confusion for six hours. She had been well until four days
prior to admission, when she came to the emergency room
with pain in her groin after walking into a cart. The patient
was sent home with pain medications. One day prior to admission,
the patient presented with three days of nausea and vomiting,
which she attributed to the pain medications. The patient
also reported left hand tremors that had been increasing
in intensity over the past day, increasing groin pain which
has spread down to her knees, and pain as well as weakness
over her chest and shoulders. The patient also complained
of a headache over the back of her head and neck. The patient
was sent home from the emergency room with new pain medications.
The patient presented to the emergency room on the day of
admission with confusion for six hours. After an additional
several hours, the patient became more confused, at which
time a lumbar puncture was performed and Internal Medicine
was called to admit the patient.
Vital signs were as follows: temperature was 102.1°F, heart rate of 112, respiratory
rate of 18, and blood pressure of 150/86. Her oxygen saturation
was 96% on room air. Physical examination was difficult
because the patient was confused, agitated, and not oriented
to person, place or time. General appearance revealed a
woman in obvious distress, crying out “pain” frequently.
On exam she was found to have rapid eye movements, lock
jaw, and neck stiffness. She was very tender over the chest
wall. There was a left hand tremor. Her lower extremities
were in a flexed position. Her pain was exacerbated by minimal
movement of her arms and by attempts to extend her hips
or her knees. A large rash on the patient’s right inner
thigh was erythemetous, indurated, and warm. Kernig and
Brudzinski signs were present but no Babinski or clonus
was appreciated. Motor and sensory systems, cranial nerves,
and deep tendon reflexes were unable to be assessed. There
was no otitis, pharyngitis, or sinus opacification appreciated.
Laboratory results upon admission revealed no leukocytosis
(wbc count 9,000/cmm) but segmented neutrophils and bands
were present (34% and 59%, respectively). Sodium and potassium
were both low (116 and 2.8) which were replaced with normal
saline and intravenous potassium chloride.
After the lumbar puncture, the patient was given Ceftriaxone
2mg IV empirically for meningitis. Several hours later,
the patient seized in the emergency room and was found to
be obtunded. She was given Lorazepam 2 mg IV, loaded with
Phenytoin, intubated and transferred to the Medical ICU.
Vancomycin 2gm IV q12 hours and Ampicillin 2gm IV q4 hours
was added empirically to her antibiotic regimen.
On CSF Gram’s stain, 3+ gram positive cocci in pairs and
chains was seen, which eventually yielded Streptococcus
pneumoniae in both CSF and blood cultures, sensitive to
both Penicillin and Vancomycin. The CSF glucose and protein
were <8 and 882, respectively (see Table 1 for CSF analysis).
Table
1. CSF Fluid Analysis
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Glucose |
<0.8 |
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Protein |
882
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WBC |
16 |
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RBC |
11 |
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A diagnosis of S. pneumoniae meningitis was made and the
management initiated was continued.
HOSPITAL COURSE
During the course of her hospital stay, the patient had remained
febrile with a persistently elevated white blood cell count.
The etiology of her meningitis has not yet been confirmed,
but is suspected to be secondary to seeding from her right
lower extremity cellulitis. A transthoracic echocardiogram
was done which was essentially negative except for a hyperdynamic
left ventricle. An MRI of the head revealed abnormal high
signal intensity in the sulci of both cerebral hemispheres
and slight ventricular enlargement, consistent with bacterial
meningitis. In addition, there were a number of punctate
areas of abnormal high signal intensities which were most
likely secondary to microinfarctions caused by the meningitis.
At the time of this writing, the patient was hemodynamically
labile, on ventilatory support, and being treated with triple
antibiotic therapy.
This patient presented with the classic clinical presentation
of acute meningitis: the triad of fever, neck stiffness,
and an altered mental state. In addition, this patient
also presented with symptoms of nausea, vomiting, headache,
and myalgias (which the patient attributed to side effects
of her pain medications). The injury that occurred at work
four days prior to admission was most likely coincidental
to the development of early meningitis.
DISCUSSION
Given the potential for neurologic morbidity and mortality,
it is important to institute antibiotic therapy promptly.
When lumbar puncture is delayed or a Gram’s stain of CSF
is nondiagnostic, empirical therapy is essential and should
be directed to the most likely pathogens on the basis of
the patient’s age and underlying health status. This patient
described was a fairly healthy individual in her mid 50s.
Thus, the most likely pathogens were S. pneumoniae, L.
monocytogenes, or gram negative bacilli. Ampicillin
plus a broad spectrum cephalosporin is the choice of empirical
antibiotics in this case. Vancomycin is usually recommended
empirically for patients with head trauma, neurosurgery,
or cerebrospinal fluid shunt. The benefit of adjunctive
empirical glucocorticoid therapy in adults is not clear.1
The recommendations for antibiotic therapy in patients with
S. pneumoniae meningitis who have a positive Gram’s
stain or CSF culture is vancomycin plus a broad spectrum
cephalosporin. The increasing prevalence of antibiotic
resistant S. pneumoniae warrants the combination
of ceftriaxone plus vancomycin in patients. According to
general pathogen-specific guidelines, the suggested duration
of therapy for patients with S. pneumoniae meningitis
is 10-14 days.1
REFERENCES
- Quagliarello,
Scheld. Treatment of Bacterial Meningitis.
New England Journal of Medicine 1997;336:708-716.
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