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A 24 year old nursing student presented to his ED with a 1 day history of headache and
fever. He expressed a dislike for bright lights. On examination his vital signs were as
follows:
BP 110/68 mm/Hg, HR 104 bpm, Temp 38.6 degrees celcius and O2 Sats 98% R/A. He
was disorientated to place and time.
What features would you look for on physical examination in support of the
suspected diagnosis?
Fever
Altered Mental Status
Rash
Cranial Nerve Palsies
Other Focal Neurological Signs
Nuchal Rigidity
Brudzinskis Sign
Kernigs Sign
Evidence of URTI- pharyngitis, otitis
Lumbar Puncture- CSF Analysis (cell count, microscopy, culture, sensitivity, protein,
glucose)
FBC
Electrolytes: Renal Impairment, Hyponatraemia (mild)
Coagulation Screen (DIC)
Blood Cultures
ABG (raised anion gap metabolic acidosis)
Consider CT Brain prior to lumbar puncture if any of the following is present:
Immunocompromised state (organ transplant, HIV, immunosuppressive medications)
History of CNS Disease (mass lesion, stroke, focal infection)
New onset seizure (within the past 1 week)
Papilloedema
Abnormal level of consciousness
Focal Neurologic Deficit
ABC
IV high dose broad spectrum antibiotics initially
Cetriaxone 2g BD IV
Vancomycin 2g BD-QID IV (if high prevalence of cephalosporin resistant streptococcus
pneumoniae)
IV Dexamethasone 0.15mg/kg Q 6 hours x 4/7 (only if strep pneumo meningitis is
suspected. Must commence immediately before or at same time as first dose of
antibiotics)- shown to reduce mortality and neurological complications in streptococcal
pneumoniae meningitis (if alternative micro-organism is cultured, stop corticosteroids
immediately).
IV Hydration
Isolate
Change ABx based on sensitivities of culture
Contact tracing- chemoprophylaxis
Notify Public Health
CSF Microscopy
Sample 1 2 3
RCC (/mm3) 5 3 2
WCC (/mm3) 1056 1023 1042 {90% neutrophils}
A patient with similar symptoms is admitted the following day. A lumbar puncture is
performed and the results of CSF analysis are as follows:
Sample 1 2 3
RCC (/mm3) 3 2 2
WCC (/mm3) 190 188 200 {predominantly
lymphocytes}