In our #AMreport @, we had a case of a patient presenting with a known history of migraines and a new fever. The clinical history revealed that the headaches were different in duration, quality and intensity from previous migraines. The other new feature was profound photophobia and fever. This was also preceded by exposure to sick contacts with a likely viral upper respiratory tract illness.
Pertinent findings on exam included a fever of 38.1°C, nuchal rigidity and positive special tests:
- Brudzinski sign (see video demonstration here)
- Kernig sign (see video demonstration here)
- Jolt accentuation
The Brudzinksi and Kernig signs have low sensitivity but high specificity for meningitis according to the JAMA RCE series (JAMA 1999 282:2)
Given those findings on exam, prompt lumbar puncture was performed and antimicrobial therapy was given concomitantly. CSF analysis showed findings suggestive of viral meningitis (Table 1)
In patients with suspected acute bacterial meningitis, broad spectrum and early antimicrobial therapy along with dexamethasone reduces mortality without increase the risk of GI bleeding.
Dexamethasone at a dose of 0.15mg/kg or 10 mg Q6H IV X 4 days with the first dose given 30 minutes before antibiotics or at the same time with antibiotics. (Study details here).
Patients with presumed meningitis should be treated with broad therapy initially which usually includes the following:
- Ceftriaxone 2g IV Q12H
- Vancomycin 500-750 mg IV Q6H (to cover penicillin-resistant pnuemococcus)
- Acyclovir 10 mg/kg IV Q6H
- Ampicillin 2g IV Q4H*
*-Ampicillin coverage for listeria for those at risk, usually age>50, immunocompromised patients, prolonged corticosteroid therapy, history of EtOH abuse and young children.
The take home message
- The presence of a new fever, headache and nuchal rigidity are concerning symptoms for meningeal infection regardless of antecedent history and prompt investigation/management should not be delayed.
- A CT scan before an LP is recommended in the following patients (read here for details):
- abnormal neurological exam including: focal deficits, altered LOC, papilledema
- new onset seizure
- Age >60
- Broad spectrum antibiotics should not be delayed and if suspecting bacterial meningitis give dexamethasone before or with the first dose of antibiotics.