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Patient Case: Meningitis

Patient Case: Meningitis

Discussion

A 30-year-old woman is brought to the emergency department by her husband after experiencing a sudden onset of fever, severe headache, and vomiting over the past 12 hours. She also complains of neck stiffness and sensitivity to light. Her husband reports that she became increasingly confused and drowsy in the last few hours. She has no recent travel history or known sick contacts but mentioned having a mild upper respiratory infection a few days ago.

On examination, her temperature is 39.5°C (103.1°F), blood pressure is 105/65 mmHg, heart rate is 110 beats per minute, and respiratory rate is 20 breaths per minute. She appears lethargic and confused. Neurological examination reveals a positive Brudzinski’s sign and Kernig’s sign, along with neck rigidity. There are no focal neurological deficits. A non-contrast CT scan of the brain is normal.

A lumbar puncture is performed, showing cloudy cerebrospinal fluid (CSF) with an elevated white blood cell count, high protein, and low glucose levels. Gram stain reveals Gram-positive diplococci, confirming Streptococcus pneumoniae as the causative organism.

The patient is immediately started on intravenous ceftriaxone, vancomycin, and dexamethasone. Over the next several days, her condition improves, and she is discharged with a follow-up for possible hearing assessment due to the risk of neurological complications.

Questions
1. What is the most likely diagnosis in this patient?

a) Viral meningitis

b) Bacterial meningitis

c) Encephalitis

d) Brain abscess

Which cerebrospinal fluid

2. Which cerebrospinal fluid (CSF) finding is most indicative of bacterial meningitis?

a) Normal glucose, normal protein, and a low white blood cell count

b) Low glucose, high protein, and an elevated white blood cell count

c) Increased red blood cells with normal glucose and protein

d) Clear CSF with a slightly elevated white blood cell count

3. What is the most appropriate initial antibiotic treatment for bacterial meningitis in this patient?

a) Oral amoxicillin

b) Intravenous ceftriaxone and vancomycin

c) High-dose corticosteroids alone

d) Supportive care only

4. Why was dexamethasone added to this patient’s treatment?

a) To reduce brain swelling and prevent neurological complications

b) To directly kill Streptococcus pneumoniae

c) To lower the fever and reduce headache intensity

d) To increase CSF glucose levels

Reveal answers

Answers

1. Answer: b) Bacterial meningitis

The presence of fever, headache, neck stiffness, altered mental status, and a positive CSF Gram stain with Streptococcus pneumoniae confirms bacterial meningitis.

2. Answer: b) Low glucose, high protein, and an elevated white blood cell count

Bacterial meningitis typically presents with elevated white blood cells (indicating infection), high protein due to inflammation, and low glucose because bacteria consume CSF glucose.

3. Answer: b) Intravenous ceftriaxone and vancomycin

Empiric therapy for bacterial meningitis includes ceftriaxone (or cefotaxime) and vancomycin to cover S. pneumoniae and Neisseria meningitidis. Dexamethasone is added to reduce complications.

4. Answer: a) To reduce brain swelling and prevent neurological complications

Dexamethasone helps lower the risk of brain edema, hearing loss, and other neurological damage by decreasing inflammation caused by bacterial toxin release.