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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Describe the signs, symptoms, and clinical presentation of CNS infections

  • List the most common pathogens causing CNS infections, and identify risk factors for infection with each pathogen

  • State the goals of therapy for CNS infections

  • Design appropriate empiric antimicrobial regimens for patients suspected of having CNS infections caused by any of the following pathogens: Neisseria meningitidis, Haemophilus influenzae, Listeria spp., group B Streptococcus spp., Gram-negative bacillary organisms, and herpes simplex encephalitis

  • Identify the candidates for vaccines and other prophylactic therapies to prevent CNS infections

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PATIENT PRESENTATION

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Chief Complaint

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The patient is currently unresponsive. Her history is from medical records and nursing staff at long-term care facility, who report somnolence and "talking out of her head."

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History of Present Illness

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Ruth Johnson is a 67-year-old female resident of a local assisted-living facility, who presents to the ED with a 3-day history of worsening confusion and somnolence. Prior to her delirium, she also complained of headache and stiff neck. None of her friends/contacts at the nursing home have reported any signs or symptoms of illness, but her 10-year-old grandson who visited last week was recently diagnosed with pneumonia. She has a history of seizure disorder and one of her friends reported that she may have had some seizure-like activity yesterday.

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Past Medical History

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Type 2 DM diagnosed 1 year ago

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Stroke at age 60, no residual neurologic deficits except seizure disorder

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Seizure disorder following stroke

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Depression diagnosed at age 62 following the death of her husband

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Family History

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Father had CAD, deceased from MI at age 72. Mother had diabetes and osteoporosis and died of "old age." She had one brother who was killed in an accident at age 16.

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Social/Work History

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The patient moved to assisted-living facility with her husband following stroke at age 60. Staff reports that she is independent in her ADLs, including taking her medications, and is quite active. She has 2 children, aged 45 and 40, and 5 grandchildren. She is a retired homemaker.

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Tobacco/Alcohol/Substance Abuse

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Unable to assess due to the patient's mental status; no known tobacco or illicit drug use.

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Allergies/Intolerances/Adverse Event History

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Morphine (itching)

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Medications

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Inpatient
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Naloxone 2 mg IV × 1 administered on arrival (no response)

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Flumazenil 0.2 mg IV × 1 administered on arrival (no response)

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0.9% sodium chloride IV at 125 mL/h

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Home
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Aspirin 81 mg PO daily

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Phenytoin ER 300 mg PO at bedtime

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