Case 076: Bacterial Meningitis

PATIENT PRESENTATION

Chief Complaint

The patient is very somnolent and unable to provide a history. His history is from his roommate, who reports that the patient has skipped the gym for several days and complained of generalized body aches, fevers, and a severe pounding headache for several days prior to presentation.

History of Present Illness

Jerrod Grant is a 21-year-old male college student, who presents to the emergency department (ED) with a 3-day history of generalized body aches, and fevers with neck stiffness beginning yesterday. The patient’s roommate is at the bedside and provided most of the history. The roommate states that he came home early from the gym approximately 3 days ago, in distress related to generalized body aches. He was in his normal state of health prior to that time. Of note, the roommate just finished antibiotics for reported pneumonia today.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. Which symptoms in this patient’s history suggest the diagnosis of bacterial meningitis?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. What do this patient’s cerebrospinal fluid (CSF) findings indicate?

   Hint: See Table 73-2 in PPP

3. What in this patient’s history may indicate the causative organism of bacterial meningitis?

   Hint: See Table 73-1 in PPP

4. Why should empiric antibiotic therapy in bacterial meningitis include broad-spectrum coverage with more than one intravenous agent?

   Hint: See Treatment in PPP

5. What vaccination(s) should be administered to help prevent invasive Streptococcus pneumoniae meningitis?

   Hint: See Treatment in PPP

FOLLOW-UP

Twenty-four hours later, CSF cultures return and are positive for Streptococcus pneumoniae. The patient continues to receive empiric antibiotics (as recommended in your Care Plan). Should your antibiotic regimen be altered? If so, how? Also, what (if any) prophylaxis would you recommend for this patient’s contacts?

Hint: See Treatment and Table 73-3 in PPP

CASE SUMMARY

Global Perspective

The incidence of bacterial meningitis in Western countries (including the United States) gradually declined by ~4% per year to ~1 per 100 000 per year in the past 10–20 years due to vaccinations. In developing countries, incidence rates are still substantially higher at ~30 per 100 000 persons per year due to limited vaccine availability and cost in the face of non-vaccine pneumococcal serotypes and the emergence of bacterial strains with reduced susceptibility to antimicrobial treatment.