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CSF

UnFiNiShEd CaSe CoMe BaCk LaTeR

History of Present Illness:

A woman in her 50s with DM presents to the ED for epigastric pain, HA and vomiting for 5 days.  The triage PA orders belly labs and an ultrasound which were unremarkable except for fatty liver.  When you see  her she states the abdominal pain is mild and her main problems are headache, chills, photophobia and vomiting.  She also mentions she was admitted at another hospital a month ago for fungal pneumonia, but doesn’t know more details about it.

Vital Signs & Physical Exam:

Vital signs are normal except for a BP of 161/99.   Physical exam is notable for having her head covered with a black sweater and a positive jolt sign.

Initial Diagnostic Testing:

  • CBC: normal except for WBC 11
  • Chem 7: normal except for glucose 161
  • Imaging: CT head normal.  CXR normal.
  • LP: opening pressure 35 with sputtering fluid
  • CSF: glucose 30/161, protein 275, WBC 1800 (50% lymphs, 15% PMNs), RBC 15

What is the most likely cause of her meningitis?

  • A) HSV
  • B) Cocci
  • C) Crypto
  • D) TB
  • E) Bacterial

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWER:

  • A) HSV: only about 50% of cases have a high RBC count
  • B) Cocci: CORRECT – causes pneumonia, which is easy to treat and also meningitis, which is hard to cure.  More common in immune compromised patients, including DM.
  • C) Crypto: doesn’t usually cause pneumonia and rare outside HIV
  • D) TB: can cause lung and CNS disease but should leave scar on CXR and not be called “fungal”
  • E) Bacterial: can cause lung and CNS disease but not be called “fungal”

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: given Rocephin, vanco and IV fluconazole all at high doses after decadron and admitted.  CSF culture, Crypto Ag and Cocci Ab in CSF all negative.  However CSF Cocci titer is known to be unreliable.  A serum titer was positive at 1:8.  She improved on IV fluconazole and was transitioned to PO and discharged with ID follow up.

CASE LESSONS:

  • History is key.  Headache is a common additional symptom that is not really important to dig into, but sometimes it is.  The history and exam will help.  If when you enter a room the patient keeps there eyes closed or face covered, it could be drama or a migraine but always consider more dangerous reasons such as meningitis or severe vertigo from a stroke
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