Case 20: Confusion

A 35 year old woman is brought to the ED by ambulance for confusion and syncope. Medics report that she was seen earlier that day in the ED and diagnosed with a URI. The patient is quite bizarre and is triaged in as a psych patient. She is oriented to name only. When asked if she is in pain she answers “20 minutes”. When asked again she speaks gibberish and is repetitive, answering “faculate”. She answers “yes” to all yes or no type questions including those that are obviously incorrect. To open ended questions she answers with more gibberish often using the words “faculate” and “brakelight”. On exam, she is purposeful, her vital signs and are normal and her exam is non-focal, but limited in that she follows only simple commands. Lab tests are normal except for 25 WBC’s in her urine a WBC count of 14, a serum glucose of 215 and a tox screen which is positive for opiates. CT of the brain is normal. A diagnostic procedure is performed with results shown below. What is the diagnosis? (For answer scroll down)

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ANSWER: Meningococcal Meningitis
It’s a good thing the doctor did the LP because it shows intracellular and extracellular gram negative diplococci! This seems in some way to be a bizarre presentation for meningococcal meningitis, but how many cases of this disease have you seen? Please feel free to share your case(s) with your colleagues by submitting a comment (below).

SHARE THIS CASE: Cut & paste this link, ERPocketBooks.com into an e-mail and forward.

BACTERIAL MENINGITIS from “QUICK ESSENTIALS: EMERGENCY MEDICINE“
History: Prior ABX? HIV RF? mimic URI: throat, myalgia, cough. Painless: HIV, Crypto
Exam: Jolt sign:99 > F > stiff neck:35. 1 source: trauma, PNA, ENT
Jolt sign: Most sensitive exam sign. In adults, “shake head”, in peds, bounce on your knee
Neck: Meningismus may be absent age<2y, Im, abscess, viral
Tap?: 95% of bacterial have at least 2/4 of: HA:87, F:77, stif neck:83, or AMS:69
CT first: Abscess?, HIV, age>60, Im, CNS hx, Sz, AMS, exam+(CN6), papilledema
Bacterial: F, neck stiff & AMS in only 44%, Focal neuro:33%, aphasia: 2-23%, CN:16%
Steroids: Decadron 10mg IV q6 x4d starting before or with ABX. Mortality halved.
Benefit outweighs risk of single dose so OK to do empirically prior to LP
ABX: Rocephin >Ampicillin(ped,age>50,listeria risks) >acyclovir 10/kg >Vanco >doxy
Comps: Death, infarct (#1 cause of focal abnormality), hydrocephalus, herniation, seizure, cranial nerves
Dispo: ICU: bacterial (PMC>Listeria)
Menigococcal: Winter; URI >rapid: bad vitals, rash, muscle ache. Asymptomatic arrier rate:5%
PEP: Rx close contacts for meningococcus: Rifampin, Cipro 500mg PO x1, Rocephin.

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