Bacterial Meningitis in the ICU
Bacterial meningitis is a condition which carries a high mortality and morbidity rate and involves inflammation of the tissues surrounding the brain and spinal cord. Bacterial meningitis is a neurologic emergency that presents with at least one of the sym
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Jennifer S. Hughes and Indhu M. Subramanian
Case Presentation A 55 year old man with a history of recurrent bacterial sinusitis was brought to the emergency department for 1 day of progressive confusion. The patient complained of a severe, generalized headache and light sensitivity. On exam he was febrile to 102.1 °F, agitated and oriented to name only. Severe nuchal rigidity was present, but no obvious focal neurologic deficits were observed on exam. Papilledema was not visualized on fundoscopy although the exam was limited due to the patient’s significant photosensitivity. Blood cultures were sent immediately and the patient was initiated on empiric IV antibiotic therapy with vancomycin, ampicillin, and ceftriaxone. A computed tomography (CT) of the brain without contrast did not reveal any mass lesions or obvious signs of increased intracranial pressure. A lumbar puncture (LP) was significant for an elevated opening pressure of 32 cmH2O and CSF analysis revealed a white blood cell (WBC)
count of 3000 cells/μL with 88 % neutrophils, glucose of 30 mg/dL and protein of 250 mg/dL. A gram stain showed gram positive cocci in pairs and chains (Fig. 36.1). During transfer of the patient from the ED, the patient developed a generalized tonic-clonic seizure and was urgently given IV lorazepam. Due to decreased level of consciousness after the seizure, the patient was intubated for airway protection and was admitted to the ICU. Question What additional inpatient precautions should be taken for the most likely diagnosis? Answer Droplet precautions for presumed acute community acquired bacterial meningitis. This patient presented with the ‘classic triad’ for bacterial meningitis of fever, neck stiffness and altered mental status (AMS). Although the
J.S. Hughes Department of Internal Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA I.M. Subramanian (*) Pulmonary and Critical Care Faculty, Department of Internal Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA e-mail: [email protected]; [email protected]
Fig. 36.1 Gram positive lancet shaped diplococcic confirming Streptococcus pneumonia (Image courtesy of Dr. Valerie Ng at Alameda Health System)
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_36
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complete triad is present only 44 % of the time [1], nearly all patients with bacterial meningitis will present with one of the three findings [2]. The absence of all three of these signs in the classic triad essentially eliminates bacterial meningitis from the differential [2]. The classic physical exams for evaluation of meningeal irritation, Kernig’s and Brudzinski’s signs are not that useful as these only have 61 % sensitivity for bacterial meningitis compared to nuchal rigidity (difficulty with chin to chest or flexion of the cervical spine) which has 84 % sensitivity for bacterial meningitis [3]. While these physical exam signs may provide support in establ
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