CLINICAL SOLVING PROBLEM Infectious Disease Doctor’s Worst Fear Vladimir Krajinovic, MD, PHD

First contact with patient 19-year-old boy with fever of 39.4°C, nausea, vomiting and headache came to ER He was previously a healthy boy, except past viral meningitis and tonsillectomy because of frequent streptococcal pharyngitis episodes He lives in student dormitory but doesn’t know someone similarly sick nearby Last week he had coryza and sore throath He had possible coamoxiclav allergy coamoxiclav (generalized rash as a toddler) Your next step: a) head CT b) basic laboratory studies c) detailed history of present disease and physical examination d) blood cultures e) all above

Correct answer: a) head CT b) basic laboratory studies c) detailed history of present disease and physical examination d) blood cultures e) all above

Detailed history and physical exam Patient presented with chills, shivering and cold extremities followed by fever severe myalgia, especially legs Physical exam: awake desoriented hypotensive 97/43 tachycardic 117/min respiratory rate 26/min fever of 38.8 °C stiff neck and positive Kernig sign no focal neurological signs petechial rash systolic murmur above heart apex Your working diagnosis: a) sepsis b) infective endocarditis with meningitis c) meningococcal meningitis d) streptococcal pharyngitis e) meningococcal sepsis and meningitis

Correct answer: a) sepsis b) infective endocarditis with meningitis c) meningococcal meningitis d) streptococcal pharyngitis e) meningococcal sepsis and meningitis

Incidence of meningococcal disease Which two age groups have the highest incidence? a) children under 2 years old b) 2 to 5 years old c) school age between 5 and 10 years old d) adolescence and early adulthood

Incidence of meningococcal disease Which two age groups have the highest incidence? a) children under 2 years old b) 2 to 5 years old c) school age between 5 and 10 years old d) adolescence and early adulthood

Signs of meningococcaemia are all except: a) toxic or moribund state b) shock c) hypotension d) leg pain e) sore throat or coryza

Correct answer: a) toxic or moribund state b) shock c) hypotension d) leg pain e) sore throat or coryza

Patient menagement Since the patient had a toxic general appearance with fever, headache and rash it is always important to think on invasive meningococcal disease and to: establish venous line, bloodcultures, antibiotic, head CT scan establish venous line, complete blood count, C-reactive protein, blodcultures, lumbar puncture, antibiotic c) establish venous line, bloodcultures, antibiotic, lumbar puncture, head CT scan d) establish venous line, bloodcultures, nasopharyngeal swab, antibiotic, head CT scan, lumbar puncture e) None of the above

Correct answer: establish venous line, bloodcultures, antibiotic, head CT scan establish venous line, complete blood count, C-reactive protein, blodcultures, lumbar puncture (LP), antibiotic c) establish venous line, bloodcultures, antibiotic, lumbar puncture, head CT scan d) establish venous line, bloodcultures, nasopharyngeal swab, antibiotic, head CT scan, lumbar puncture e) none of the above

Empiric antimicrobial drug of choice and the dose in your patient is: a) penicillin 4 million IU iv b) ceftriaxone 2 gr iv c) meropenem 2 gr iv d) moxifloxacin 400 mg iv e) gentamicin 240 mg iv

Correct answer: a) penicillin 4 million IU iv b) ceftriaxon 2 gr iv c) meropenem 2 gr iv d) moxifloxacin 400 mg iv e) gentamicin 240 mg iv

Meningococci are susceptible to several antimicrobial agents: a) Ceftriaxone, cefotaxime, and cefuroxime are cephalosporins that penetrate sufficiently into CSF from blood and are useful in the treatment of bacterial meningitis b) Meningococci, are susceptible to chloramphenicol, rifampin, erythromycin, and tetracyclines and ciprofloxacin c) Treat children aged older than 3 months with intravenous ceftriaxone d) Most patients with uncomplicated meningococcemia defervesce within the first 24 hours of antibiotic therapy e) All above

Correct answer: a) Ceftriaxone, cefotaxime, and cefuroxime are cephalosporins that penetrate sufficiently into CSF from blood and are useful in the treatment of bacterial meningitis b) Meningococci, are susceptible to chloramphenicol, rifampin, erythromycin, and tetracyclines and ciprofloxacin c) Treat children aged older than 3 months with intravenous ceftriaxone d) Most patients with uncomplicated meningococcemia defervesce within the first 24 hours of antibiotic therapy e) All above

Patient management and lab findings The patient is admitted in to the intensive care unit His rash progressed to a purpuric form Which lab results can be expected? leukocytosis high C-reactive protein, high serum lactate high blood urea nitrogen, high creatinine, hypoalbuminaemia thrombocytopenia, prolonged prothrombin time all of the above

Correct answer: leukocytosis high C-reactive protein, high serum lactate high blood urea nitrogen, high creatinin, hypoalbuminaemia thrombocytopenia, prolonged prothrombin time all above

Your patient had… But he survived Leukocytosis 17.8 x109 CRP 217 mg/L lactate 4.7 mmol/L Acute kidney injury Capillary leak syndrome Disseminated intravascular coagulation But he survived

Possible complications of meningococcal septicaemia and meningitis include all except: a) Hearing loss b) Hepatosplenomegaly c) Damage to bones and joints d) Skin scarring from necrosis e) Psychosocial problems

Correct answer: a) Hearing loss b) Hepatosplenomegaly c) Damage to bones and joints d) Skin scarring from necrosis e) Psychosocial problems

SUMMARY The typical initial presentation of meningitis due to N. meningitidis consists of the sudden onset of fever, nausea, vomiting, headache, decreased ability to concentrate, and myalgias in an otherwise healthy patient. Myalgias may be an important differential sign, and occasionally the pain is quite intense. These are generally more painful than myalgias seen in viral influenza. Disease progression is usually quite rapid with transition from health to severe disease in a matter of hours.

SUMMARY Preceding symptoms of pharyngitis, which in meningococcal meningitis is nonsuppurative, can lead to a preliminary misdiagnosis of streptococcal pharyngitis. However, patients with meningococcal meningitis either present with, or soon develop, a degree of illness that is much too severe to warrant this diagnosis. Although initial clinical features of patients with meningococcal disease are similar to many common, self-limiting viral illnesses seen in primary care, signs of early sepsis should differentiate the patient who merits clinical monitoring. The vital signs often show a low blood pressure with an elevated pulse rate. An intensive search for petechiae and ecchymoses should be undertaken.