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

2. 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

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

4. 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

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

6. 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

7. 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

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

21. 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.

22. 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.