1. Meningitis

2. J.K., a 67-year-old white woman with a history of orthotopic liver transplant was brought to the emergency room by her family because of a decreased level of consciousness. The patient was taking mycophenolate 1.5 g PO BID, prednisone 10 mg daily and tacrolimus 2 mg PO BID. Associated symptoms were headache, nausea, vomiting, and diarrhea for 3 days. J.K. has experienced fatigue, chills, headache, difficulty with speech, watery diarrhea and neck stiffness. On admission to the ED, J.K. had a temperature of 39.4◦C.

3. Her weight is 50 kg. Blood cultures were also obtained
Her weight is 50 kg. Blood cultures were also obtained. Lumbar puncture revealed cloudy spinal fluid, white blood cell count of 2,400/mm3; with 65% polymorphonuclear leukocytes, total protein 225 mg/dL and glucose 41 mg/dL consistent with bacterial meningitis.
The cryptococcal antigen was negative. The Gram stain of the CSF was positive for gram-positive rods. The patient is started empirically on ceftriaxone 2 g IV Q 12 hours and vancomycin 1 g IV Q 8 hours and ampicillin 2 g IV Q 4 hours. Blood cultures are positive 24 hours later with a gram-positive rod.

4. 1. Apply SOAP module to this scenario
Subjective Evidence
Objective Evidence
Assessment
Plan

5. 2. What are the important features of Listeria meningitis?
Individuals at greatest risk for Listeria monocytogenes include neonates, the elderly, pregnant women, and immunocompromised individuals.
The most common cause of bacterial meningitis in patients with solid organ transplant, lymphomas, or corticosteroid exposure is Listeria.
Listeria moncytogenes is a grampositive, non–spore-forming rod found in soil and on vegetation.

6. Infection with this pathogen has been associated with the ingestion of certain foods, such as
undercooked meats, deli meat and hotdogs, soft cheeses, pate and unpasteurized milk.
clinical laboratory features of Listeria meningitis are similar to other types of bacterial meningitis.
Listeria has a fondness for not only causing meningitis but also brain abscess.

7. Very few choices are available for the treatment of Listeria meningitis.
Third-generation cephalosporins are not active against Listeria.
Vancomycin is not a good choice.
Meropenem is active in vitro and in experimental animal models but no clinical data.
Ampicillin has excellent activity against Listeria

8. TMP-SMX is an attractive alternative to ampicillin in penicillin-allergic patients because it has excellent penetration in the CSF, is bactericidal against isolates of Listeria.
Although adjunctive steroids are important in treating other types of bacterial meningitis, their role in the treatment of listerial CNS infection is unknown.
Listeria meningitis should be treated for at least 21 days based on clinical experience.

9. Case-2
Mathew is an 84-year-old man who is taken to the Emergency Department complaining of fever, “stiff neck” and splitting headache for 3 days that is not relieved by acetaminophen or ibuprofen. He had undergone a surgery for a recent head injury.
Over the past 24 to 36 hrs, he is been increasingly lethargic and has not been making sense when speaks. The medical team performs a lumbar puncture and the findings support the initial diagnosis of meningitis, but the medical team wants to begin empiric antibiotic therapy.

10. 1. What are the likely pathogens that would have caused meningitis?
Individuals at greater risk of Gram – ve meningitis include neonates, elderly, debilitating individuals and open trauma to head.
E.coli and K.pneumoniae

11. 2. Suggest suitable empiric treatment for the patient.
Vancomycin + ampicillin + cefotaxime
or ceftriaxone