A 19-year-old man comes to the emergency department during the summer due to vomiting. He was well this morning but developed an increasingly painful headache and vomiting approximately 4 hours ago while playing golf. The patient is a college student who lives in a fraternity house on campus. Temperature is 40.1 C (104.2 F), blood pressure is 90/50 mm Hg, and pulse is 120/min. The patient is initially alert but becomes increasingly obtunded over the course of the examination. There is resistance to passive flexion of the neck. The hands and feet are cold and slightly mottled with a diffuse, petechial rash over the extremities. Which of the following is the best next step in management of this patient?

Question

A 19-year-old man comes to the emergency department during the summer due to vomiting.  He was well this morning but developed an increasingly painful headache and vomiting approximately 4 hours ago while playing golf.  The patient is a college student who lives in a fraternity house on campus.  Temperature is 40.1 C (104.2 F), blood pressure is 90/50 mm Hg, and pulse is 120/min.  The patient is initially alert but becomes increasingly obtunded over the course of the examination.  There is resistance to passive flexion of the neck.  The hands and feet are cold and slightly mottled with a diffuse, petechial rash over the extremities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1b6_af1c_bc81_c3b770517523_MD0003_00 This patient developed fever, headache, and vomiting with rapid progression to a petechial rash, nuchal rigidity, and obtundation. These findings are concerning for meningococcal meningitis, a life-threatening infection caused by the gram-negative diplococcus Neisseria meningitidis. Adolescents and young adults are most commonly affected, and outbreaks on college campuses put students living on campus at highest risk. Initial symptoms are nonspecific and include the acute onset of fever, headache, vomiting, and severe myalgias. Mottled skin and cold hands and feet are other early signs of illness. Patients rapidly progress (within 12-24 hr) and develop nuchal rigidity and altered mental status. A petechial rash is common and may become purpuric in late stages. Treatment of meningococcal meningitis is a third-generation cephalosporin (eg, ceftriaxone) and should be administered as soon as possible. Although cerebrospinal fluid culture is diagnostic, treatment should not be delayed for lumbar puncture in patients with suspected meningococcal meningitis due to significantly increased mortality (Choice D). Empiric antibiotic regimens should also include vancomycin for coverage of penicillin-resistant Streptococcus pneumoniae, a common cause of bacterial meningitis in all age groups. Although lumbar puncture can be delayed, blood cultures should be obtained prior to antibiotic initiation. Even with appropriate treatment, meningococcal meningitis is potentially fatal due to complications of shock, multiorgan failure, and/or disseminated intravascular coagulation. (Choice B) Exertional heat stroke presents with a high temperature (>40 C [104 F]) and signs of encephalopathy; management includes cooling measures (eg, ice water immersion). This patient's petechial rash and nuchal rigidity are not consistent with heat stroke. (Choice C) CT scan of the head is performed for suspected intracranial bleeding, which may present with headache and vomiting. However, this patient's fever and petechiae make meningococcal infection more likely and prompt antibiotic initiation the priority. (Choice E) Doxycycline treats Rocky Mountain spotted fever, which presents with fever, headache, and myalgias over several days; a petechial rash does not typically develop until after day 3 of illness. This patient's sudden onset of symptoms and rapid deterioration over hours make this diagnosis less likely. Educational objective: Meningococcal meningitis is a potentially fatal infection that presents with rapidly progressive symptoms (eg, fever, headache, nuchal rigidity, petechiae) over 12-24 hours. If clinical suspicion is high, empiric vancomycin and ceftriaxone should be administered as soon as possible; lumbar puncture should not delay treatment. References: Meningococcal disease in childhood: epidemiology, clinical features and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/26788732) Neisseria meningitidis. (http://www.ncbi.nlm.nih.gov/pubmed/31751039)

A 19-Year-Old Man Comes to the Emergency Department During the Summer