A 9-year-old boy is brought to the emergency department for fever and headache. He has had a runny nose, sore throat, and tactile temperatures for the last few days. The patient has a headache that started 2 days ago and has worsened progressively despite taking acetaminophen every 4 hours. After he awoke this morning with vomiting, he appeared confused, which prompted this visit. Two weeks ago, his 4-year-old sister had a febrile illness with rash and mouth sores. The patient has no chronic medical conditions, and immunizations are up to date. Temperature is 39.5 C (103.1 F), blood pressure is 102/62 mm Hg, pulse is 122/min, and respirations are 24/min. He is drowsy but arousable. Pupils are equal and reactive to light, and funduscopic examination is normal. Cardiopulmonary examination is normal. The abdomen is soft and nontender. Bending the patient's neck elicits flexion of his knees and hips. The tone on the right side of the body is increased, and the right arm is weak. Deep tendon reflexes are brisk on the right compared to the left. Which of the following is the best next step in management of this patient?

Question

A 9-year-old boy is brought to the emergency department for fever and headache.  He has had a runny nose, sore throat, and tactile temperatures for the last few days.  The patient has a headache that started 2 days ago and has worsened progressively despite taking acetaminophen every 4 hours.  After he awoke this morning with vomiting, he appeared confused, which prompted this visit.  Two weeks ago, his 4-year-old sister had a febrile illness with rash and mouth sores.  The patient has no chronic medical conditions, and immunizations are up to date.  Temperature is 39.5 C (103.1 F), blood pressure is 102/62 mm Hg, pulse is 122/min, and respirations are 24/min.  He is drowsy but arousable.  Pupils are equal and reactive to light, and funduscopic examination is normal.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender.  Bending the patient's neck elicits flexion of his knees and hips.  The tone on the right side of the body is increased, and the right arm is weak.  Deep tendon reflexes are brisk on the right compared to the left.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfb0_107d_8f63_134e2f69a459_MD0005_00 This boy has fever, headache, vomiting, and neurologic findings concerning for a central nervous system infection. Given his preceding upper respiratory symptoms and recent exposure to likely hand-foot-mouth disease (via his sister with fever, mouth sores, and a rash), the patient likely has viral meningoencephalitis. In children, enteroviruses such as coxsackievirus are the most common cause, followed by herpes simplex virus (HSV) and arboviruses. Meningoencephalitis is characterized by inflammation of both the meninges and the brain parenchyma. Nuchal rigidity and a positive Brudzinski sign, in which passive neck flexion causes involuntary flexion of the knees and hips, are indicative of meningeal irritation. In contrast, encephalitis causes altered mental status (eg, confusion, behavioral changes), seizures, and diffuse or focal neurologic abnormalities (eg, hypertonicity, hyperreflexia, weakness). Brudzinski sign A lumbar puncture is required for definitive diagnosis; however, empiric acyclovir and antibiotics (vancomycin and a third-generation cephalosporin) should be initiated while awaiting results. Once HSV and bacterial infections are excluded, treatment for viral meningoencephalitis is generally supportive. (Choice B) Dexamethasone helps prevent neurologic complications in adults with pneumococcal meningitis. For viral meningoencephalitis, steroids are not recommended as they do not improve outcomes. (Choice C) Doxycycline is initiated for suspected rickettsial disease (eg, Rocky Mountain spotted fever). Although encephalitis can occur, illness usually follows a tick bite, and fever and headache are typically accompanied by a maculopapular or petechial rash originating on the ankles/wrists, which is not seen in this patient. (Choice D) Intravenous immunoglobulin may be considered for the treatment of enterovirus myocarditis in neonates and immunocompromised (B cell immunodeficiency) patients with severe enterovirus infections. This patient has no chronic medical conditions and no chest pain or vital signs instability, as would be expected with myocarditis. (Choice E) N-acetylcysteine is the treatment for acetaminophen toxicity, which can result in encephalopathy but not fever and meningeal signs. In addition, this patient's symptoms began prior to acetaminophen administration. Educational objective: Viral meningoencephalitis is characterized by inflammation of the meninges and brain parenchyma. Symptoms include fever, headache, nuchal rigidity, altered mental status, and diffuse or focal neurologic abnormalities. Empiric acyclovir is indicated until herpes simplex virus is excluded. References: Viral meningoencephalitis: a review of diagnostic methods and guidelines for management. (http://www.ncbi.nlm.nih.gov/pubmed/20236175)

A 9-Year-Old Boy Is Brought to the Emergency Department for Fever