A 38-year-old woman comes to the emergency department due to 2 days of headache, nausea, and photophobia. She has had migraines since her early 20s but has had more frequent episodes over the last few years. The current headache is more severe than usual, and ibuprofen did not relieve the pain. A flulike illness preceded the symptoms. Temperature is 38.3 C (100.9 F), blood pressure is 144/86 mm Hg, and pulse is 110/min. The patient appears lethargic. Cranial nerves, sensation, and motor functions are normal. She reports neck pain when instructed to touch the chest with her chin. No skin rash is present. Noncontrast CT scan of the head shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman comes to the emergency department due to 2 days of headache, nausea, and photophobia.  She has had migraines since her early 20s but has had more frequent episodes over the last few years.  The current headache is more severe than usual, and ibuprofen did not relieve the pain.  A flulike illness preceded the symptoms.  Temperature is 38.3 C (100.9 F), blood pressure is 144/86 mm Hg, and pulse is 110/min.  The patient appears lethargic.  Cranial nerves, sensation, and motor functions are normal.  She reports neck pain when instructed to touch the chest with her chin.  No skin rash is present.  Noncontrast CT scan of the head shows no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Although migraine headaches are often associated with photophobia and nausea, this patient's fever, stiff neck, and lethargy make bacterial meningitis the far more likely diagnosis. Bacterial meningitis is most commonly caused by Streptococcus pneumoniae and Neisseria meningitidis. These pathogens colonize the host's mucous membranes, spread into the bloodstream, and penetrate the blood-brain barrier. A lack of humoral components (eg, complement system, immunoglobulins) within the central nervous system allows bacteria to rapidly proliferate within the cerebrospinal fluid. The resultant cytokine-mediated inflammatory response causes the classic triad of symptoms: high fever (>38 C [100.4 F]), stiff neck, and altered level of consciousness. A generalized severe headache is also usually present. Patients with suspected bacterial meningitis require urgent blood cultures, empiric antibiotics, and lumbar puncture with cerebrospinal fluid analysis to confirm the diagnosis, identify the underlying pathogen, and determine antibiotic sensitivity. (Choice A) 100% oxygen can be used to abort cluster headaches, which are seen primarily in men and are usually characterized by severe orbital or periorbital pain, restless agitation, and autonomic symptoms (eg, lacrimation, rhinorrhea, ptosis, miosis). Fever and nuchal rigidity would be atypical. (Choices C, E, and F) Metoclopramide and sumatriptan can be used to abort acute migraines; topiramate is an effective treatment for the prevention of chronic migraine headaches. Migraines are usually characterized by a unilateral throbbing headache with or without associated symptoms such as nausea, aura, or photophobia. Fever, nuchal rigidity, and lethargy would be atypical. (Choice D) MRI of the brain can be used to evaluate for potential brain tumor. Patients with brain tumors commonly develop dull, constant headaches, focal neurologic symptoms, and seizures. Fever would be atypical. Although brain imaging is often recommended prior to lumbar puncture to evaluate for signs of elevated intracranial pressure, non-contrast head CT is used primarily because it offers rapid results and fewer treatment delays. This patient had a negative head CT; MRI would not be necessary prior to LP. Educational objective: The classic triad of fever, stiff neck, and altered mentation should raise suspicion for acute bacterial meningitis. Evaluation requires prompt blood cultures, empiric antibiotics, and lumbar puncture with cerebrospinal fluid analysis. __________ References: The evaluation and management of bacterial meningitis: current practice and emerging developments. (http://www.ncbi.nlm.nih.gov/pubmed/20445424)

A 38-Year-Old Woman Comes to the Emergency Department Due to 2