A 28-year-old woman with fever and lethargy is brought to the emergency department accompanied by her roommate. The roommate reports that the patient appeared well last night but awoke this morning confused. Throughout the morning she became increasingly confused and eventually unarousable, prompting her roommate to call an ambulance. Her past medical history is significant for idiopathic thrombocytopenia purpura. There is no history of recent travel.
Her temperature is 39.4 C (103 F), blood pressure is 84/42 mm Hg, pulse is 122/min, and respirations are 28/min. Oxygen saturation is 90% on room air. Physical examination shows an ill-appearing woman. Pupils are equal and round but sluggish. Lungs have patchy rales. Abdominal examination reveals a surgical scar in the left upper quadrant. There are diffuse ecchymotic areas throughout the torso and lower extremities, with areas of bullae and vesicle formation. There is no rash on the palms or soles. There are no meningeal signs.
Laboratory results as follows:

Chest x-ray reveals bilateral pulmonary infiltrates.
Which of the following antibiotics would be most effective at targeting the suspected pathogen?

Question

A 28-year-old woman with fever and lethargy is brought to the emergency department accompanied by her roommate.  The roommate reports that the patient appeared well last night but awoke this morning confused.  Throughout the morning she became increasingly confused and eventually unarousable, prompting her roommate to call an ambulance.  Her past medical history is significant for idiopathic thrombocytopenia purpura.  There is no history of recent travel.
Her temperature is 39.4 C (103 F), blood pressure is 84/42 mm Hg, pulse is 122/min, and respirations are 28/min.  Oxygen saturation is 90% on room air.  Physical examination shows an ill-appearing woman.  Pupils are equal and round but sluggish.  Lungs have patchy rales.  Abdominal examination reveals a surgical scar in the left upper quadrant.  There are diffuse ecchymotic areas throughout the torso and lower extremities, with areas of bullae and vesicle formation.  There is no rash on the palms or soles.  There are no meningeal signs.
Laboratory results as follows:

Chest x-ray reveals bilateral pulmonary infiltrates.
Which of the following antibiotics would be most effective at targeting the suspected pathogen?

Quizplus · Accepted Answer

11ec193a_9641_b9af_853d_45d4083b9b2c_MD0002_00 This patient has fever, hypotension, altered mental status, and rash (very likely purpura fulminans). She likely has a history of splenectomy (left upper quadrant surgical scar), which increases her risk for an encapsulated organism (eg, Neisseria meningitidis, Streptococcus pneumoniae, or Haemophilus influenzae). Her presentation and rapid deterioration with severe sepsis and DIC make meningococcemia from N meningitidis the most likely diagnosis. N meningitidis is the second most common cause of adult bacterial meningitis in the world and is transmitted via the respiratory route through pharyngeal secretions. Patients may present with fever, severe myalgias (often misdiagnosed early as viral influenza), or severe sepsis without focal signs of meningitis (summarized in the table). Nearly 25% of patients may present with purpura fulminans due to circulating bacterial endotoxin causing cutaneous hemorrhage, progressive skin and soft-tissue necrosis, and subsequent DIC. Early empiric broad-spectrum antibiotics, aggressive fluids, oxygen, and vasopressor support should be initiated immediately. Third-generation cephalosporins (eg, ceftriaxone or cefotaxime) are the most appropriate therapy for N meningitidis, but vancomycin is also added to cover for possible pneumococcal infection until final culture results are available. (Choice A) Ampicillin is effective for suspected Listeria meningitis, which is seen more commonly in neonates, adults > age 50, and immunocompromised patients. (Choice C) Clindamycin is used to treat streptococcal toxic shock syndrome (TSS), which usually presents with extremity or soft-tissue pain followed by ecchymoses, skin sloughing, and necrotizing myositis/fascitis. Although TSS can present with fever and altered mental status, it does not usually have the petechial rash seen in this patient. Clindamycin also does not have activity against Neisseria species. (Choice D) Doxycycline is used to treat Rocky Mountain spotted fever, in which rash usually does not appear until the third to fifth day after onset of fever. The rash starts around the ankles and wrists, involves the palms and soles, and is usually petechial. This patient's rash started abruptly along with the fever, has evolved into bullae, and is not present on the palms and soles. (Choice E) Vancomycin is added to a third-generation cephalosporin for the treatment of bacterial meningitis to include coverage for possible penicillin-resistant pneumococcus. However, it is not effective against N meningitidis and should not be used as monotherapy. Educational objective: Patients with history of splenectomy are susceptible to severe infections from encapsulated bacteria (eg, N meningitidis). Meningococcemia may present with fever, myalgias, purpura fulminans, meningitis, DIC, and shock (with or without adrenal insufficiency). Treatment includes third-generation cephalosporins (eg, ceftriaxone or cefotaxime) and vancomycin. Close respiratory contacts of affected individuals require prophylaxis with rifampin, ciprofloxacin, or ceftriaxone. __________ References: Purpura fulminans in sepsis. (http://www.ncbi.nlm.nih.gov/pubmed/17170624) Meningococcemia. (http://www.ncbi.nlm.nih.gov/pubmed/8958165)

A 28-Year-Old Woman with Fever and Lethargy Is Brought to the Emergency