A 68-year-old man is brought to the emergency department due to lethargy and fever. He called his daughter this morning and told her that he had been having fever, chills, and headache. When she visited him a few hours later, he was warm to the touch and lethargic and soon had a tonic-clonic seizure. The patient is a widower who lives independently and is in excellent health. He has no history of previous seizure and has not recently traveled. He does not use alcohol or tobacco and has no allergies.
Temperature is 39.4 C (103 F), blood pressure is 80/50 mm Hg, pulse is 98/min, and respirations are 20/min. Pulse oximetry shows 96% on room air. The patient is lethargic and oriented only to person. He responds intermittently to questions but moves all 4 extremities on command. Moderate neck pain and stiffness are present. Deep-tendon reflexes are symmetric. No genital lesions are noted.
Laboratory workup is obtained and head CT scan and lumbar puncture are planned.
Which of the following is the best next step in management of this patient?

Question

A 68-year-old man is brought to the emergency department due to lethargy and fever.  He called his daughter this morning and told her that he had been having fever, chills, and headache.  When she visited him a few hours later, he was warm to the touch and lethargic and soon had a tonic-clonic seizure.  The patient is a widower who lives independently and is in excellent health.  He has no history of previous seizure and has not recently traveled.  He does not use alcohol or tobacco and has no allergies.
Temperature is 39.4 C (103 F), blood pressure is 80/50 mm Hg, pulse is 98/min, and respirations are 20/min.  Pulse oximetry shows 96% on room air.  The patient is lethargic and oriented only to person.  He responds intermittently to questions but moves all 4 extremities on command.  Moderate neck pain and stiffness are present.  Deep-tendon reflexes are symmetric.  No genital lesions are noted.
Laboratory workup is obtained and head CT scan and lumbar puncture are planned.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9646_c2c8_853d_d392990e9779_MD0002_00 This older patient has all 3 classic manifestations (high fever, neck stiffness, altered mental state) of acute bacterial meningitis. Most cases are due to Streptococcus pneumoniae (~70%), but Neisseria meningitidis, group B streptococci, Haemophilus influenzae, and Listeria monocytogenes (in those age >50) are also common culprits. The underlying organism is typically identified by blood and/or cerebrospinal fluid (CSF) cultures. Patients with suspected acute bacterial meningitis require urgent empiric treatment to limit neurologic sequelae and reduce the risk of death. First-line antibiotic therapy includes ceftriaxone, vancomycin, and ampicillin (added for those age >50 to empirically cover L monocytogenes). In addition, dexamethasone is given just prior to or with the first dose of empiric antibiotics to reduce neurologic sequelae (eg, hearing loss) and mortality in those with pneumococcal meningitis; it should be discontinued if CSF gram stain or culture (or blood culture) indicates infection with a nonpneumococcal organism. Most patients are initiated on treatment after blood cultures and lumbar puncture. However, those who require a head CT scan prior to lumbar puncture (eg, altered mental state, new seizure, focal deficit, immunocompromise, central nervous system disease, papilledema) should first receive empiric therapy to limit treatment delays. (Choice A) Acyclovir is used to treat herpes encephalitis, which commonly presents with high fever, altered mental status, seizure, and/or focal neurologic deficits but is rarely associated with neck stiffness or nuchal rigidity. Most (85%) cases of herpes meningitis are accompanied by genital lesions. Compared to bacterial meningitis, herpes central nervous system (CNS) infections are less likely to cause marked hypotension (as seen in this patient) in the absence of immunosuppression. Although patients undergoing empiric treatment for bacterial meningitis sometimes receive concurrent empiric acyclovir therapy until herpes CNS infection is ruled out, acyclovir would not be used alone. (Choices B and D) Cefepime or meropenem are used in place of ceftriaxone for the empiric treatment of bacterial meningitis when patients have underlying immunocompromise or health care-associated meningitis (eg, head trauma, recent neurosurgery) to cover for opportunistic bacterial pathogens such as Pseudomonas aeruginosa. This patient has no evidence of immunocompromise or risk for health care-associated meningitis. (Choice E) Because this patient is age >50, he requires ampicillin to cover for L monocytogenes. In addition, dexamethasone is required to reduce adverse outcomes in the setting of possible pneumococcal meningitis. Educational objective: Patients with suspected acute bacterial meningitis require urgent empiric treatment with ceftriaxone and vancomycin. Ampicillin should be added for those age >50 to empirically cover for Listeria monocytogenes. All patients should also receive adjunctive dexamethasone to reduce risk of neurologic sequelae and death from potential pneumococcal meningitis. __________ References: Delays in the administration of antibiotics are associated with mortality from adult bacterial meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/15760921) Corticosteroids for acute adult bacterial meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/19386456)

A 68-Year-Old Man Is Brought to the Emergency Department Due