A 15-year-old girl is brought to the emergency department due to 18 hours of headache and lethargy. The headache began last night after she returned from a camping trip with her friends during which she had been healthy. The patient had fever and vomiting overnight, and this morning her family had difficulty waking her. She has no significant medical history. Temperature is 39.6 C (103.3 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 22/min. The patient is obtunded and responds only to deep, painful stimuli. Physical examination shows resistance to passive neck flexion and several petechiae on the lower extremities. Cerebrospinal fluid test results are as follows: Which of the following is the most likely cause of this patient's condition?

Question

A 15-year-old girl is brought to the emergency department due to 18 hours of headache and lethargy.  The headache began last night after she returned from a camping trip with her friends during which she had been healthy.  The patient had fever and vomiting overnight, and this morning her family had difficulty waking her.  She has no significant medical history.  Temperature is 39.6 C (103.3 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 22/min.  The patient is obtunded and responds only to deep, painful stimuli.  Physical examination shows resistance to passive neck flexion and several petechiae on the lower extremities.  Cerebrospinal fluid test results are as follows:  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d1b5_ebcb_bc81_536cb7cd4e8d_MD0003_00 Neisseria meningitidis is a gram-negative diplococcus that is the most common cause of bacterial meningitis in teens and young adults. Symptoms include the acute onset of fever, headache, vomiting, and severe myalgias. Illness rapidly progresses, and patients typically develop nuchal rigidity (eg, resistance to neck flexion) and altered mental status within 12-24 hours. A petechial rash (correlating with thrombocytopenia) is common and may become purpuric in later stages. Analysis of cerebrospinal fluid (CSF) reveals low glucose, high protein, and neutrophilic leukocytosis (>1000/mm³). cerebrospinal fluid (CSF) Treatment of meningococcal meningitis is a third-generation cephalosporin (eg, ceftriaxone). Empiric antibiotic regimens should also include vancomycin for coverage of penicillin-resistant Streptococcus pneumoniae, a common but less likely pathogen in this age group. Even with appropriate treatment, the mortality rate of meningococcal meningitis is up to 15% due to complications, including shock and disseminated intravascular coagulation. (Choice A) Early disseminated Lyme disease can present with meningitis. Unlike in this patient, symptoms of headache, fever, and neck stiffness develop over many days (not acutely), and shock is atypical. In addition, CSF testing shows a lymphocytic (not neutrophilic) predominance. (Choice B) Encephalitis caused by arboviruses (eg, West Nile virus) typically presents more gradually with several days (not hours) of prodromal symptoms (eg, fatigue, headache, vomiting) prior to severe, devastating encephalitis. In addition, CSF analysis reveals moderate pleocytosis (<500/mm³) and normal glucose. (Choice D) S pneumoniae is a common cause of community-acquired bacterial meningitis in all age groups, but adolescents are at particularly high risk of N meningitidis. In addition, a petechial rash is more commonly associated with N meningitidis. (Choice E) Rocky Mountain spotted fever (RMSF) symptoms can include fever, headache, and a rash. However, symptoms evolve over days (not <24 hr); and the associated rash, which typically develops several days into the illness, starts as a maculopapular rash that involves the palms and soles and spreads centrifugally before becoming petechial. In addition, in contrast to other causes of bacterial meningitis, CSF findings in RMSF usually include normal glucose and leukocytes <100/mm³. (Choice F) Toxic shock syndrome is caused by a Staphylococcus aureus exotoxin and may result in erythroderma (ie, macular rash like a sunburn), altered mental status, shock, and multiorgan failure. This patient's CSF findings suggestive of bacterial meningitis make this diagnosis unlikely. Educational objective: Meningococcal meningitis presents most commonly in teens and young adults with an abrupt onset and rapid progression of fever, headache, myalgias, petechial rash, nuchal rigidity, and shock. Cerebrospinal fluid shows evidence of bacterial meningitis (eg, low glucose, high protein, neutrophilic leukocytosis). References: Neisseria meningitidis. (http://www.ncbi.nlm.nih.gov/pubmed/31751039) Meningococcal disease in childhood: epidemiology, clinical features and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/26788732)

A 15-Year-Old Girl Is Brought to the Emergency Department Due