An 8-year-old girl is brought to the emergency department with lethargy and fever. The patient has had intermittent cough, fever, and headache for the past 3 weeks. She vomited before dinner last night and went to bed early. This morning, her father could not wake her up. The patient is otherwise healthy. She traveled with her family to rural Ecuador 2 months ago for a mission trip. She has no other recent travel and no known sick contacts. Temperature is 39.8 C (103.6 F). The patient is minimally responsive on examination. Funduscopy shows papilledema, and chest auscultation reveals decreased breath sounds and crackles over the right middle lobe. The results of lumbar puncture are as follows: Which of the following organisms is the most likely cause of this patient's symptoms?

Question

An 8-year-old girl is brought to the emergency department with lethargy and fever.  The patient has had intermittent cough, fever, and headache for the past 3 weeks.  She vomited before dinner last night and went to bed early.  This morning, her father could not wake her up.  The patient is otherwise healthy.  She traveled with her family to rural Ecuador 2 months ago for a mission trip.  She has no other recent travel and no known sick contacts.  Temperature is 39.8 C (103.6 F).  The patient is minimally responsive on examination.  Funduscopy shows papilledema, and chest auscultation reveals decreased breath sounds and crackles over the right middle lobe.  The results of lumbar puncture are as follows:  Which of the following organisms is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d577_6085_bc81_0576f9306dbc_MD0003_00 This child's cerebrospinal fluid (CSF) findings, in combination with the abnormal lung examination and travel history, are highly concerning for tuberculous (TB) meningitis. CNS involvement is a rare but serious complication that occurs in approximately 5% of children with primary TB infection. The mycobacteria spread hematogenously to the subarachnoid space, most commonly at the base of the brain, and proliferate. The resulting thick exudate can lead to meningeal irritation, obstruction of CSF flow, and infarction. CSF findings include pleocytosis with a lymphocytic predominance, high protein, and significantly low glucose (a particularly characteristic finding). The clinical onset of TB meningitis is usually gradual, with several weeks of nonspecific headache, fever, and fatigue before a more rapid progression to lethargy, nuchal rigidity, focal neurologic defects, and seizures. Coma, herniation, and death can follow. Treatment during the early stages is associated with recovery, but permanent neurologic deficits or death is likely once signs of overt meningitis appear. (Choice A) Fungal infections of the CNS or lungs are extremely rare in immunocompetent individuals, and when Aspergillus invades the brain it generally presents with a focal brain abscess rather than meningitis, as in this patient. (Choice B) Enteroviruses are common causes of aseptic meningitis, which can present with a lymphocytic predominance in the CSF, as in this patient. However, enteroviruses usually have an acute onset and would not be associated with low glucose. (Choice C) Listeria monocytogenes can present with subacute to chronic meningitis with a lymphocytic predominance, low glucose, and high protein in the CSF. However, Listeria meningitis is usually seen in neonates, the elderly, or pregnant women; meningitis is extremely rare in immunocompetent hosts even during outbreaks. In addition, Listeria would not account for this patient's abnormal lung findings. (Choice E) Streptococcus pneumoniae is an important cause of bacterial meningitis. However, pneumococcus has an acute onset (<7 days) and presents with a predominance of neutrophils in the CSF. This patient has had prolonged symptoms and a predominantly lymphocytic response. (Choice F) Toxoplasmosis in immunocompetent children and adults usually presents with disseminated lymphadenopathy, chorioretinitis, and fever. CNS involvement is unusual outside of the neonatal period. Educational objective: Tuberculosis meningitis is a rare but serious complication of primary TB infection due to the hematogenous spread of mycobacteria to the subarachnoid space. The onset is gradual, with weeks of nonspecific symptoms before rapid progression to fulminant meningitis. Cerebrospinal fluid analysis shows lymphocytic pleocytosis, high protein, and low glucose. References: The pathogenesis of tuberculous meningitis. (http://www.ncbi.nlm.nih.gov/pubmed/30645042)

An 8-Year-Old Girl Is Brought to the Emergency Department with Lethargy