A 16-year-old boy is brought to the emergency department due to high fever and sore throat. He also has severe, diffuse leg pain. The symptoms started abruptly 8 hours ago, and the patient says that he has "never felt as terrible" as in the last few hours. Due to his rapid progression of illness, his parents felt an evaluation could not wait for a scheduled outpatient appointment later today. Temperature is 39.1 C (102.4 F). On examination, the patient appears pale. There is diffuse erythema of the posterior pharynx without exudate. The tonsils are 2+ bilaterally. The neck is supple without significant adenopathy. Heart and lung examinations are normal. There is no hepatosplenomegaly. The bilateral lower extremities are diffusely tender to palpation with mottling of the skin. Rapid streptococcal and influenza testing are negative. A complete blood count and blood culture are obtained. Which of the following additional tests is the best next step in evaluation of this patient?

Question

A 16-year-old boy is brought to the emergency department due to high fever and sore throat.  He also has severe, diffuse leg pain.  The symptoms started abruptly 8 hours ago, and the patient says that he has "never felt as terrible" as in the last few hours.  Due to his rapid progression of illness, his parents felt an evaluation could not wait for a scheduled outpatient appointment later today.  Temperature is 39.1 C (102.4 F).  On examination, the patient appears pale.  There is diffuse erythema of the posterior pharynx without exudate.  The tonsils are 2+ bilaterally.  The neck is supple without significant adenopathy.  Heart and lung examinations are normal.  There is no hepatosplenomegaly.  The bilateral lower extremities are diffusely tender to palpation with mottling of the skin.  Rapid streptococcal and influenza testing are negative.  A complete blood count and blood culture are obtained.  Which of the following additional tests is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5e8_9880_bc81_ff0899f07581_MD0003_00 This adolescent has an abrupt onset of fever and pharyngitis plus severe myalgias and signs of poor perfusion (ie, pale, mottled skin). Given the rapid progression of disease over 8 hours, these findings are concerning for sepsis due to Neisseria meningitidis. Although meningococcal meningitis classically presents with fever, nuchal rigidity, petechial rash, and altered mental status, early meningococcal infection typically causes nonspecific symptoms (eg, fever, headache, vomiting). Nonsuppurative pharyngitis, as seen here, is a rare presentation of meningococcal meningitis that may be mistaken for streptococcal or viral pharyngitis. However, patients with pharyngitis due to meningococcus have rapid disease progression (<12 hours) and often describe their illness as the "worst I have ever felt." Other key features distinguishing meningococcal disease from more benign illnesses include: Severe myalgias (eg, diffuse leg pain) Cold hands/feet Mottled skin or pallor These features likely reflect the significant inflammatory response to meningococcal infection (eg, interleukin-6 causing myocardial depression and poor perfusion). Prompt recognition and evaluation is crucial because the illness can quickly progress to shock, disseminated intravascular coagulation, multiorgan failure, and death. Patients with suspected meningococcal infection should undergo a lumbar puncture; the presence of N meningitidis on cerebrospinal fluid culture is diagnostic. Treatment is a third-generation cephalosporin (eg, ceftriaxone). (Choice A) Evaluation of deep neck space infections may warrant CT scan. However, patients with these infections usually have trismus, and examination often reveals uvular deviation (in peritonsillar abscess) or pharyngeal wall bulging (in retropharyngeal abscess). (Choice B) The presence of heterophile antibodies is diagnostic of infectious mononucleosis, which can present with sore throat, fever, and fatigue. In contrast to this case, examination typically reveals an exudative pharyngitis and posterior cervical lymphadenopathy. In addition, rapid progression of symptoms with severe leg pain and mottling would not be expected. (Choice C) HIV antigen/antibody testing can identify acute HIV infection, which often presents with fever and sore throat. However, patients also usually have diffuse lymphadenopathy, generalized rash, and diarrhea, none of which are seen here. (Choice E) Diphtheria, diagnosed by throat culture, is a potentially fatal infection that presents with sore throat and fever. In contrast to this case, a gray, adherent, posterior pharyngeal pseudomembrane is classically present. Educational objective: Early meningococcal infection is often nonspecific (eg, fever, pharyngitis) but should be suspected in a patient with rapidly progressive illness, severe myalgias (eg, leg pain), and poor perfusion (eg, mottled skin, cold hands/feet). Positive cerebrospinal fluid culture obtained via lumbar puncture is diagnostic. References: Which early 'red flag' symptoms identify children with meningococcal disease in primary care? (http://www.ncbi.nlm.nih.gov/pubmed/21375891) Atypical clinical presentation of meningococcal meningitis: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/27668905)

A 16-Year-Old Boy Is Brought to the Emergency Department Due