A 2-year-old girl is brought by her parents to the emergency department due to fever. Approximately 10 hours ago, the patient had several episodes of vomiting and began to feel increasingly lethargic. Vaccinations are up to date. Temperature is 39.8 C (103.6 F), blood pressure is 70/36 mm Hg, and pulse is 135/min. The patient is poorly responsive on examination. The abdomen is nontender and nondistended. A rash is present on the bilateral lower extremities. A representative photograph is shown below: Antibiotic therapy is initiated, and a lumbar puncture is obtained. Gram stain of cerebrospinal fluid shows gram-negative diplococci. Which of the following additional studies should be obtained in this patient?

Question

A 2-year-old girl is brought by her parents to the emergency department due to fever.  Approximately 10 hours ago, the patient had several episodes of vomiting and began to feel increasingly lethargic.  Vaccinations are up to date.  Temperature is 39.8 C (103.6 F), blood pressure is 70/36 mm Hg, and pulse is 135/min.  The patient is poorly responsive on examination.  The abdomen is nontender and nondistended.  A rash is present on the bilateral lower extremities.  A representative photograph is shown below:  Antibiotic therapy is initiated, and a lumbar puncture is obtained.  Gram stain of cerebrospinal fluid shows gram-negative diplococci.  Which of the following additional studies should be obtained in this patient?

Quizplus · Accepted Answer

11ec25c8_d6c7_1253_bc81_d3d7baf5a3a0_MD0003_00 This patient has an acute fever, purpuric rash, and altered mental status in addition to gram-negative diplococci in the cerebrospinal fluid, findings consistent with meningitis caused by Neisseria meningitidis. Early symptoms of meningococcal meningitis include the acute onset of fever, headache, vomiting, and petechial rash. Symptoms progress rapidly over 12-24 hours to include a purpuric rash and altered mental status (eg, lethargy). Meningococcal meningitis is potentially fatal due to complications, which include shock, multiorgan failure, adrenal hemorrhage, purpura fulminans, and disseminated intravascular coagulation (DIC). DIC is caused by an overwhelming activation of coagulation and fibrinolysis, leading to clotting factor and platelet consumption. Manifestations include oozing at an intravenous line site, gastrointestinal hemorrhage, and purpura; laboratory evidence of DIC includes thrombocytopenia, elevated PT and PTT, and low fibrinogen. Management is supportive (eg, hemodynamic stabilization). Purpura fulminans, a less common complication of meningococcal meningitis, presents with gangrenous necrosis of purpuric lesions. (Choice A) Positive antinuclear antibodies are seen in systemic lupus erythematosus (SLE), which can cause fever and a purpuric rash due to thrombocytopenia or vasculitis. However, this patient has no additional manifestations of SLE (eg, arthritis, nephritis), and rapid progression over hours would not be expected. (Choice B) Dermatologic sequelae of group A streptococcal pharyngitis, which is associated with increased anti-streptolysin O antibody, include a sandpaper-textured rash in scarlet fever and annular lesions (ie, erythema marginatum) in acute rheumatic fever. Neither condition causes purpura. (Choice C) Patients with terminal complement (C5-C9) deficiency are at increased risk for invasive infection with encapsulated organisms, such as N meningitidis. Early complement component (C1-C4) deficiencies do not typically affect the risk for N meningitidis, so obtaining levels is not indicated. (Choice E) Skin biopsy may be necessary to confirm the diagnosis of Henoch-Schönlein purpura (HSP), which can present with a purpuric lower extremity rash. However, this patient's rapidly progressive mental status changes make this diagnosis unlikely. In addition, HSP also typically causes joint pain and abdominal pain. Educational objective: Purpura is a late manifestation of meningococcal meningitis and suggests disseminated intravascular coagulation (DIC), which is characterized by clotting factor and platelet consumption. Laboratory evidence of DIC includes thrombocytopenia, elevated PT and PTT, and low fibrinogen. References: Invasive meningococcal disease in the vaccine era. (http://www.ncbi.nlm.nih.gov/pubmed/30474022) Neisseria meningitidis. (http://www.ncbi.nlm.nih.gov/pubmed/31751039)

A 2-Year-Old Girl Is Brought by Her Parents to the Emergency