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November 2002
A previously
healthy 15-year-old male presented to a community hospital with
a decreased level of consciousness. Five days prior, he attended
a community fair after which he developed a flu-like illness including
fatigue, nausea and vomiting. The illness did not resolve and
after three days his parents noticed red spots on his hands, arms
and legs. On the day of admission, he was found to be delirious
and becoming less responsive, so his parents brought him to the
emergency department. All his routine vaccinations were up to
date. His past medical history was significant only for recreational
cannabis use. While he still lived at home with his parents, he
frequently went to “sleep-overs” at his friends’
homes.
On
presentation to the emergency, the patient was found to be afebrile
with a temperature of 37.5°C, but hypotensive and tachycardic.
He had a score of 8 on the Glascow Coma Scale. Physical examination
revealed marked nuchal rigidity and petechiae on the face and
limbs.
Laboratory
investigations showed leucocytosis with a white blood cell count
of 16.8 x 109/L. The electrolytes were normal and the serum glucose
was 7.7 mM. Lumbar puncture was attempted twice but unsuccessful.
The patient was empirically started on vancomycin, ceftriaxone
and decadron and transferred by helicopter to an intensive care
unit at a tertiary-care hospital on the same day. Cerebral spinal
fluid was finally obtained. It was turbid and contained 13,300
x 106/L leucocytes (95% polymorphs). The protein was 4.4 g/L and
glucose 1.4 mM. The Gram stain of the fluid showed many polymorphonuclear
cells and gram-negative diplococci. With that result, the vancomycin
was discontinued. The patient improved after a single day of antibiotics
and was transferred to the regular ward. He subsequently made
a full recovery after a full seven days of antibiotic therapy.
Unfortunately there was no growth from his CSF or blood cultures
to confirm the identity of the microorganism causing his disease.
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What are the most common organisms causing meningitis? How do
these differ in different age groups?
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Based on the results, which agent is most likely in this case?
What are risk factors for acquiring this infection?
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How is the identity of this organism confirmed in the laboratory?
What other diagnostic tests are available to determine the presence
of this organism?
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What is the empiric treatment for meningitis? What is the treatment
for meningitis caused by this organism? What about close contacts
of the patient?
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Could this infection have been prevented? How?
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