Meningitis

Question 1

A 16 year old boy has been unwell for two days with fever and headaches. He has now become drowsy and is brought to the ED. He is febrile (T39), drowsy with neck stiffness but no focal neurological signs and no papilloedema. There is a fine petechial rash over his body and legs. How would you assess and manage him?

Answer 1

Impression
Provisionally concerned about meningococcal meningitis given characteristic rash with fevers and neck stiffness.

Important Ddx include;
- Infective: encephalitis, other form of meningitis (viral, sepsis, other focus of infection (skin, resp, urinary, sepsis).

Goals
- Call for senior help, take key investigations including cultures and initiate empirical treatment for meningococcal meningitis including dexamethasone (0.15-0.6mg/kg) prior to starting empirical ABx with ceftriaxone.

Question 2

Meningitis - Assessment

Answer 2

Assessment
- call for senior help
- begin A to E assessment and start empirical treatment as early as possible

A - patent, maintaining
B - RR, SP02, supplemental as required
C - BP/HR/ECG. Assess for evidence of systemic toxicity. 2xIVC and take initial bloods (VBG, CRP, FBC, UEC, LFT, cultures, coags, BSL). Get LP as well (unless prevents early treatment) whilst starting fluid resus with 0.9% NS, 500mL bolus then infusion. Administer Dexamethasone (0.15-0.6mg/kg) at or before starting IV empirical ABx (Ceftriaxone). Involve ICU and ID early for management input and dispositioning
D - GCS, PEARL, neuro examination for focal signs
E - assess rash, other sites of infection

Complete rest of history and examination once stabilised

Question 3

Meningitis - History

Answer 3

History
- Sx: onset, duration, progression. neck stiffness, photophobia, headache, altered mental state, non-blanching rash
- RISKS: sick contacts, unvaccinated, immunocompromised, recent travel
- PMHx
- Medications, allergies, fam history

Question 4

Meningitis - Examination

Answer 4

Examination
- general appearance + vitals
- Neuro examination: focal neurology ,evidence of raised ICP (papilloedema, Cushing response), features of meningism (photophobia, neck stiffness), other features of meningitis: Kernigs and Brudzinski’s signs

Question 5

Meningitis - Investigations

Answer 5

Investigations
Diagnostic
- LP for CSF MCS, looking for raised WCC, low glucose, elevated protein - gram stain looking for N. Meningitides
- otherwise, blood cultures

Additional
- CT if concerned about raised ICP before LPing patient, or for alternative diagnosis

Question 6

Meningitis - Management

Answer 6

Management
Definitive
- Dexamethasone 10mg given at or before ABx, otherwise limited utility - continue for 4 days of therapy.
- IV Ceftriaxone 2g
- add ben pen if ?listeria, add Vanc if gram +ve cocci on gram stain, addacyclovir if concerned about viral meningitis
- switch to direct ABx once sensitivities are returned

Supportive
- fluid resus for hypotension in setting of sepsis
- consider vasopressor support under senior guidance
- may need ICU/PICU depending on severity and HD status, ICU if on vasopressors
- contact tracing, prophylactic treatment of close contacts (IM ceftriaxone)