A previously well 76-year-old male presents to ED having been found on the floor at home by a relative. Collateral history reveals ‘flu-like’ symptoms and headache within the last week.
On arrival he is soiled, agitated and combative with a GCS of 9/15 (E2 V2 M5). There are no obvious localising neurological signs. Pupils are equal and reactive. Temperature is 39.0.A basic delirium screen in ED is negative (urine dip and chest x-ray). As you continue assessing the patient, he has a short-lived generalised tonic-clonic seizure.
- What is your differential diagnoses?
- How would you investigate further?
The patient is subsequently intubated and ventilated and a CT head is requested. A CNS cause for the presentation is suspected. Intravenous Ceftriaxone and Aciclovir are administered pending further investigations; the salient results are shown below.
- FBC: Hb 135 g/dl, WCC 17.4, Plt 405
- U&E: Urea 8.5, Cr 95, Na 130, K 4.5, CK 905
- Coag: Normal Limits
- CT – head and neck – nil acute
- CXR – clear
- Turbid in appearance
- Cell Count 1200 cells/mm3 (95% Polymorphs)
- Protein 0.6g/l
- Glucose 2.1 (Serum 7.6)
- Gram Stain – Gram +ve diplococci
The presumptive diagnosis at this point was Pneumococcal Meningitis. Treatment with broad-spectrum antibiotics and antivirals was continued, and dexamethasone was added. The patient spent 10 days in critical care and a further 22 days in hospital. He was left with significant speech and balance disorders as a result of his meningitis and was eventually discharged to a rehab facility.
Written by Dr Colin McAdam
First published on 14 May 2020