This is the second in a series of articles titled “What’s wrong with this patient?” In it, I will present the history, exam findings, and lab and imaging results. Then, together we will formulate a diagnosis from the information provided.
This is the case of a 14 year old boy who came to the office with a 2-day history of headache, nausea, vomiting, and generalized weakness. His headache was worsening, but became much worse when he developed a temperature of 103°. He had developed a red, spotty, measles-like rash on his arms. On exam he was pale, weak, and looked sick. His throat was a little inflamed. He complained of a stiff neck and was unable to bend it to put his chin on his chest. That motion was painful. His lungs were clear. His had no heart murmurs, but his heart rate was 110 beats per minute (bpm). His neurologic exam, other than lethargy, was negative.
Suspecting he had a serious illness, he was referred to the ER for further evaluation. ER physicians ordered a CBC (complete blood count). His WBC (white blood cell count) was high at 24,000 (normal is 5000-12,000). His white cells were 87% neutrophils (normal is 55-70%). Neutrophils are high in a bacterial infection.
Next, a spinal tap (lumbar puncture) was done. Spinal fluid is normally clear; his was cloudy. Spinal fluid analysis showed 2300 white blood cells (normally there are none), and they were 96% neutrophils (indicative of a severe bacterial infection). Spinal fluid protein level was high and glucose level was low. The spinal fluid was then mixed with a liquid dye called Gram stain. It showed reddish pink-colored, double-bodied, bacteria adjacent to the white blood cells (Gram negative extra-cellular diplococci). The spinal fluid and blood were sent to the lab for culture to identify the bacteria seen on Gram stain in the spinal fluid and to be certain the infection hadn’t “spilled” into the blood. These test results all point to a specific problem. We now had enough to make a diagnosis.
“What’s wrong with this patient?” He has acute, severe, bacterial meningitis, probably caused by a Gram negative bacteria called Neisseria meningitidis. He has Meningococcal Meningitis.
He was admitted to the pediatric ICU, was placed in isolation, and treated with intravenous antibiotics, IV fluids, and supportive care.
Meningitis is a potentially fatal infectious disease. Bacterial meningitis occurs more often in males and 1 in 10 patients die. To diagnose meningitis requires the doctor to have the clinical suspicion that this sick child might just might have it. The doctor must decide from noting the child’s appearance, hearing his symptoms, and examining him carefully that he is seriously ill and needs the tests mentioned above. I was taught if a patient appeared sick enough for you to even think about doing a lumbar puncture, you should do it. That was good advice. Missing a case of meningitis, or diagnosing it late, has disastrous consequences. This child would fit that category.
Of the survivors of meningitis, 1 in 7 have lingering complications-deafness, partial brain damage, etc. Early recognition and diagnosis and aggressive treatment will lessen the chances of long term neurologic sequelae.
“What’s wrong with this patient?” Acute Bacterial Meningitis.
References: www.weber.edu/casestudies/meningitis.html
Bonugulapati LNR, Gilkes CE. Just another case of bacterial meningitis… or is it? BMJ Case Rep 2018.doi:10.1136/bcr-2018-225344.
