Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Managing Postpartum Complications in the Emergency Department correct.
Case Presentation: Emergency Department Management of Adults with Infectious Meningitis and Encephalitis
A 24-year-old woman with a history of migraine presents to the ED with a “splitting” headache…
The patient says this headache is more severe than any migraine she has had before. She is noted to have a temperature of 38.3°C, a heart rate of 115 beats/min, and a blood pressure of 105/70 mm Hg. You wonder whether this episode is simply another migraine or something else entirely.
Noting her fever and headache, meningitis immediately jumped to the top of your differential diagnosis. Your examination did not reveal focal deficits, but flexion of the patient’s neck did elicit discomfort. She reported ongoing nausea and that she vomited en route to the ED. These symptoms improved somewhat with IV antiemetics. She had no contraindications to lumbar puncture or indications for CT, so lumbar puncture was performed immediately in the lateral decubitus position. Empiric IV vancomycin, ceftriaxone, and dexamethasone were subsequently administered. CSF analysis showed opening pressure of 18 cm H2O, 29 WBCs, 2 RBCs, protein of 61 mg/dL, and CSF to blood glucose ratio of 0.63.
She remained very nauseated, and her headache was minimally improved after IV ketorolac and metoclopramide. You suspected viral meningitis, but recognized that her CSF results were borderline. You continued antibiotics and admitted her to the medical ward. Several hours later, CSF PCR results identified enterovirus as the causative agent.
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Last Updated on January 26, 2023