CASE 56
A 20-year-old white male college student was brought to an emergency department in early January with a 12-hour history of high fever, chills, and severe headache. Soon after arriving at the ED, he vomited twice. He looked confused and was highly agitated. He was admitted to the hospital, and within two hours he developed purpuric skin lesions. He had received all appropriate immunizations and was otherwise healthy.
PHYSICAL EXAMINATION
LABORATORY STUDIES
Diagnostic Work-Up
Table 56-1 lists the likely causes of illness (differential diagnosis). Lumbar puncture is performed if the patient does not have papilledema or lateralizing neurologic findings. Laboratory examination of the CSF usually confirms the presence of meningitis (viral or bacterial). Investigation approach should include
TABLE 56-1 Differential Diagnosis and Rationale for Inclusion (consideration)
Rationale: The presentation of acute meningitis is one of the most dramatic in medicine. There are relatively few organisms commonly associated with this syndrome. The age of the patient is important in determining the most likely organisms. In this case, S. pneumoniae and N. meningitidis are the most common causes, and the purpuric rash is highly characteristic of one of these pathogens. Rocky Mountain spotted fever can also cause a very similar clinical picture, especially the rash. The other causes listed do not generally present with a characteristic rash.
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