Question

Case Studies:

Case Study 1

​A frantic mother brought her 12-year-old son to a hospital’s emergency room at 11 pm. The child was rigid and in a stupor. The attack was of sudden onset 30 minutes earlier. The child had experienced a mild, upper respiratory infection and an earache in the last 24 hours. When his temperature started to rise, his mother gave him some Tylenol and put him to bed. On later checking the child’s condition, the mother noticed the fever had risen significantly and she was unable to wake up the child.

​In the ER, the patient’s temperature was 39.5OC and he was unresponsive, showing increased muscle tone and unconscious irritability during his examination, which also uncovered evidence of otitis media. His lungs were clear and his heart rate was elevated. A well-healed scar over the abdominal ULQ was observed; it was determined the child had had his spleen removed following its rupture in a motor vehicle accident three years previously.

​Blood and urine samples were obtained for testing and a chest X-ray was taken; urine and chest X-ray results were normal but WBC counts were elevated. A lumbar puncture was also done and indicated a cloudy CSF under increased pressure. CSF had a depressed glucose level, protein and WBC counts were up, and Gram-positive diplococci were present.

1) What is the most likely diagnosis? Provide reasons.

2) Why might the fact that the child had had his spleen removed be important here?

3) Given the likely diagnosis, how was the patient treated. Would they have waited for the C&S results?

Answer 1

Answer ;

1. The most likely diagosis is acute bacterial meningitis. The patient is showing signs and symptoms of typical case of meningitis like upper respiratory infection with earache, fever etc. Which is followed by rigid and stupor and on examination patient is showing unresponsiveness and incresed muscle tone.X-ray report shows normal which ruleout the possibility of pneumonia. WBC count elevated, which indicate acute bacterial infections.

Lumbar puncture shows typical fetures of bacterial meningitis like cloudy CSF, elevated opening pressure, elevated proteins decreased glucose. Gram stains shows Gram-positive diplococci. Most common bacterial cause of Gram positive diplococci causing meningitis is STREPTOCOCCUS PNEUMONIAE.

2. Spleen is an important organ which is necessory for the removal of polysaccharide encapsulated organism like streptococcus pnemoniae, haemophilus influenza, neisseria meningitidis. Spleen has large amount of lymphoid tissues including splenic macrophages that kills encapsulated organisms. So in spleenectomized patients, there is high chance of infection with these encapsulated organisms.

3. Since it is a very emergency and life threatening condition, we should start emprical therapy with IV antibiotics, IV fluids other supportive management etc once the clinically suspected it is a case of acute bacterial meneingitis. Before starting the emprial therapy we should send blood and CSF fluid for lab investigations. If the culture and snsitivity report of CSF shows that organism is sensitive to the emprical IV antibiotics, then continue the course of same antibiotics. If the organism is resistansive to the emprical antibiotic then cange accordingly and complete the course. Most commonly used emprical antibiotics is cephalosporin like ceftriaxone and cefotaxim.