ID Conference

(Bacterial Meningitis)
 General Data
• C.L.
• 72/F
• Filipino
• Married
• Catholic
 Chief Complaint:
Change in sensorium
 History of Present Illness
• (+) productive cough, yellowish sputum
• (+) right ear impairment (70%)
• Self medicated with Cefuroxime BID for 7 days,
2 month PTA which did not prompt any relief
• (-) fever
• (-) aural discharge
• (-) change in BM
• (-) dysuria
 History of Present Illness
• (+) noted progression of right ear pain radiating to
the jaw accompanied by undocumented fever
• (+) noted progression of hearing loss, now
2 days PTA bilateral.
• Self medicated with Paracetamol which did not
prompt any relief.
• Advised to seek consult, but refused.
 History of Present Illness

• (+) fever, undocumented

• (+) behavioural change (refused to take
medications and refused to eat)
Few hrs PTA
• (+) persistence of hearing loss
• Prompted consult
 Review of Systems
• GENERAL: (-) weight loss
• SKIN: (-) rashes, (-) pruritus
• HEENT: (-) epistaxis, (-) sore throat, (-) palpable lymphadenopathies
• RESPIRATORY: (-) dyspnea, (-) tachypnea
• CARDIOVASCULAR: (-) chest pain, (-) palpitations, (-) orthopnea
• URINARY: (-) frequency, (-) urgency, (-) incontinence, (-) hematuria
• HEMATOLOGIC: (-) easy bruisability/bleeding
• ENDOCRINE: (-) heat or cold intolerance
 Past Medical History
• (+) Hypertension, uncontrolled
• (-) DM
• (-) Malignancy
• (-) Heart Disease
 Family History
• (-) DM
• (-) HTN
• (-) malignancy
• (-) allergies/asthma
• (-) thyroid diseases
 Personal and Social History
• (-) smoker
• (-) alcohol beverage drinker
• (-) illicit drug use
 Physical Examination
• GENERAL: lethargic, agitated when awake, does not follow command

• BP: 130/80 HR: 92 RR 21 T38.8C O2 sat: 98%

• HEENT/Neck: (+) nuchal rigidity, anicteric sclerae, pink palpebral

conjunctivae, moist oral mucosa, non hyperemic posterior pharyngeal
wall, (-) cervical lymphadenopathy
 Physical Examination
• CARDIAC: adynamic precordium, AB on 5th LICS MCL, non distended
neck veins, distinct heart sounds, no murmurs

• CHEST: symmetrical chest expansion, no retractions, (+) crackles on

the right lower lobe

• ABDOMEN: soft, non tender, no masses, no CVA tenderness

• EXTREMITIES: (+) full equal pulses, no cyanosis, no edema

 Physical Examination
• NEUROLOGIC: GCS 10 (E4 V1 M5)
• CN I : N/A
• CN II, III: 1-2mm EBRTL
• CN III, IV, VI: Full EOMs, no noted peripheral gaze
• CN VII: no facial asymmetry
• CN VIII: (+) hearing loss (LEFT 0%; RIGHT 30%)
• MOTOR: no noted weakness on both extremities
• SENSORY: N/A
• REFLEXES: (++) on all DTRs (including brachial and ankle reflexes)
 SALIENT FEATURES
• Subjective • Objective
• 72/F • Arrived at ER lethargic
• 2month hx loss of • Agitated when awake
hearing • (+) nuchal rigidity
• (+) progression of • (-) rashes
hearing loss with ear
pain • (-) focal neurologic
deficit
• (+) fever
• (+) change in behavior
 Admitting Diagnosis

T/C Bacterial Meningitis; T/C Otitis Media, both;

Hypertension, uncontrolled
 On Admission
S O A P
2month hx loss of BP 130/80 T/C Bacterial NGT inserted, started OF
hearing HR 92 RR 21 Meningitis; T/C Otitis feeding
(+) progression of T 38.8OC Media, both; Blood CS x 2site
hearing loss with O2 sat: 97% Hypertension, Chest Xray, portable
ear pain uncontrolled Paracetamol 300mg/IV q4 as
(+) fever (+) nuchal rigidity needed for fever
(+) change in (+) hearing loss (LEFT Citicoline 1g/IV q12
behavior 0%, RIGHT 30%) Ceftriaxone 2g/IV q12
(+) crackles RLL Metronidazole 500mg/IV q6
Soft, flabby, (-) Plain Cranial CT Scan
abdominal
tenderness
 9/10
9/10
Sodium 133
WBC 16.1 Potassium 3.2
HGB 100 SGPT 21
HCT 0.300 BUN 5.8
Crea 102
PLT 184
Seg 85 9/10
Lymph 06 Tot Protein 67
Mono 09
Albumin 39
Eosino
Globulin 28
A/G ratio 1.39
 Cranial CT Scan
• No acute intracranial haemorrhage, edema nor infarct seen
• No extra-axial fluid collection nor compression effect noted
• No midline shift noted
• Ventricular system not dilated
• Mucosal thickening and retained secretions are noted in the
paranasal sinuses and polypoid density in both maxillary sinuses
 1st HD
S O A P
(+) agitated BP 150/60 T/C Bacterial Start K-lyte tab 1 tab TID
GCS 10 (E4 V1 M5) HR 81 RR 20 Meningitis; T/C Otitis Incorporate 20mEq KCl to IVF
(+) hearing loss, afebrile Media, both; Referred to ENT service
bilateral O2 sat: 97% Hypertension, Sinupret Forte TID
(-) nasoaural uncontrolled; For Cranial MRI with Contrast
discharge (+) nuchal rigidity Hypokalemia prob For Lumbar Tap CSF
(+) crackles RLL secondary to poor oral examination
(-) abdominal intake Start Dexamethasone 8mg/IV
D1 Ceftriaxone tenderness q6 30 mins before dose of
D1 Metronidazole Ceftriaxone
 9/10 9/11 9/10 9/11
WBC 16.1 23.3
Sodium 133
HGB 100 109
Potassium 3.2 3.5
HCT 0.300 0.331 SGPT 21
PLT 184 172 BUN 5.8
Seg 85 90 Crea 102 85
Lymph 06 06
Mono 09 04
Eosino
 2nd HD
S O A P
GCS 15 BP 150/60 T/C Bacterial Lumbar Tap done, CSF sent
Awake, coherent, HR 81 RR 20 Meningitis; T/C Otitis for analysis
oriented afebrile Media, both; Transfuse 1u pRBC properly
Still with hearing O2 sat: 97% Hypertension, typed and crossmatched
loss uncontrolled; Cranial MRI done
No noted focal (+) nuchal rigidity Hypokalemia prob
neurologic deficit (+) clear BS secondary to poor oral
(-) abdominal intake
tenderness
D2 Ceftriaxone
D2 Metronidazole
 9/10 9/11 9/12
9/10 9/11 9/12 Sodium 133
WBC 16.1 23.3 23.0 Potassium 3.2 3.5 3.7
HGB 100 109 89 SGPT 21
HCT 0.300 0.331 0.262 BUN 5.8
Crea 102 85
PLT 184 172 165
Seg 85 90 77 9/10 9/12
Lymph 06 06 02 Tot Protein 67 55
Mono 09 04 04
Albumin 39 26
Eosino
Globulin 28 29
A/G ratio 1.39 0.90
 Cranial MRI (9/12)
(1) Subtle abnormal leptomeningeal enhancement involving both
cerebellar hemispheres, basilar, prepontine/peripontine, ambient,
and suprasellar cisterns, and to a lesser extent the bilateral cerebral
hemispheres, highly suggestive of meningitis
(2) Non specific non enhancing punctate signal abnormality involving
the right frontal subcortical white matter, commonly seen in
association with chronic small vessel ischemia
(3) Pansinusitis and bilateral mastoiditis, multiple mucous retention
cysts within the maxillary and sphenoid sinuses bilateral
 3rd HD
S O A P
GCS 15 BP 160/80 T/C Bacterial Start Amlodipine 50mg/tab
Awake, coherent, HR 70 RR 20 Meningitis; T/C Otitis OD
oriented afebrile Media, both; Discontinue Metronidazole
(+) occasional O2 sat: 97% Hypertension,
headache uncontrolled
Still with hearing (+) clear BS
loss (-) abdominal
No noted focal tenderness
neurologic deficit

D3 Ceftriaxone
D3 Metronidazole
 CSF Analysis
CSF Fluid CSF Fluid
Color/ Appearance Colorless/ Hazy CSF PROTEIN 230 (elevated)
Tot RBC Count 38.89 x 10 ^6 CSF SUGAR 2.73 (low)
Non crenated 0.99 CSF/Serum Glucose 0.344
Crenated 0.01
Tot WBC Count 125.56 x 10^6 CSF Fluid
Neutrophiles STREP B NEG
Lymphocytes ALL LYMPHOCYTES
SEEN H INFLUENZAE B NEG
S PNEUMONIAE NEG
CSF Cytology N MENINGITIDIS NEG
Cell Findings show Few Mature Lymphocytes CALAS NEG
 4th HD
S O A P
GCS 15 BP 160/80 T/C Bacterial NGT removed, soft diet
Awake, coherent, HR 70 RR 20 Meningitis; T/C Otitis Started on Losartan 50mg/tab
oriented afebrile Media, both; BID
Still with hearing O2 sat: 97% Hypertension, Shift Ceftriaxone to Penicillin
loss uncontrolled G 4 million units q4
No noted focal (+) clear BS
neurologic deficit (-) abdominal
tenderness

D4 Ceftriaxone
 Blood Culture
RESULT: Streptococcus pneumoniae
Antimicrobials MIC Interpretation
Benzylpenicillin <= 0.06 S
Cefotaxime <= 0.12 S
Ceftriaxone <= 0.12 S
Levofloxacin 0.5 S
Erythromycin 1 R
Clindamycin >= 1 R
Linezolid <= 2 S
Vancomycin 0.5 S
Tetracycline <= 0.25 S
Trimethoprim/ Sulfamethoxazole <= 10 S
 5th HD
S O A P
Awake, BP 150/80 T/C Bacterial Transferred to regular room
responsive, HR 70 RR 20 Meningitis; T/C Otitis Last dose of Dexamethasone
oriented afebrile Media, both; (Day 4)
O2 sat: 97% Hypertension, Repeat CBC, K
No complain of uncontrolled
headache (+) clear BS
(-) abdominal
D1 Penicillin G tenderness
(D5 Treatment)
 9/10 9/11 9/12 9/15
9/10 9/11 9/12 9/15 Sodium 133
WBC 16.1 23.3 23.0 13.8 Potassium 3.2 3.5 3.7 4.1
HGB 100 109 89 115 SGPT 21
HCT 0.300 0.331 0.262 0.343 BUN 5.8
Crea 102 85
PLT 184 172 165 228
Stabs 02 02 9/10 9/12
Seg 85 90 92 77 Tot Protein 67 55
Lymph 06 06 04 19
Albumin 39 26
Mono 09 04
Eosino Globulin 28 29
A/G ratio 1.39 0.90
Introduction