Midnight Madness Crazy psychologist in the ED late at night
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Midnight MadnessMidnight MadnessCrazy psychologist in the ED Crazy psychologist in the ED
late at nightlate at night
J. Stephen Huff, MD, FACEP
Department of Emergency Medicine
University of Virginia
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Teaching points to be addressedTeaching points to be addressed
• When should a CNS infection be considered in the differential diagnosis?
• What is optimal timing of imaging, procedures, and therapy?
• What empiric therapy should be given?
• What adjunctive therapy should be administered?
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Case PresentationCase Presentation
• 53-year-old school psychologist had flu symptoms and headache for most of day
• Participated in evening choir practice
• Went to bed early not feeling well
• Awakened confused; could not recognize partner
• EMS called; transported to ED
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Past Medical History & Social HistoryPast Medical History & Social History
• No details available
• School psychologist
• No chronic medications
• History of “sinus surgery” years ago
• History supplied by partner
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Physical ExamPhysical Exam
• VS: 38.3, 149/palp, 108, 18, sat 97%• Somnolent / confused• Few words uttered “Farfalla” (?)• “Uncooperative” with examination• Pulmonary, cardiac, abdomen: Normal• No cutaneous abnormalities• Localized painful stimuli, spontaneous eye
opening and movements• Context of the moment….
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Your Differential Diagnosis?Your Differential Diagnosis?
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Differential DiagnosisDifferential Diagnosis
• Neurologic• Meningitis• Encephalitis
• Other infectious etiologies• Sepsis
• Metabolic• Endocrine• Toxicologic
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Pragmatic Differential DiagnosisPragmatic Differential Diagnosis
• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis• Acute Bacterial Meningitis
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ED CourseED Course
• What should be done and in what order?
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ED Course-what occurredED Course-what occurred
• Verify A,B,C’s
• IV access, labs, blood cultures
• Empiric antibiotic therapy-ceftriaxone
• Immediate noncontrast cranial CT
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ED CourseED Course
• Lumbar puncture in presence of partner
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Lumbar punctureLumbar puncture
• Slightly cloudy fluid to inspection
• 16,000 WBC (99% segs)
• Glucose <10 Protein 522
• Lactic acid 10.9
• Gram stain - no bacteria
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Lab ResultsLab Results
• WBC = 18.5
• Hct =42
• Platelets = 203
• Chemistry = wnl
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• What is the next step in this patient’s management?
ED CourseED Course
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Case courseCase course
• Patient given ceftriaxone (before CT), vancomycin, and acyclovir
• ICU admission - • Blood cultures +4 S. pneumoniae• Continued ceftriaxone and vancomycin• Culture- sensitive to ceftriaxone• Discharged day 7 continue OP therapy
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Case courseCase course
• ENT referral• Pansinusitis on CT• Endoscope-encephalocele from earlier
surgery• Elective surgical repair• Return to work - functional
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Farfalla
Butterfly---Italian
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Risk FactorsRisk Factors
• Bacterial meningitis may occur in any adult
• Identified risk factors• Diabetes mellitus• Otitis media• Pneumonia• Sinusitis• Alcohol abuse
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Pattern of Presentation-TriadPattern of Presentation-Triad
• Fever, neck stiffness, altered mental status• Fever-high sensitivity, low specificity• Sens 85%; spec 45%
• Neck stiffness 70% pooled sensitivity• Altered mental status-67% pooled sensitivity
• Triad is imperfect to detect meningitis by this pooled retrospective analysis
• Attia J, Hatala R, Cook DJ, Wong JG: Does this adult patient have meningitis? JAMA 1999; 282:175.
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Neck StiffnessNeck Stiffness
• Kernig’s sign - knee extension / response• Brudzinski’s sign-neck flexion / response• Nuchal rigidity “stiff neck” on exam
• Prospective study, “…these diagnostic tools are too insensitive to identify the majority of patients with meningitis in contemporary practice….”
• Thomas KE, Hasbun R, Jekel J, Quagliarello VJ: The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in patients in adults with suspected meningitis. Clin In Dis 2002;35:46.
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A new sign?A new sign?
• Jolt accentuation of headache…
• Patient turns head horizontally• 2-3 rotations / second• Does headache get worse?
• One study…• Attia J, Hatala R, Cook DJ, Wong JG: Does this adult patient have meningitis?
JAMA 1999; 282:175.• Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign
of CSF pleocytosis. Headache 1991;31:167.
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Anatomy and PathophysiologyAnatomy and Pathophysiology
• Vicious cycle of pathophysiology• Bacteremia• Meningeal inflammation• Blood-brain barrier breach• Inflammatory responses within brain with
neuronal injury• Vasculitis• Cerebral edema
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OrganismsOrganisms
• < 3 months
• 3 months - 18 years
• 18 years - 50 years
• > 50 years
• E.coli, Listeria, Streptococci
• N. meningitidis, H. influenzae, S. pneumoniae
• N. meningitidis, S. pneumoniae
• S. pneumoniae, Listeria, gram-negative bacilli
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Complications-Complications-S. pneumoniaeS. pneumoniae
• Increased cerebral pressure from edema
• Seizures
• Stroke syndromes
• Intracranial hemorrhage
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Lab studiesLab studies
• CBC, chemistries
• Coagulation studies?
• Blood cultures
• Other cultures as appropriate
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ProceduresProcedures
• Lumbar puncture• Neutrophilic predominance in bacterial
meningitis• Low glucose, high protein
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• Alternative diagnoses?
• Mass lesion?
• Do not delay therapy in high-suspicion cases for imaging….
CT before LP?CT before LP?
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Emergency Department CareEmergency Department Care
• Prompt recognition
• Prompt intervention• Diagnostic• Therapeutic-do not delay pending diagnostic
interventions in high-suspicion cases• Antibiotics-multiple• Anti-inflammatory-steroids
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AntibioticsAntibiotics
• < 3 months
• 3 months - 18 years
• 18 years - 50 years
• > 50 years
• Ampicillin, third-generation cephalosporin
• Third-generation cephalosporin (ceftriaxone) + vancomycin
• Third-generation cephalosporin (ceftriaxone) + vancomycin
• Ampicillin, third-generation cephalosporin, vancomycin
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Anti-inflammatory medicationsAnti-inflammatory medications
• Dexamethasone - 10 mg IV at or before (15-20 minutes) antibiotics…
• 10 mg q 6h for 4 days• Adults…• Pediatrics?
De Gans J, van de Beek D, et al: Dexamethasone in adults with bacterial meningitis. NEJM 2002;347:1549.
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ConsultationsConsultations
• Will depend upon institution
• Ill patients - ICU admission
• Infectious disease, neurology, or others might be helpful
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SummarySummary
• Acute bacterial meningitis may be a life or function-limiting event
• Acute intervention may limit morbidity and mortality
• Antibiotics-broad, multiple
• Anti-inflammatory agent-dexamethasone recommended at this time
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Teaching pointsTeaching points
• When should a CNS infection be considered in the differential diagnosis?
• What is optimal timing of imaging, procedures, and therapy?
• What empiric therapy should be given?
• What adjunctive therapy should be administered?
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Teaching pointsTeaching points
• When should a CNS infection be considered in the differential diagnosis?
• Altered behavior, altered consciousness, fever, or seizures may suggest presence of a CNS infection
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Teaching pointsTeaching points
• When should a CNS infection be considered in the differential diagnosis?
• What is optimal timing of imaging, procedures, and therapy?
• What empiric therapy should be given?
• What adjunctive therapy should be administered?
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Teaching pointsTeaching points
• What is optimal timing of imaging, procedures, and therapy?
• Do not delay therapy-antibiotics-for imaging or procedures in patients with high probability of bacterial meningitis
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Teaching pointsTeaching points
• When should a CNS infection be considered in the differential diagnosis?
• What is optimal timing of imaging, procedures, and therapy?
• What empiric therapy should be given?
• What adjunctive therapy should be administered?
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Teaching pointsTeaching points
• What empiric therapy should be given?
• Empiric therapy should include antibiotics for likely organisms based on age….in adults, third generation cephalosporin and vancomycin should constitute initial therapy
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Teaching pointsTeaching points
• When should a CNS infection be considered in the differential diagnosis?
• What is optimal timing of imaging, procedures, and therapy?
• What empiric therapy should be given?
• What adjunctive therapy should be administered?
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Teaching pointsTeaching points
• What adjunctive therapy should be administered?
• Steroids are back….