Core EM Modular CME Course
Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.
Patient Presentation & Workup
Patient: 36-year-old male, currently shelter-domiciled, presenting with 3 weeks of generalized weakness, fevers, weight loss, and headaches.Vitals (Initial): BP 147/98, HR 150s, Temp 100.2°F, RR 18, O2 99% RA.Clinical Evolution: Initial assessment noted cachexia and a large ventral hernia. Following initial workup, the patient became acutely altered (A&O x0) and febrile to 102.9°F.Physical Exam Findings:Brudzinski Sign: Positive (knees flexed upward upon passive neck flexion).Kernig Sign: Discussed as highly specific (resistance/pain during knee extension with hip flexed at 90°).Meningeal Triad: Fever, nuchal rigidity, and AMS (present in 40% of cases; 95% of patients have at least two of the four cardinal symptoms including headache).Imaging:Chest X-ray: Scattered opacities (pneumonia) and a small pneumothorax.CT Abdomen/Pelvis: Confirmed asplenia (secondary to 2011 GSW/exploratory laparotomy).Head CT: Ventricle enlargement concerning for obstructive hydrocephalus and diffuse sulcal effacement.CSF Analysis & Microbiology
Bacterial MeningitisOpening Pressure: Elevated (Normal is <170 mm H2O).Color: Cloudy or turbid.Gram Stain: Positive in 60%–80% of cases before antibiotics; drops to 7%–41% after antibiotics.Cell Count: Very high (>1000–2000/mm3 WBC); dominated by neutrophils (>80% PMN).Glucose: Low (<40 mg/dL); CSF/blood glucose ratio is <0.3–0.4.Protein: High (>200 mg/dL).Cytology: Negative.Viral MeningitisOpening Pressure: Normal.Color: Clear or bloody.Gram Stain: Negative.Cell Count: Slightly elevated (<300/mm3 WBC); dominated by lymphocytes (<20% PMN).Glucose: Normal.Protein: Moderately elevated (<200 mg/dL).Cytology: Negative.Fungal MeningitisOpening Pressure: Normal to elevated.Color: Clear or cloudy.Gram Stain: Negative.Cell Count: Elevated (<500/mm3 WBC).Glucose: Normal to slightly low.Protein: High (>200 mg/dL).Cytology: Negative.Neoplastic (Cancer-related) MeningitisOpening Pressure: Normal.Color: Clear or cloudy.Gram Stain: Negative.Cell Count: Elevated (<300/mm3 WBC).Glucose: Normal to slightly low.Protein: High (>200 mg/dL).Cytology: Positive (this is the key differentiator).Management Protocol
Immediate Treatment: Early administration of antibiotics/antivirals is critical to reduce mortality.Antibiotics: Ceftriaxone 2g IV q12h + Vancomycin (or Rifampin in cephalosporin-resistant areas).Listeria Coverage: Add Ampicillin for patients > 50 years old.Antivirals: Acyclovir 10 mg/kg q8h.Steroids: Dexamethasone 10 mg IV q6h for 4 days (proven to reduce mortality and improve outcomes).Surgical Intervention: Neurosurgery performed an emergent EVD in the ED to relieve pressure from obstructive hydrocephalus.Post-Exposure Prophylaxis: Indicated only for N. meningitidis (not S. pneumoniae) for contacts < 24 hours from diagnosis.Regimens: Rifampin for 2 days, single-dose Ciprofloxacin, or IM Ceftriaxone (if pregnant).Stats & Clinical Pearls: Austrian Syndrome
The Triad: Concurrent pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae.Risk Factors: Asplenia (due to the spleen’s role in filtering encapsulated bacteria), alcohol use disorder, and immunosuppression.Mortality Rate: Extremely high at 28%; mortality is highest when there is CNS involvement.Incidence: Worldwide, S. pneumoniae is the leading cause of bacterial meningitis, accounting for 3,000–6,000 cases annually.The post PODCAST: Meningitis 2.0 first appeared on האיגוד הישראלי לרפואה דחופה.
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