Meningitis
Patient Presentation
S.W., a previously healthy four-week old female infant is rushed back from triage and the triage nurse states “I think she had a seizure”, but the patient is without seizure activity by the time she reaches the resuscitation room. The patient is awake, but with an irritable, shrill cry. She is tachypneic, and expiratory grunting is noted. The patient is pale, mottled, and peripheral capillary refill time of 5 seconds. The patient is hypotonic with an exaggerated startle reflex, and is easily startled by even subtle movements and sounds. The patient’s pupils are equal and reactive. A bulging anterior fontanel is noted. The patient is calmer when lying alone on the stretcher; when she is held by her mother or touch by anyone, she is inconsolable. The patient’s heart rate is between 180-200 beats per minute, sinus tachycardia without ectopy is noted on the monitor. Her pulse oximetry reading is 100 percent on room air but supplemental oxygen is administered. Her rectal temperature is 101.2. Her mother states she only noticed that the patient exhibited lethargy, poor feeding, a few hours earlier and that she developed a fever (100.9 at home) only one hour prior to arrival to ER.
Differential Diagnoses:
Neonatal sepsis, meningitis, encephalitis, febrile seizure, subarachnoid hemorrhage, and brain tumor.
Diagnosis:
Several laboratory tests were performed, including a complete blood count, serum electrolytes and glucose, blood culture, urinalysis, and urine culture. A lumbar puncture is performed; the patient’s cerebrospinal fluid is purulent, yellow in color, and cloudy. Several tubes of the CSF are collected, including a CSF culture. A diagnosis of neonatal meningitis/neonatal sepsis is made. The lab results confirm fulminant sepsis, which requires aggressive treatment. See significant results below:
Complete Blood Count with Diff:
WBC 1.3 K/uL, RBC 3.01 K/uL, HGB 10.1 g/dL, HCT 29.3%, MCV 87 fL, MCH 33.7 pg, RDW 16.4%, PLATELET CO 127 K/uL, MEAN PLT. VOL 8.4 fL, NEUTROPHILS 14.0%, LYMPHOCYTES 78.0%, MONOS 4.0%,
Basic Metabolic Panel
SODIUM: 140 mmol/L, POTASSIUM: 6.5 mmol/L, CHLORIDE: 109 mmol/L, CO2: 18 mmol/L, GLUCOSE: 81 mg/dL, BUN: 11 mg/dL, CREATININE: 0.4 mg/dL, CALCIUM: 9.1 mg/dL
Blood Culture (results from 48 hrs after ED admission): Streptococcus beta-hemolytic, group B
Cerebrospinal Fluid Analysis
GLUCOSE: 0 mg/dL, PROTEIN: 338 mg/dL, APPEAR. cloudy AB, CSF RBC 3 /mm3, CSF WBC 77/mm3, POLYS 53 %, LYMPH 26%
CSF Culture and GM Stain: Heavy growth of Streptococcus beta-hemolytic, group B
Many Gram positive cocci chains on Gram stain
CT Scan: No abnormal masses or midline shift. No axial fluid collections. Impression: normal examination
Treatment
Intravenous access was obtained, the patient required several intravenous crystalloid boluses to maintain circulatory status. IV antibiotics were started immediately. The patient received both ampicillin and cefotaxime. Seizure precautions were also strictly followed in the ED. The patient was then transferred to the Pediatric Intensive Care Unit.
Outcome
After transfer to the floor, the patient began to have continuous seizure activity. Intubation was performed and the patient soon was flown to a facility which could provide a higher level of care for her. The patient remained hospitalized for over one month at that facility. The patient experienced an ischemic stroke while in intensive care. The patient was eventually discharged home. She has severe developmental delays and it is unlikely she will recover from the insults she endured. She does not require ventilatory assistance. She is fed by g-tube, and she requires nearly twenty medications and hormones daily. She is unable to regulate her temperature, and her hypothalamus and pituitary gland do not function properly. She now suffers from seizures on a regular basis.
Case created by Stephanie Wilhelm, 2010.