A 45-year-old male is admitted from the ward to your high dependency unit for observation of his neurological state. On examination, his temperature is 38.°7C. His is confused and agitated with a GCS of 12. He has a stable respiratory and cardiovascular status. A blood culture showed Gram-positive cocci in both bottles.

His relevant background history is a splenectomy  following a motor vehicle accident 20 years ago, hypertension and mild asthma.

a)  What is the likely diagnosis and what other investigations would you order?

b) Outline  your specific treatment for this condition

c)  list 5 predisposing factors for this condition

d) what prophylactic measures could have been taken to prevent this condition  in this patient?

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College Answer

a)  What is the likely diagnosis and what other investigations would you order?

pneumococcal bacteraemia likely meningitis

Investigations -

  • urine pneumococcal antigen
  • CT head
  • Routine bloods FBC/EUC/LFTS/CMP/COAGS/BSL
  • Lumbar Puncture – argument can be made for performing LP after CT or not performing an LP at all. Both responses are acceptable.
  • PCR for pneumococcus

b) Outline  your specific treatment for this condition

1) Empirical antibiotics ideally within 30 minutes
3rd generation cephalosporin Ceftriaxone 2 gm BD or cefotaxime 2gm tds
Plus Vancomycin 1 gm BD / 500 tds
Then target Pen 1.8 gm 4 hour if MIC < .125 gm/l      Cease Vancomycin if sensitive

2) Dexamethasone before or with antibiotics. Risk with altering vancomycin penetration for 4 days. 0.15gm /KG max 10 gm for 4 days.

c)  list 5 predisposing factors for this condition

Extreme of age <2 or >65
Chronic lung disease
Asplenia both functional and anatomic
Immunosuppression Transplant patients CSF leaks
Cochlear implants

d) what prophylactic measures could have been taken to prevent this condition  in this patient?

Vaccination 14 days before or 14 days post splenectomy (early vaccination not immunogenic)
Re vaccinate 5 year intervals
Patient’s penicillin/ amp daily for 2 years after splenectomy Antibiotics empirically if he develops temperature. (eg Augmentin) In this patient consider life long antibiotics orally

Discussion

This question vaguely resembles Question 9 from the first paper of 2013.

However, the end is slightly different. "What preventitive steps could have been taken?"

The college wants to hear about the postsplenectomy vaccines.

References

Reihsaus, E., H. Waldbaur, and W. Seeling. "Spinal epidural abscess: a meta-analysis of 915 patients." Neurosurgical review 23.4 (2000): 175-204.