College Answer

Pneumococcal bacteraemia – probably meningitis

Investigations: 
CT head ± lumbar puncture

PCR for pneumococcus

Urine pneumococcal antigen (Routine bloods)

b) 
Empiric antibiotics – ideally within 30 minutes

3rd generation cephalosporin + vancomycin (steroids may limit penetration to CSF) or rifampicin

May change to penicillin if susceptible

Alternative regime – any reasonable combination

Dexamethasone before or with first dose of antibiotics

c)

Age <2 or >65 years

Chronic lung disease

Asplenic – functional or post splenectomy

Immunosuppression 
Transplant recipient

CSF leak 
Cochlear implants

d)

Vaccination and re-vaccinate at 5 year intervals 
Empiric antibiotics if develops temperature and consider life long antibiotic therapy in this patient.

Discussion

a) The asplenic man is prone to infections by encapsulated organsisms. S.pneumoniae is the likely culprit. One would want a CT brain and LP; a urinary pneumococcal antigen should confirm the pathogen.

b) Immediate management should consist of dexamethasone, vancomycin and ceftriaxone.

c) Predisposing factors to pneumococcal meningitis:

• Immunosuppression
• Splenectomy
• Extremes of age (very young and very old)
• Intracranial implants, eg. cochlear implants
• A CSF leak, for any reason
• Cochlear implants
• Sickle cell disease
• Unvaccinated patient

d) Post splenectomy vaccination and chronic oral suppression antibiotics will be required.

The specific details of precisely which vaccinations are required are available in the splenectomy chapter of the Required Reading section. A lot of spleen-associated wank is there, including references to such hard-hitting medical sources as the Japanese Journal of Ichthyology.