This is the second part of a multi-part SAQ. The first part was as follows:
You are called to review a 48-year-old male in the post-operative recovery unit (PACIJ) who has just undergone resection of a TSH-secreting pituitary adenoma via a trans-sphenoidal approach. He is febrile (38.5'C) and is hypertensive (160/50 mmHg) with tachycardia (130 beats/min) and hyper-dynamic circulation, and is hyper-reflexic.
Give the likely diagnosis. (10% marks)
List your immediate pharmacological management. (30% marks)
The patient subsequently recovered and was discharged home. He re-presented two weeks later with increasing drowsiness, confusion, fevers, neck stiffness and a clear nasal discharge.
Give the likely diagnosis. (10% marks)
Briefly outline your immediate management. (30% marks)
c) CSF leak post-surgery with meningitis
d)
The previous question using this stem had the patient develop a thyroid storm following the resection of a TSH-secreting adenoma, a rare complication. The complication in the SAQ is more common.
This is basal meningitis due to a dural breach. The breach has allowed filthy nose organisms into the brain, and now they swarm though the meninges.
Management of this:
As far as choice of antibiotics goes, it is unclear wherther one should treat this as a meningitis following base of skull fracture (which it pathophysiologically resembles) or post-surgical meningitis (which it ontologically is). In the former, S.pneumoniae and H.influenzae are the dominant organisms, whereas in post-operative cases the bug is either S.aureus or S.epidermides. In either case, vacomycin and ceftriaxone are recommended by the Sanford Guide. In both cases, dexamethasone (0.15mg/kg) is recommended.
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Mathias, Tiffany, et al. "Contemporary approach to the diagnosis and management of cerebrospinal fluid rhinorrhea." The Ochsner Journal 16.2 (2016): 136-142.