A 17-year-old female, a recent migrant from Southeast Asia, was admitted with an 8-day history of fever, rigors, headache and neck stiffness. On admission her temperature was 40°C, and Glasgow Coma Scale 15 with photophobia and marked neck stiffness. The chest radiograph was normal, and thick and thin films demonstrated no evidence of malaria.
An analysis of her cerebrospinal fluid (CSF) showed the following results:
|
Parameter |
Patient Value |
Adult Normal Range |
|
Opening pressure |
40 cm* |
15 – 25 |
|
Glucose |
0.8 mmol/L* |
3.3 – 6.1 |
|
Protein |
0.62 g/L* |
0.1 – 0.5 |
|
Red Cell count |
5 cells/high power field |
0 – 5 |
|
White Cell Count |
320 cells/high power field* |
0 – 5 |
|
Neutrophils |
70% |
|
|
Lymphocytes |
30% |
|
|
Gram stain |
Nil bacteria seen |
a) List five likely infective organisms. (25% marks)
After a week of treatment with Ceftriaxone, her cultures were negative, and her clinical state remained static. A repeat CSF examination on day 4 showed the following results:
|
Parameter |
Patient Value |
Adult Normal Range |
|
Opening pressure |
41 cm* |
15 – 25 |
|
Glucose |
0.2 mmol/L* |
3.3 – 6.1 |
|
Protein |
1.5 g/L* |
0.1 – 0.5 |
|
Red Cell count |
0 cells/high power field |
0 – 5 |
|
White Cell Count |
560 cells/high power field* |
0 – 5 |
|
Neutrophils |
50% |
|
|
Lymphocytes |
50% |
|
|
Gram stain |
Nil bacteria seen |
b) List five other CSF tests that would help determine the underlying diagnosis.
(20% marks)
a) List five likely infective organisms. 25% marks
b) List five other CSF tests that would help determine the underlying diagnosis. 20% marks
What clues are present here, to suggest specific organisms?
So, it could be something related to the patient's country of origin or it might be some standard Australian meningitis. The list of possible bugs is therefore broad:
Common local organisms (representative of the developed world in general):
Southeast Asian organisms, according to Chong & Tan (2005), are totally different:
b) so, whatever this is, it is resistant to ceftriaxone, and it does not Gram-stain.
What could it be?
Additionally, one might wish to consider non-infectious causes, such as lymphoma, vasculitis, or drug-induced meningitis (eg. due to cotrimoxazole or azathiaprine).
Tests for this broad range of possibilities would have to include:
Oh's Intensive Care manual: Chapter 54 (pp. 597) Meningitis and encephalomyelitis by Angus M Kennedy
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Beer, R., P. Lackner, and B. Pfausler. "Nosocomial ventriculitis and meningitis in neurocritical care patients." Journal of neurology 255.11 (2008): 1617-1624.
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NSW Health. Infants and children: acute management of bacterial meningitis: clinical practice guideline. North Sydney: NSW Ministry of Health; 2014.
Tunkel, Allan R., et al. "Practice guidelines for the management of bacterial meningitis." Clinical infectious diseases 39.9 (2004): 1267-1284.
Hearmon, Christine J., and Salil K. Ghosh. "Listeria monocytogenes meningitis in previously healthy adults." Postgraduate medical journal 65.760 (1989): 74-78.
Chong, H. T., and C. T. Tan. "Epidemiology of central nervous system infections in Asia, recent trends." Neurology Asia 10 (2005): 7-11.