A previously well, 19-year-old female presents with fever, headache, photophobia and neck stiffness.

a) List three clinical features that would indicate the need for a brain CT scan prior to lumbar puncture in this patient.    (25% marks)
 

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College answer

a)  

  • Papilloedema
  • Immunocompromised state
  • Altered level of consciousness
  • Focal neurology (? Space occupying lesion)
  • History of CNS disease (mass lesion, stoke, local infection)
  • New onset seizures

Discussion

Features which would make one want to exclude space-occupying lesions before performing an LP:

  • Hypertension and bradycardia
  • Focal neurological signs
  • Decreased level of consciousness
  • A new onset of seizures - however, this does not necessarily scream "abscess" because about 25% of meningits patients will have a seziure during their meningitis episode.
  • Predisposition to infection (eg. immunocompromised state)
  • History of stroke or intracranial space-occupying lesion
  • Papilloedema

Oh's Manual only lists papilloedema seizures and focal neurological signs as contraindications to an LP.

References

References

Oh's Intensive Care manual: Chapter   54  (pp. 597)  Meningitis  and  encephalomyelitis by Angus  M  Kennedy

Beaman, Miles H. "Community‐acquired acute meningitis and encephalitis: a narrative review." Medical Journal Of Australia209.10 (2018): 449-454.

Lee, Bonita E., and H. Dele Davies. "Aseptic meningitis." Current opinion in infectious diseases 20.3 (2007): 272-277.

Beer, R., P. Lackner, and B. Pfausler. "Nosocomial ventriculitis and meningitis in neurocritical care patients." Journal of neurology 255.11 (2008): 1617-1624.

Korinek, A-M., et al. "Prevention of external ventricular drain–related ventriculitis." Acta neurochirurgica 147.1 (2005): 39-46.

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.