A 75-year-old male with chronic lymphocytic leukaemia (CLL) presents with a 4-day history of fever,
headache and neck stiffness.
On examination, his temperature is 39°C, with a Glasgow Coma Score of E3M6V4 and a positive Kemig's sign. There are no focal neurological signs.
Cerebrospinal fluid results are shown below:
Parameter |
Patient Value |
Adult Normal Range |
Opening Pressure |
24 cmH2O |
12 – 25 |
Total protein |
1.20 g/L* |
0.15 – 0.45 |
Glucose |
1.2 mmol/L* |
3.3 – 4.4 |
White Cell Count |
970 cells/µL* |
< 5 |
Mononuclear cells |
50 cells/µL* |
< 3 |
Polymorphonuclear cells |
920 cells/µL* |
0 |
Gram-stain |
Gram-positive cocci |
a) What is the most likely diagnosis? (10% marks)
b) What is the most appropriate anti-microbial therapy? (15% marks)
1. Streptococcal Pneumoniae (pneumococcal) meningitis
2. IV Benzyl Penicillin 2.4g 4-hrly or IV Ceftriaxone 2g 12-hrly Or
IV Moxifloxacin 400mg daily or IV Vancomycin (penicillin or beta-lactam allergy), to target plasma trough levels of 15-20 mg/L
Let's go through these data systematically.
So, the question "what is the most appropriate antimicrobial therapy" really means "which coccus is it?" A betting man would put their money on S.pneumoniae, as that's the most common organism in the community which answers this description. The CLL patient is often found to be immunocompromised due to a failure of humoural immunity, even without cytotoxic treatment, which would put them at risk from these encapsulated organisms (Morra et al, 1999). For the record, the other two organisms commonly seen in this immunoglobulin-deficient population are L.monocytogenes and H.influenzae.
Thus, the most appropriate choice for a suspected S.pneumoniae meningitis (via eTG) is
Morra, E., A. Nosari, and M. Montillo. "Infectious complications in chronic lymphocytic leukaemia." Hematology and cell therapy 41.4 (1999): 145-151.