Medical Case Report 5 : with answer

CASE REPORT

A 28-year-old man with no significant previous medical history came to the emergency department with a complaint of mild sore throat that had persisted for three days, accompanied by arthralgia, myalgia, and low-grade fever. The day before, he had had a severe headache with neck stiffness, nausea, and vomiting. he claimed not to have a cough, shortness of breath, abdominal pain, diarrhea, or urinary tract symptoms. he had no history of tick exposure or skin rash, was not taking any medications, had no known drug allergies, and did not smoke. he lived with his wife and two children, all of whom were well.

On physical examination, he was thin, alert, and oriented but had an inappropriate affect. His temperature was 98.6°F; pulse, 100; respirations, 20; and blood pressure, 110/70 mm Hg. His neck was stiff, but Kernig and Brudzinski signs were not present. The pharynx was slightly injected but without exudate. Findings on heart and lung examination were normal. No rash was present. The neurologic examination revealed intact cranial nerves, normal reflexes, and no sensory or motor deficits. His white blood cell count was 21,800/mm3 with 67% polymorphonuclear leukocytes and 26% band cells. Platelet count was 200,000/mm3. Electrolyte levels were within normal range, and the glucose level was 131 mg/dL. A chest film showed no signs of pneumonia. A lumbar puncture revealed clear cerebrospinal fluid (CSF) with a glucose level of 88 mg/dL and a total protein level of 33 mg/dL and no cells.

The patient underwent intravenous hydration after he was admitted with a diagnosis of meningismus, accompanied by the instruction to "rule out early viral meningitis versus viral syndrome." Approximately 12 hours later, he became acutely lethargic and a second spinal tap was performed. The CSF appeared cloudy and now contained 871 white blood cells, of which 93% were polymorphonuclear leukocytes; the glucose level was 1 mg/dL; the total protein level, 417 mg/dL. Gram stain revealed rare gram-negative diplococci, the latex agglutination test for bacterial antigens was positive for Neisseria meningitidis, and both the original and repeated CSF cultures grew N. meningitidis.

Mx

The patient was given high-dose intravenous penicillin G, 24 million units a day, and was transferred to the medical intensive care unit for observation. Despite the 12-hour delay in diagnosis, he recovered completely. Intimate household contacts received prophylactic rifampin, and the patient was given rifampin before discharge to eliminate nasopharyngeal carriage of Neisseria.