A 20-year-old woman comes to the emergency department in January due to severe myalgias, fever, headache, and nausea that developed 4 hours ago. She has also had several episodes of nonbloody emesis over the past hour. The patient was feeling well this morning before her symptoms started. She does not use tobacco, alcohol, or illicit drugs. The patient has no known medication allergies. Temperature is 40.3 C (104.5 F), blood pressure is 100/70 mm Hg, and pulse is 115/min. She is confused and has difficulty concentrating. Lung examination is normal. There is marked tenderness to palpation of the muscles along her extremities, which are mottled and cool to the touch. Complete blood count reveals a white blood cell count of 28,000/mm3 with 12% bands. A noncontrast head CT is unremarkable. Which of the following is the best next step in management of this patient?
Meningococcal meningitis | |
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*Rifampin, ciprofloxacin, or ceftriaxone. AMS = altered mental status. | |
This young adult has an abrupt onset of fever, vomiting, and severe myalgias with findings of mottled skin, cool extremities, and confusion. This rapid progression of symptoms over 4 hours is concerning for meningitis with septicemia caused by Neisseria meningitidis.
Early meningococcal infection typically causes an acute onset of nonspecific symptoms (eg, fever, headache, vomiting). However, key features that should prompt consideration of meningococcal disease include severe myalgias (eg, marked leg pain), which are often more painful than those in viral illnesses, and signs of poor perfusion (eg, cold hands/feet, mottled skin) reflecting myocardial depression (possibly interleukin-6–mediated). In addition, symptoms progress rapidly (over 12-24 hours) and may include a petechial/purpuric rash, nuchal rigidity, and altered mental status. Leukocytosis with elevated immature white blood cells (ie, bands) is common.
Prompt recognition and evaluation of early meningococcal infection is crucial because the illness can quickly progress to shock, disseminated intravascular coagulation, multiorgan failure, and death. Patients with suspected meningococcal infection should undergo a lumbar puncture. Blood cultures should be drawn prior to antibiotic therapy, which should not be delayed while waiting for lumbar puncture to be performed. Treatment is ceftriaxone.
(Choices A and E) Influenza (often treated with supportive care and oseltamivir) can cause the abrupt onset of fever, headache, and myalgias and, in rare cases, be complicated by myositis and encephalopathy. Although this patient should be tested for influenza, her lack of respiratory symptoms, rapid deterioration, altered mental status, severe myalgias, leukocytosis with bandemia, and skin mottling warrant prompt evaluation and empiric treatment for bacterial meningitis.
(Choice B) Gastroenteritis, which can present with sudden-onset vomiting and fever, can lead to dehydration requiring intravenous fluids and antiemetics. However, this patient's severe myalgias and altered mental status make this diagnosis unlikely. Although the patient should receive fluids and antiemetics, holding her for observation only without performing additional workup and providing empiric meningitis treatment would be inappropriate.
(Choice C) Lower extremity pain and tachycardia may raise suspicion for pulmonary embolism, which can be diagnosed by chest CT scan with contrast. However, symptoms also typically include dyspnea and cough; high fever, altered mental status, and marked leukocytosis would not be expected.
Educational objective:
Early meningococcal meningitis presents with nonspecific symptoms that rapidly progress over 12-24 hours and may include a petechial/purpuric rash, nuchal rigidity, and altered mental status. Signs of poor perfusion and severe myalgias should prompt a lumbar puncture to evaluate for Neisseria meningitidis infection.