Question

An 18-year-old male high school student was brought by ambulance to the hospital emergency room. The patient was acutely agitated and incoherent. According to the patient's parents, he had complained that morning at breakfast of diffuse muscular aching, malaise, and anorexia. He had vomited his breakfast soon after eating and declined to go to school. Because of a very severe headache that was unresponsive to aspirin, and a rise in temperature to 104 F during the early afternoon a physician was consulted and examined the patient in his home. During the next several hours, the patient became extremely agitated, began to mutter in an incoherent fashion, and was totally disoriented. There was no history of previous sinus or middle ear disease or surgery. Brief physical examination in the emergency room revealed a temperature of 100.8 F (estimate axillary recording) and a blood pressure of 150/60-mm Hg. The patient was flailing about in a violent manner. The neck was stiff. A few 1-3 mm petechial skin lesions were observed over the thighs and in each antecubital fossa. The lungs appeared clear; the heart seemed to be of normal size, and no murmurs were heard. Immediate lumbar puncture was performed, with the patient securely restrained. The cerebrospinal fluid appeared moderately cloudy and contained 15,000 leukocytes per cubic mm, of which 94% were segmented neutrophils. The CSF glucose was less than 5 mg per 100 ml, and simultaneous blood glucose was 194 mg per 100-ml. Direct gram stain on the centrifuged CSF revealed gram-negative diplococci.

Answer 1

Ans) Brief physical examination in the emergency room revealed a temperature of 104°F and a blood pressure of 150/60 mm Hg. The patient was flailing about in a violent manner. His neck was stiff and even a small degree of dorsiflexion was impossible and a positive Kernig’s sign was noted.