18 yo M, "won't talk to anyone"

[Doczilla]

I thought I would share this interesting case that I had the other night. SWATSurgeon and DocT are our experts on trauma cases, so I'll leave those to them.

18yo previously healthy male comes to the emergency department at approx. 11pm because, as his parents state, he won't talk to anyone, and hasn't since 3pm. Review of systems is notable only for a headache for the past 2 days, though this is not unusual for his history of recurrent headaches.

Paramedics were called for the above complaint. Physical exam, other than the fact that he is alert and moving but not talking, was unremarkable. Vitals obtained by EMS:
Pulse 88, Respirations 14, BP 126/76, Room air pulse ox 99%, Blood glucose 190. He is transported to the ER without incident.

PMHx: Hereditary spherocytosis, which had led to removal of the spleen at age 7 (the spleen will take out too many of his defective red cells, leaving him profoundly anemic.). Also has a hx of chronic headaches.
Medications: None
Allergies: None known
Soc Hx: high school student. Known to have abused marijuana in the past, and parents are unsure if he might be into anything else. Known to occasionally use alcohol. Some piercings, but otherwise a normal kid.

Our vitals: Temp 99 Pulse 88 Resps 14, BP 120/72, SaO2 99% on room air. Blood glucose 188.
On physical exam, he is alert, looking around the room. He looks at people who are talking to him, but does not follow commands or say anything. When examined, he'll push your hands away. He didn't seem to like me mashing on his belly. He rolled over to prevent me from palpating it any more, and would defend his belly with his elbow as I reached in to palpate it again.
HEENT: Normal
Neck: supple, no neck stiffness or meningeal signs, no lymphadenopathy
Chest: nontender, clear to auscultation.
Heart sounds: regular rate and rhythm, no murmurs, rubs, or gallops.
Abdomen soft, no masses or guarding.
GU: normal external male genitalia
Extremities: no cyanosis, rash, or edema. No bruises or petichiae.
Neuro: unable to complete a full neuro exam due to mental status, but grossly moves all 4 extremities and gaze has a full range.

Our initial differential includes drug intoxication, CNS infection, sepsis, toxic exposure (particularly CO, since he had a preceding headache, but nobody else in the house was ill), and being an idiot teenager that is pissed at his folks.

He is sent to CT for his head, but they send him back since he won't sit still. Given 4mg of versed, which initially snows him, and sent back to CT. He is sent back again, still won't hold still for images. Given another 5mg of versed, which has no apparent effect. Becoming more combative when handled, seeming to want to be left alone. At this point, CBC comes back, with WBC of 69K with 32% bands. Hemoglobin 14, normal platelets. Badness is in the air.

After discussion with the family, we sedate, paralyze, and intubate him. He's given 10 mg of decadron IV and 2 g rocephin IV and taken back to CT. Returns from CT, no gross masses or bleeding noted. Wet read from the radiologist reveals possible early cerebral edema. Vancomycin and acyclovir are started. He's requiring 45cc of diprivan per hour to keep him sedated, and must be paralyzed with vecuronium for the LP. LP returns an opening pressure of 33 cm, with cloudy fluid, confirming suspected diagnosis of bacterial meningitis/encephalitis. CSF: WBC 4700, RBC 250, protein 300, glucose 50, also consistent with this diagnosis.

Other lab studies and xrays are unremarkable.

Postexposure prophylaxis is not initiated on close contacts, since it is felt that he is likely suffering from strep pneumonia encephalitis, which is an organism that folks with no spleens are vulnerable to (and why they must be given the vaccine after losing their spleen). Blood cultures and CSF cultures return the following day positive for strep pneumo.

He is extubated 2 days later in the ICU.

This is the second case of strep pneumo encephalitis that I have seen this year. The other one was brain dead within 16 hours of ED arrival.

Important lessons in this case:
If a CNS infection is suspected, treatment is more important than good cultures. This means that if it's a choice between delaying antibiotics and getting CSF cultures, and giving the antibiotics right away and possibly getting a sterile tap, give the antibiotics.

Steroids must accompany antibiotics in suspected meningitis and encephalitis since they have been shown to reduce morbidity and mortality. Decadron is appropriate. There is some evidence to support giving the initial dose of rocephin and decadron, but waiting 30 minutes to give the vancomycin after the steroids.

Viral meningitis/encephalitis, particularly herpes, should be suspected in these cases. Acyclovir has virtually no downside, so it can be given empirically.

Antibiotics will possibly kill most of the organisms in the CSF smear, but will not do away with other diagnostic criteria, such as elevated CSF WBC, protein, and decreased glucose. Whether or not the culture actually grows if obtained after antibiotics is anyone's guess. In this case, it did grow.

Blood cultures are more easily and quickly obtained than CSF cultures, so it's reasonable to get these before antibiotics are given. In 2 cases that I've had like this, the blood cultures were diagnostic before the CSF cultures.

Vital signs are just that: vital. In his case, the blood glucose of 190 in a non-diabetic raised a red flag that this was more than just a personality defect.

In this case, the sky-high WBC count put CNS lymphoma on the differential, so waiting for head CT to be completed before performing LP is appropriate.

Don't screw around for too long on folks you think are sick. If you can't get them under control for studies and treatment, pull the trigger and paralyze and intubate them.

Resistance to large doses of sedatives (in this case versed and diprivan) are not uncommon with encephalitis and other really bad neurological problems.

In suspected cases of neisseria meningitis (clusters in military facilities or other close living situations), postexposure prophylaxis of all of the patient's close contacts is appropriate with a single dose of rocephin, cipro, or 2 days of rifampin.

I bring this up here because he was an otherwise healthy kid, who contracted a potentially devastating (and treatable!) disease, and could easily be a soldier presenting to the aid station because of a suspected case of "dipshititis".

'zilla

[Eagle5US]

Great case. Thank you.

Eagle

[shr7]

'zilla,

Question about the Decadron? Is there any discussion about the effect of the anti-inflammatory on the penetration of the Vanco, and resultant CSF concentrations? I know there is a bit of conflicting literature out there on the subject, but most of it is just observational studies. If this patient had risk factors indicating a resistant strep, would there be any thought to withholding the steroid? Also, if the cultures returned without any growth, or indicating another organism, do you still continue the Decadron?

I am aware of what the guidelines say, but I'm still wondering if any of this was discussed, or if the data are too powerful now for there to be any doubt.

Thanks,
SR

[Red Flag 1]

Great case 'zilla. Thanks for posting it!!

[RichL025]

You didn't present it in his hx, but at the time of his ED eval, did anyone ask about immunizations pre- or post- splenectomy?

Not a ding, not sure if it's something _I_ would have remembered to ask.

[skydoc60A5G]

Thanks for the case...makes us all think more carefully when these guys present...when I see 'em in consultation in the ER/ICU. Not much fever...vitals seemed sort of normal....good catch. How has he done post extubation?