Assignment task:
S.C., a 5-year-old boy, is brought to the emergency department (ED) by his mother, who says her son has a temperature of 39?C, is irritable and lethargic, and has a rash. S.C. was in his usual state of good health until last night, when he awoke crying. When she went to investigate, her son began to stiffen up and rock back and forth in his bed. Because he was not arousable, S.C.'s mother rushed him to the hospital. S.C.'s medical history is noncontributory except for an allergy to amoxicillin described as a skin rash. S.C., his mother and father, and his 7-year-old brother recently moved to the United States. S.C.'s vaccination history currently is unknown. S.C. and his brother currently attend a community day-care center. On physical examination, S.C. was in marked distress, with a temperature of 40?C, blood pressure of 90/60 mm Hg, and a respiratory rate of 32 breaths/minute. His weight on admission was 20 kg. Neurologic examination showed evidence of nuchal rigidity; he was lethargic and difficult to arouse.. On head, eyes, ears, nose, and throat examination, S.C. demonstrated photophobia (he squinted severely when the examiner shone a light in his eyes), but no evidence was noted of papilledema. A petechial rash was visible on his extremities. The remainder of S.C.'s examination was essentially normal. Blood drawn for laboratory tests revealed the following results: Sodium (Na), 128 mEq/L Potassium (K), 3.2 mEq/L Chloride (Cl), 100 mEq/L Bicarbonate (HCO3), 25 mEq/L Blood urea nitrogen (BUN), 16 mg/dL Serum creatinine (SCr), 0.6 mg/dL Serum glucose, 80 mg/dL The WBC count was 18,000 cells/μL with 95% polymorphonuclear (PMN) cells; the hemoglobin (Hgb), hematocrit (Hct), and platelet count all were within normal limits.
Q1. What clinical and laboratory features does S.C. display that are suggestive of meningitis?
In the ED performs a lumbar puncture, which yielded the following: Opening pressure, 300 mm CSF (normal, <20) CSF glucose, 20 mg/dL (normal, 60% of plasma glucose) Protein, 250 mg/dL (normal, <50 mg/dL) WBC count, 1,200 cells/μL, with 90% PMN, 4% monohistiocytes, and 6% lymphocyte The CSF red blood cell (RBC) count was 50/μL. A stat Gram stain of CSF revealed numerous WBCs but no organisms. CSF, blood, and urine cultures are pending.
Q2. What CSF findings in S.C. are consistent with a diagnosis of bacterial meningitis?
Q3. What constitutes appropriate empiric therapy for childhood meningitis? Which antibiotic would be appropriate for S.C.? What dose and route of administration should be used?
Q4. What is the rationale for adjunctive corticosteroid therapy in acute bacterial meningitis, and would it be appropriate for S.C.?