July 2024 Critical Care Case of the Month: Community-Acquired Meningitis

Robert A. Raschke MD

The University of Arizona College of Medicine – Phoenix

Phoenix, AZ USA

History of Present Illness

A 59-year-old man was brought to our emergency department at 0300 with a possible stroke. He was last known well at 2230 the previous evening, when he complained of severe headache and took some acetaminophen before going to bed. His wife (who provided all history) noted that the patient awoke about midnight, vomited and took some naproxen. The wife next heard the patient awake at 0230, and found him back in the bathroom vomiting again, slow to respond, “mumbling” and confused. The wife was able to get the patient into their car with some difficulty and drove him to the ER.

Past Medical History, Social History, Family History

Only minimal past medical history was elicited. There was no known trauma, no fever and no recent illnesses. The patient took no prescription medications. He did not have any history of neurological disease or of substance abuse.

Physical Examination

Vitals from the ER at 0300 included: BP 157/130 mmHg, HR 101 bpm, RR 16 bpm, temperature 97.7°F.

The patient was described as “non-toxic appearing.” His eyes were open, but he was mute and didn’t obey commands. His Glascow Coma Scale was E4, V1, M5. Formal strength testing wasn’t performed, but he was observed to spontaneously move his arms. No facial asymmetry was noted.

Hospital Course

A “Stroke alert” was called based on the clinical presentation. The laboratory evaluation was significant for: WBCC 14.9x10⁹/L, hemoglobin 13.2 g/L, platelets 181x10⁹/L; Na 135 mmol/L, K 4.0 mmol/L, Cl 100 mmol/L, CO2 23 mmol/L, BUN 14 mg/dL, creatinine 0.7 mg/dL, glucose 349 mg/dL and INR 1.0. A procalcitonin was elevated at 0.8 ng/mL. Urinalysis showed >500 mg/dL glucose, moderate leukocyte esterase, WBCC 19/hpf, and no bacteria. A urine drugs of abuse screen was negative. CT head, CTA head/neck and brain perfusion scans were all negative for acute abnormalities. A virtual stroke neurologist recommended against lytics and/or thrombectomy, due to the lack of radiographic evidence of a large vessel occlusion.

The patient was admitted to the family medicine service. Ceftriaxone 1gm was administered for a presumed urinary tract infection. His temperature was retaken at 0630, at which time it had risen to 102.7°F. At 0730 the patient became agitated, diaphoretic and his SpO₂ fell to 79%. His BP was 223/139 mmHg, HR 115 bpm, and RR 53 bpm and he was emergently intubated and transferred to the ICU.

Which of the following is false regarding the clinical findings of community-acquired bacterial meningitis? (Click on the correct answer to be directed to the second of 5 pages)

1. Fifty percent of patients present within 24 hours of symptom onset.
2. The majority of patients have the classic triad of fever, stiff neck and altered mental status.
3. Ninety-five percent of patients have at least two of four findings: (headache, fever, stiff neck and altered mental status).
4. Patients may less commonly present with community-acquired hemiplegia, aphasia, seizure, and cranial nerve deficits.
5. All are true.

Cite as: Raschke RA.  2024 Critical Care Case of the Month: Community-Acquired Meningitis. Southwest J Pulm Crit Care Sleep. 2024;29(1):1-5. doi: https://doi.org/10.13175/swjpccs027-24 PDF

October 2019 Critical Care Case of the Month: Running Naked in the Park

Spencer Jasper MD

Matthew Adams DO

Jonathan Boyd MD

Jeremiah Garrison MD

Janet Campion MD

The University of Arizona College of Medicine

Tucson, AZ USA

History of Present Illness

A 34-year-old man with a history of IV drug abuse was brought into emergency department by EMS and Tucson Police Department after complaints of naked man running and behaving erratically in a park. On arrival to emergency department patient was acting aggressively towards staff, spitting and attempting to bite. The ER staff attempted multiple times to sedate the patient with benzodiazepines, however, due to continued aggressive behavior, ongoing encephalopathy and the need for increased sedation, the patient was intubated for airway protection.

The patient was febrile (40.6° C), tachycardic (122) and hypertensive (143/86). On physical exam patient was not cooperative, was diaphoretic, cachectic, with reactive constrictive pupils, track marks in antecubital fossa bilaterally. No clonus or hypertonicity. During intubation, there was noted to be nuchal rigidity.

He was then admitted to the medical ICU. Drug intoxication from possible methamphetamines was the presumptive diagnosis of encephalopathy but given nuchal rigidity and fevers there was concern for other etiologies.

Physical Exam

• Vitals: T 40.6 °C, HR: 122, RR: 22, BP: 143/86, SpO2: 97% WT: 55 kg
• General: Intubated and sedated, cachectic
• Eye: Pupils constricted but reactive to light
• HEENT: Normocephalic, atraumatic
• Neck: Stiff, non-tender, no carotid bruits, no JVD, no lymphadenopathy
• Lungs: Clear to auscultation, non-labored respiration
• Heart: Normal rate, regular rhythm, no murmur, gallop or peripheral edema
• Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses
• Skin: Skin is warm, dry and pink, multiple abrasions on the lower extremities bilaterally, track marks noted in the antecubital fossa bilaterally. Large abrasion with bruising around the right knee and erythema and welts on the right shin. Erythematous area on the dorsal surface of the right hand
• Neurologic: Nonfocal prior to intubation, no clonus or hypertonicity noted

Drug overdose/intoxication was presumptive diagnosis for his acute encephalopathy. Based on physical exam and vitals, what other etiologies should be considered? (click on the correct answer to be directed to the second of seven pages)

1. Embolic stroke
2. Heat stroke
3. Hyperthyroidism
4. Meningitis
5. All of the above

Cite as: Jasper S, Adams M, Boyd J, Garrison J, Campion J. October 2019 critical care case of the month: running naked in the park. Southwest J Pulm Crit Care. 2019;19(4):110-8. doi: https://doi.org/10.13175/swjpcc054-19 PDF

October 2018 Critical Care Case of the Month: A Pain in the Neck

Robert A. Raschke, MD

Critical Care Medicine

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

History of Present Illness

A 54-year-old man was admitted after he had a decline in mental status. He complained of neck and back pain for one week prior to admission for which he took acetaminophen. He was seen in the emergency department two days prior to admission and diagnosed with “arthritis” and prescribed oxycodone/acetaminophen and cyclobenzaprine. On the day of admission be became unresponsive and was transported by ambulance to the emergency department where he was intubated for airway protection.

Past Medical History, Social History, Family History

• Alcoholism
• Hepatitis C
• Esophageal varices
• Family history is noncontributory

Physical Examination

• Vitals: T 102° F, BP 150/60 mm Hg, P 114 beats/min, 20 breaths/min
• Unresponsive
• Dupuytren’s contractures, spider angiomata
• 3/6 systolic murmur
• Deep tendon reflexes 3+  
• Bilateral Babinski’s sign (toes upgoing)

Which of the following are diagnostic considerations at this time? (Click on the correct answer to be directed to the second of six pages)

1. Bacterial endocarditis
2. Hypoglycemia
3. Liver failure
4. 1 and 3
5. All of the above

Cite as: Raschke RA. October 2018 critical care case of the month: a pain in the neck. Southwest J Pulm Crit Care. 2018;17(4):108-13. doi: https://doi.org/10.13175/swjpcc098-18 PDF

September 2013 Critical Care Case of the Month: Revenge of the Pharaohs

Robert A. Raschke, MD

Elijah Poulos, MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

The patient was a 68 year-old man, admitted to our ICU through the emergency room (ER) in July 2013 with suspected urinary tract origin sepsis.

The patient was evaluated in ER by the ICU team. He was in his usual state of general good health until he visited his primary care physician for what he felt was a left inguinal hernia, and underwent a prostate examination, four days previously. The patient associated this prostate examination with the onset of fevers and chills that began the next morning. He was seen in an urgent care center where he was told his urinalysis was normal, and antibiotics were not prescribed. Over the intervening 3 days, he suffered recurrent fevers, had vomited three times, and had one diarrheal bowel movement. Earlier on the day of presentation, he had been mowing his lawn (in >100° F environment) and had become a little dizzy. His wife, a retired nurse, finally convinced him to report to the ER.

He denied dysuria, urinary frequency or urgency, headache, sore throat, cough, or abdominal pain.

PMH, SH, FH

He had a prior history of hypertension, gastroesophageal reflux, gout and hypercholesterolemia. He drank alcohol about twice a month and did not smoke.

There was no family history of illnesses.

Medications

• Atorvastatin
• Allopurinol
• Hydrochlorothiazide
• Lisinopril
• Temazepam

Physical Exam

On ER triage, his temperature was 41.2° C, but vitals at the time of our initial examination were temp 38.2° C, HR 93 beats/min, BP 103/48 mm Hg, and respiratory rate 20 breaths/min. He was awake and alert, but made a few errors while relating his history – for instance, he initially answered yes when asked if he had a headache, then corrected himself and said no – he meant he had a fever. He was actively rigoring. HEENT exam was unrevealing. He had no lymphadenopathy. His lungs were clear. His abdomen was soft and nontender. He had a sliding left inguinal hernia that was not tender. None of his joints were acutely inflamed. His prostate was not enlarged or tender to palpation. He had no focal neurological deficits.

Laboratory

Pertinent laboratory values in the ER:

• WBC: 7.7 x10⁹/L
• Hematocrit: 38.4%
• Sodium: 131 me/L
• Potassium: 3.1 me/L
• BUN:28 g/dL
• Creatinine: 1.3 mg/dL
• Lactate: 2.1 mMol/L.

The rest of his admission labs and urinalysis were unremarkable.

Chest Radiography

His initial portable chest x-ray is shown in Figure 1.

Figure 1. Initial portable chest x-ray.

Which of the following is the likely cause of his fever?

1. Prostatitis exacerbated by digital rectal exam
2. Right middle lobe pneumonia
3. Urinary tract infection
4. All of the above
5. None of the above

Reference as: Raschke RA, Poulos E. September 2013 critical care case of the month: revenge of the pharaohs. Southwest J Pulm Crit Care. 2013;7(3):142-50. doi: http://dx.doi.org/10.13175/swjpcc104-13 PDF