Transcript ID Case Conference 10-10-07

ID Case Conference 1-2-08 #2
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: AMS
26 year old gentleman who presents with headache, fever, and
AMS. He starting complaining of an earache on Thursday,
12/27/07. He had a refill of flonase from a prior bout of sinusitis
so his wife filled the prescription and he took flonase around
lunchtime. By dinner he said he was feeling better. On Friday
the patient woke up with what he described as a "sinus
headache." He took tylenol and benadryl on Friday and went to
bed. At 6pm on Friday when his wife went to check on him he
was altered and "seemed like he was trying to say something but
couldn't talk." She called 911 who took him to a local hospital.
HPI
At ED the patient was found to be febrile to 102.7F, tachycardic
to 119, received Rocephin at 2125pm, LP done 2310pm
Vancomycin dosed at 2310pm. The patient was also started
empirically on acyclovir in the ED. Blood cultures were done in
the ED prior to Rocephin dose. Steroids were not given prior to
or with antibiotics.
The patient has not had any sick contacts or been around any
daycare centers. He did see his 5 year old nephew and 8 month
old niece on Christmas eve and Christmas day but both children
were healthy.
They have two outdoor dogs, no recent travel. 12 point review of
systems is negative as described above.
PMH
h/o adenotonsillectomy
h/o bilaterally eustasian tube placment at age 9
or 10
Otherwise unremarkable
Medications
Flonase
Allergies - NKDA
Social History / Family History
Social History: denies tobacco or drugs. No h/o
STDs, the patient's wife denies any HIV risk
factors. Rare alcohol (1 beer every month or so)
Family History: father and mother both alive and
healthy, no diseases run in the family
ROS
The patient has not had any sick contacts or
been around any daycare centers. He did see
his 5 year old nephew and 8 month old niece on
Christmas eve and Christmas day but both
children were healthy.
They have two outdoor dogs, no recent travel.
12 point review of systems is negative as
described above
Physical Exam
37.2 - 120/70 - 90 - 16 - 98% on RA
General obtunded, not answering questions.
Eyes EOMI, PERRLA, nonicteric
ENT no e/e on OP. dry mucous membranes. vesicle on R upper lip
Neck no JVD
Lymph Nodes no LAD appreciated in cervical, supraclavicular, or inguinal regions
Cardiovascular tachycardic, no murmurs
Lungs CTAB
Skin no rash or lesions
Abdomen soft NT nabs, no HSM
Extremeties no c/c/e
Musculo Skeletal nl tone, full ROM present
Neurological obtunded. hyperreflexic in BLE with 2 beats of clonus bilaterally. reflexes
in BUE are 2+, no clonus. normal cerebellar function, strength is intact in BU and LE
Labs
134 102 15 1668.9
3.5 21 0.9
23.6
15.0
43.4
N-92.9
L-2.1
M-5.0
E-0.0
B-0.0
176
1.0
16
46
37
TProt 6.9
Albumin 3.8
Head CT - WNL
Discussion
“A Diagnostic test was performed…”
The patient was admitted to the ICU and CSF showed gram
positive diplococci. Bacterial antigen detection was negative for
strep B, H flu, N men, and positive for strep pneumo. Blood
cultures grew strepcocci in 2/2 cultures, CSF culture grew strep
pneumo that was resistant to cefotaxime, intermediate to PCN
and CTX, and sensitive to vancomycin. The patient was admitted
to the ICU, when the sensitivities were discovered he was
transferred to UNC MICU for further management.
ID was consulted regarding the questions of steroid
administration and whether the current antibiotic regimen was
sufficient.
Bacterial Meningitis
Review of 493 pts with acute bacterial meningitis
published in 1993
40% nosocomial
Of the 296 cases of cases of community acquried
meningitis, most common pathogens were
•
•
•
•
Strep pneumo 37%
Neisseria meningitis 13%
Listeria monocytogenes 10%
H. flu 4%
Bacterial Meningitis
Risk factors for death among community
acquired bacterial meningitis
Age >60
Obtunded mental state at admission
Seizures within the first 24 hours
Mortality Rate
25% for community acquired strains
Streptococcus pneumoniae
meningitis
Case fatality rate for meningitis-related strep
pneumo meningitis was 25%, compared to 10%
for N. meningitidis.
Review of 109 cases of pneumococcal
meningitis from 1994-96
9% of cases were resistant to cefotaxime
11% had intermediate suseptibility
Strep Pneumo and Steroids
Randomized, placebo-controlled trial involving 301 adults with
suspected meningitis
Dexamethasone before or with the first dose of ABX reduced the risk of
unfavorable outcome from 25 percent to 15 percent (number needed to
treat, 10 patients).
Mortality was reduced from 15 percent to 7 percent.
The benefit was greatest in patients with intermediate disease severity
In those with pneumococcal meningitis
Unfavorable outcomes declined from 52 percent to 26 percent (number
needed to treat, four).
Mortality was reduced from 34 percent to 14 percent. Benefit was a result
of reduced mortality from systemic causes
Steroids and Vanc?
Prospective Multicenter Observational Study of 14
patients (13 with proven pneumococcal meningitis)
All patients started empiric treatment with CTX,
vancomycin, and dexamethasone
Vancomycin levels measured in CSF on day 2 or 3 of
therapy and correlated with protein in CSF and vanc in
serum
Mean levels of vancomycin in serum and CSF were
25.2 and 7.2 respectively, and positively coorelated
Penicillin-nonsusceptible Strep
pneumoniae meningitis
Retrospective, nested case-control study
comparing cases with PNSP meningitis with
controls with PSSP meningitis obtained from the
Immunization Monitoring Program, Active
(IMPACT) cross-Canada surveillance study of
invasive infections
No difference in outcomes between PNSP and
PSSP – pediatric literature
References
Stucki A, Cottagnoud M, Winkelmann V, Schaffner T, Cottagnoud P.Daptomycin produces an enhanced bactericidal activity
compared to ceftriaxone, measured by [3H]choline release in the cerebrospinal fluid, in experimental meningitis due to a penicillinresistant pneumococcal strain without lysing its cell wall. Antimicrob Agents Chemother. 2007 Jun;51(6):2249-52. Epub 2007 Mar
19.
Ricard JD, Wolff M, Lacherade JC, Mourvillier B, Hidri N, Barnaud G, Chevrel G, Bouadma L, Dreyfuss D. Levels of vancomycin in
cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter
observational study.Clin Infect Dis. 2007 Jan 15;44(2):250-5. Epub 2006 Dec 15.
Lee H, Song JH, Kim SW, Oh WS, Jung SI, Kiem S, Peck KR, Lee NY.Evaluation of a triple-drug combination for treatment of
experimental multidrug-resistant pneumococcal meningitis. Int J Antimicrob Agents. 2004 Mar;23(3):307-10.
Fiore AE, Schuchat A, et al.Clinical outcomes of meningitis caused by Streptococcus pneumoniae in the era of antibiotic
resistance.Clin Infect Dis. 2000 Jan;30(1):71-7.
Kellner JD, Vaudry W, et al. Outcome of penicillin-nonsusceptible Streptococcus pneumoniae meningitis: a nested case-control
study.Pediatr Infect Dis J. 2002 Oct;21(10):903-10
*Ribes S, Gudiol F, et al. Evaluation of ceftriaxone, vancomycin and rifampicin alone and combined in an experimental model of
meningitis caused by highly cephalosporin-resistant Streptococcus pneumoniae ATCC 51916.J Antimicrob Chemother. 2005
Nov;56(5):979-82. Epub 2005 Sep 20.
*Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS Jr, Swartz MN.Acute bacterial meningitis in adults.
A review of 493 episodes.N Engl J Med. 1993 Jan 7;328(1):21-8.
*Nguyen TH, Farrar JJ, et al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis.N Engl J Med. 2007
Dec 13;357(24):2431-40.
*Scarborough M, Zijlstra EE, et al. Corticosteroids for bacterial meningitis in adults in sub-Saharan Africa.N Engl J Med. 2007 Dec
13;357(24):2441-50.
*Peltola H, Sarna S, et al. Adjuvant glycerol and/or dexamethasone to improve the outcomes of childhood bacterial meningitis: a
prospective, randomized, double-blind, placebo-controlled trial.Clin Infect Dis. 2007 Nov 15;45(10):1277-86. Epub 2007 Oct 15.
*de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators.Dexamethasone in
adults with bacterial meningitis.N Engl J Med. 2002 Nov 14;347(20):1549-56.
*van de Beek D, de Gans J, McIntyre P, Prasad K.Steroids in adults with acute bacterial meningitis: a systematic review.Lancet
Infect Dis. 2004 Mar;4(3):139-43.