Fever and Stiff Neck

A previously healthy 10-year-old white male was transferred to the pediatric intensive care unit (PICU) for management of suspected acute bacterial meningitis. One day prior to admission he was seen at a community hospital emergency department (ED) with a 4-day history of fever, headache, decreased appetite and activity, and a 1-day history of severe neck stiffness. The patient had no sick contacts, no surgical history, a past medical history of attention deficit/hyperactivity disorder treated with dexmethylphenidate 10 mg daily, and was up to date on his immunizations. Of note, the patient had a history of a head injury 3 weeks prior to admission, at which time he and another boy head-butted each other while playing football. The impact was severe enough to leave tooth marks on the side of the patient’s face, although there were no scars or evidence of trauma at the time of admission. Bacterial meningitis was suspected but a lumbar puncture was not performed at the time of presentation to the ED. Blood cultures were drawn and the patient was empirically started on ceftriaxone and vancomycin before transfer to our facility for further care. On arrival to the PICU, vital signs were as follows: blood pressure 96/63 mm Hg, pulse 98 beats/minute, temperature 99.3°F, and respiratory rate of 33 breaths/minute. Physical exam revealed a somnolent but responsive child who answered questions appropriately with occasional inappropriate words. Neurologic exam revealed significant nuchal rigidity, positive Kernig’s and Brudzinski’s signs, photophobia, and diplopia. Examination of the tympanic membranes and oropharynx was unremarkable. No rash or dermatologic abrasions were noted. The rest of the physical exam was unremarkable. Laboratory data (normal range is given in parentheses) on admission included a hemoglobin of 10.6 g/dL (11.515.5 g/dL), hematocrit 31.6% (38% to 42%), platelet count 80 000/mm (150 000/mm to 350 000/mm), white blood cell (WBC) count 6290/μL (6100/μL to 10 100/μL) with 93% segmented neutrophils, 3% bands, 2% lymphocytes, and 2% monocytes. Serum chemistry revealed a sodium level of 138 mmol/L (133-146 mmol/L), potassium of 3.6 mmol/L (3.4-4.7 mmol/L), chloride of 104 mmol/L (98-107 mmol/L), carbon dioxide of 19 mmol/L (20-28 mmol/L), blood urea nitrogen 15 mg/dL (5-18 mg/dL), creatinine 0.5 mg/dL (0.3-0.7 mg/dL), and glucose 69 mg/dL (60-100 mg/dL). Liver enzymes were normal. A lumbar puncture was performed, which showed xanthochromic cerebrospinal fluid (CSF) with glucose less than 5 mg/dL (40-80 mg/dL), protein 571 mg/dL (5-40 mg/dL), red blood cells 2680, WBC 67/μL (0/μL to 7/μL) with 82% segmented neutrophils, 16% lymphocytes, and 2% monocytes. CSF gram stain was positive for Gram positive cocci and subsequently grew group A streptococcus (GAS) that was sensitive to penicillin (minimum inhibitory concentration [MIC] 0.006 μg/mL), vancomycin (MIC 0.75 μg/mL), and ceftriaxone (MIC 0.12 μg/ml). The initial blood culture obtained in the community hospital ED prior to initiation of antibiotic treatment was also positive for GAS. Vancomycin was discontinued at this time and the patient was continued on ceftriaxone (100 mg/kg/d divided every 12 hours).