A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination.
Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
The 4-month-old boy with a history of cough, pallor, fever, and decreased feeding was placed in a warmer on a cardiorespiratory monitor with continuous pulse oximetry. His heart rate and respiratory rate rose and his degree of responsiveness declined. You decided the patient needed a lumbar puncture, knowing that vital sign abnormalities and subtle neurologic changes can be the first signs of bacterial meningitis in this age group. After obtaining consent from the mother, CSF was obtained on the first attempt, and was visibly purulent. The CSF WBC count was 2257 with 85% polys. The CBC showed a peripheral WBC of 9.9, Hb of 9, and platelets of 329,000. A CSF Gram stain revealed gram-positive cocci in pairs and occasional chains. You immediately suspected pneumococcal meningitis and initiated IV dexamethasone 0.15 mg/kg and IV cefotaxime 100 mg/kg and admitted the patient to the PICU. The CSF grew S pneumoniae that was sensitive to cefotaxime. Over the next 24 hours, the patient developed respiratory failure and progressive cerebral edema, the complication that you feared most. Over the next several days, his cerebral edema was unresponsive to therapy and the child died on the seventh day of hospitalization due to this complication.