Publication Date: November 2018 (Volume 15, Number 11)
No CME for this activity
The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Inflammatory markers, such as procalcitonin, in the serum and cerebrospinal fluid may help distinguish between bacterial meningitis and viral meningitis. Appropriate early antibiotic treatment and management for bacterial meningitis is critical for optimal outcomes. Although debated, corticosteroids should be considered in certain cases. This issue provides evidence-based recommendations for the early identification and appropriate management of bacterial meningitis in pediatric patients.
On a warm day in June, an unvaccinated 9-year-old girl is sent to your ED. Earlier that day, she was seen at her primary care physician’s office by a physician assistant who reported that the child had headache and fever intermittently for 3 to 4 days. The PA was concerned that she might have meningitis. The patient arrives, ambulatory and alert, complaining of a bitemporal headache. Her fever at home was 38.3°C (101°F). There has been no photophobia or rash, and there are no ill contacts. The child took acetaminophen 2 hours prior to arrival. On physical examination, the child is tired but not toxic-appearing. She had an episode of vomiting in triage. Her vital signs are: temperature, 38.7°C (101.6°F); heart rate, 142 beats/min; respiratory rate, 22 breaths/min; blood pressure, 119/77 mm Hg; and oxygen saturation, 95% on room air. Her pain score is 8/10. Her physical examination is notable for head and neck discomfort when moving from sitting to the supine position. Her neck has full range of motion and she is negative for Kernig sign and Brudzinski sign. The remainder of her examination is normal. The patient is given a 20 mL/kg normal saline bolus IV, 6 mg ondansetron IV, and 10 mg/kg ibuprofen orally. An hour later, her vital signs are: temperature, 37.2°C (99°F); heart rate, 126 beats/min; respiratory rate, 20 breaths/min; and blood pressure 111/67 mm Hg. Her pain score is now 4/10. Her peripheral white blood cell count is 16,000 with a left shift, and her chemistry is notable only for a glucose level of 146 mg/dL. Given the girl’s lack of frank meningismus and improvement with ibuprofen, is a lumbar puncture indicated? What are the most common causes of meningitis in this age group? Should antibiotics be given?