A 22 year old college student presents to the emergency department with a temperature of 39 C, photophobia, and confusion. This began about 12 hours ago. She tried acetaminophen with minimal relief. She complains of a severe, generalized headache. Although she has had migraines in the past, this is much worse. She takes an oral contraceptive, smokes and drinks occasionally, and uses marijuana (last use last night). When you flex her neck, you note that her hips spontaneously flex. When her hips are flexed 90 degrees, she cannot fully extend her knees. Here's a diagram of those maneuvers:
She has no papilledema and no focal neurologic deficits.Challenge: What's your next diagnostic test? Will you give empiric treatment?
Related Questions:
1. What's the leading diagnosis?
2. What is shown in the diagrams above?
Both images are in the public domain.
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3 comments:
kernig?
brudzinski?
The differential diagnoses seem to be:
Subarachnoid hemorrhage (more likely)
Meningitis.
Next diagnostic test - Head CT scan without contrast. If equivocal, go for lumbar puncture ("Quincke's" puncture?).
Empirical treatment - Yes, since getting a CT scan may take time in some places and meningitis cannot be entirely ruled out without it's results.
leading diagnosis - SAH
The diagrams show Brudzinski's (upper figure) and Kernig's sign.
You've co-labelled the post 'Psychiatry'. I didn't get that. Is that because of the marijuana?
Very nice - this is meningitis. SAH is important to exclude (also by LP) but fever and age group suggest against it. Right now, the labels group neurology and psychiatry together - at some point, I might go back and distinguish between the two. Here, it's a neurology case and not a psych one.
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Quincke I
This is acute bacterial meningitis with the triad of high fever, mental status change, and nuchal rigidity. The tests suggesting nuchal rigidity include the Brudzinski sign and the Kernig sign. The patient needs a lumbar puncture; screening CT before LP is suggested only if there is a risk factor for a mass lesion (immunocompromised, history of CNS disease, new onset seizure, papilledema, abnormal level of consciousness, or focal neurologic deficit). Empiric antibiotics include third generation cephalosporins (ceftriaxone, cefotaxime).
Sources: UpToDate; nlm.nih.gov.
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