temperature to 39.20 C, chills, anxiety, headache and vomiting. In dynamics, there is an increase in body temperature to 39.90 C, headache and repeated vomiting with a fountain. Epid. anamnesis The child goes to kindergarten. Objective the general condition is severe. The child is lying with his bead thrown hack, crying monotonously. The skin is pale, clean. There is moderate hyperemia of the palatine arches and the posterior pharyngeal wall in the pharynx, the tonsils are not enlarged, there are no plaque. There is vesicular breathing in the lungs, there are no wheezing. Respiration rate is 31 minute. Heart sounds are muffled, tachycardia Heart rate is 148 per minute. The abdomen is soft during palpation, palpation is available in all departments. The liver and spleen are not enlarged. Urination is not disturbed. The chair is decorated. The rigidity of the occipital muscles by 2, the symptoms of Kerning. Brudzinsky are positive. General blood test: Hb-116 g/l, er. -3.5*1012/1, tr. 109/(1-27 1091, p-27%, s-53%, c-2%, I- 10%, m-8%, ESR-22 mm/h Analysis of cerebrospinal fluid: cerebrospinal fluid flows out under pressure, cloudy color, cytosis-1000 cl. neutrophils-87%, lymphocytes-13%, protein-0.6 g/1, sugar-2.5 mmol/1
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Clinical Analysis
Diagnosis: Purulent (Bacterial) Meningitis — most likely Meningococcal (Neisseria meningitidis)
1. Clinical Reasoning
Key findings pointing to bacterial meningitis:
| Feature | Significance |
|---|---|
| High fever (39.2°C → 39.9°C, progressive) | Systemic infection with bacteremia |
| Severe headache | Meningeal irritation / raised ICP |
| Projectile ("fountain") vomiting | Raised intracranial pressure |
| Head thrown back (opisthotonus position) | Meningeal irritation |
| Monotonous crying | Cerebral irritation in a child |
| Pale skin, tachycardia (HR 148), muffled heart sounds | Systemic inflammatory response / sepsis |
| RR 31/min | Compensatory / meningeal involvement |
| Nuchal rigidity +2 | Meningismus — cardinal meningeal sign |
| Kernig's sign positive | Resistance to knee extension after hip flexion |
| Brudzinski's sign positive | Involuntary knee flexion on neck flexion |
| Pharyngeal hyperemia (no exudate) | Likely nasopharyngeal portal of entry |
| Kindergarten attendance | Epidemiological risk (close-contact community setting) |
2. CSF Analysis — Interpretation
| Parameter | Patient's Value | Interpretation |
|---|---|---|
| Appearance | Cloudy | Confirms purulent (bacterial) meningitis |
| Opening pressure | Elevated (flows under pressure) | Raised ICP |
| Cytosis | 1000 cells/µL | Marked pleocytosis |
| Neutrophils | 87% | Bacterial pattern (neutrophilic pleocytosis) |
| Lymphocytes | 13% | Minor |
| Protein | 0.6 g/L (normal <0.45) | Elevated — disrupted blood-brain barrier |
| Glucose (CSF) | 2.5 mmol/L | Low-normal (normal ~2.8–4.4); CSF:serum ratio reduced |
Classic bacterial CSF triad: cloudy fluid + neutrophilic pleocytosis + elevated protein + decreased glucose. ✓ All present.
3. Blood Count Interpretation
| Parameter | Value | Interpretation |
|---|---|---|
| Hb 116 g/L, RBC 3.5×10¹²/L | Mildly low | Mild anemia (infection) |
| Band neutrophils (p) 27% | Markedly elevated | Left shift — hallmark of acute bacterial infection |
| Segmented (s) 53% | Elevated | Neutrophilia |
| Eosinophils 2%, lymphocytes 10%, monocytes 8% | ||
| Platelets 109–271×10⁹/L | Low-normal | Watch for DIC (meningococcal) |
| ESR 22 mm/h | Mildly elevated | Acute inflammation |
Leukocyte formula: total neutrophilia with left shift (bands 27%) is highly consistent with acute bacterial infection.
4. Most Likely Pathogen
Neisseria meningitidis is the leading diagnosis, given:
- Child of kindergarten age (3 months–18 years: S. pneumoniae, N. meningitidis, H. influenzae — Table 41-14)
- Kindergarten attendance = crowded community setting (classic meningococcal risk factor)
- Acute, rapidly progressive course with high fever
- Pharyngeal hyperemia (nasopharyngeal colonization/invasion is the usual route)
- Absent skin rash does not exclude meningococcemia; petechial/purpuric rash may develop later
S. pneumoniae remains a close differential, but N. meningitidis is predominant in this age group in community outbreaks. — ROSEN's Emergency Medicine, p. 2268; Textbook of Family Medicine 9e, p. 1232
5. Management
Immediate priorities (do not delay for CT if no focal neuro signs):
Step 1 — Blood cultures × 2 → LP (already done) → Start antibiotics IMMEDIATELY
Empiric Antibiotic Therapy (age 1 month–18 years):
Vancomycin + Third-generation cephalosporin (Ceftriaxone or Cefotaxime) — Textbook of Family Medicine 9e, Table 41-18, p. 1233
| Drug | Pediatric Dose |
|---|---|
| Ceftriaxone | 100 mg/kg/day IV ÷ q12h (max 4 g/day) |
| or Cefotaxime | 200–300 mg/kg/day IV ÷ q6–8h |
| + Vancomycin | 60 mg/kg/day IV ÷ q6h (covers resistant pneumococcus) |
Adjunctive Therapy:
- Dexamethasone 0.15 mg/kg IV q6h × 2–4 days — start before or with the first antibiotic dose
- Proven benefit for H. influenzae meningitis; reduces sensorineural hearing loss
- Considered for pneumococcal and meningococcal meningitis
- Do not give if antibiotics have already been administered — benefit is lost
- — Textbook of Family Medicine 9e, p. 1234
Supportive Care:
- Strict isolation (droplet precautions) until 24h of effective antibiotics
- Monitor ICP: elevate head 30°, restrict fluids mildly, avoid hypotonic fluids
- Seizure precautions
- Close monitoring of HR, BP, urine output (septic shock risk)
- Antipyretics (paracetamol/ibuprofen)
Chemoprophylaxis for contacts:
- Rifampicin or single-dose ciprofloxacin for household and close kindergarten contacts (if N. meningitidis confirmed)
6. Differential Diagnoses to Exclude
| Diagnosis | Against |
|---|---|
| Viral (aseptic) meningitis | CSF predominantly lymphocytic, lower cytosis, clear fluid |
| Tuberculous meningitis | Lymphocytic CSF, subacute onset, high protein, very low glucose |
| Brain abscess | Focal neuro signs, papilledema, normal/mild CSF changes |
| Encephalitis | Altered consciousness predominates over meningism |
7. Summary
This child presents with acute purulent bacterial meningitis, most consistent with meningococcal etiology, based on:
- Classic clinical triad (fever + headache + meningism)
- Positive Kernig and Brudzinski signs
- Purulent CSF with neutrophilic pleocytosis, elevated protein
- Progressive fever in a kindergarten-age child from a community setting
- Left-shifted leukocyte formula in blood
Prognosis without prompt treatment is very poor. Immediate empiric antibiotics (ceftriaxone ± vancomycin) with adjunctive dexamethasone are the standard of care.
— ROSEN's Emergency Medicine, pp. 2268–2269; Textbook of Family Medicine 9e, pp. 1232–1234
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