EMERGENCY CASE CONFERENCE
Meningitis Missed Judith E. Tintinalli, M D - editor Detroit, Michigan
Tintinalli JE: Meningitis missed. JACEP 5:334-338, May 1976. meningitis, diagnosis; abscess, spinal; lumbar puncture, indications for. INTRODUCTION
mg/100 ml. G r a m stain of the CSF d e m o n s t r a t e d gram positive cocci. The following d a y he died on the medical ward. P o s t m o r t e m d i a g n o s e s w e r e s t a p h y l o c o c c a l lep, t o m e n i n g i t i s a n d lower spinal, s u b d u r a l a n d epidural abscesses.
J u d i t h E. T i n t i n a l l i , MD: The cases for discussion t o d a y are those of two m a l e p a t i e n t s who p r e s e n t e d to t h e e m e r g e n c y d e p a r t m e n t of D e t r o i t G e n e r a l Hospital in t h e s a m e w e e k w i t h c o m p l a i n t s of low back pain. R a l p h D. Cushing, MD, a s s i s t a n t professor of medicine at W a y n e S t a t e U n i v e r s i t y and chief of infectious disease at D e t r o i t G e n e r a l Hospital, will be the discussant.
C a s e N u m b e r T w o . This p a t i e n t was a 58-year-old black m a n who h a d a chief c o m p l a i n t of left-sided back p a i n of s e v e r a l h o u r s ' d u r a t i o n . P h y s i c a l examination and l a b o r a t o r y studies, i n c l u d i n g WBC, urinalysis, and r a d i o g r a p h s of t h e l u m b a r spine, were w i t h i n normal limits. The p a t i e n t was d i s c h a r g e d to the medical clinic for follow-up care.
Case Reports
Three days l a t e r he r e t u r n e d to the e m e r g e n c y departm e n t confused a n d t r e m u l o u s . T h e d i a g n o s i s was del i r i u m t r e m e n s a n d he was t r e a t e d w i t h intravenous fluids, t h i a m i n e and chlordiazepoxide. Twenty-four hours later, while still in the e m e r g e n c y d e p a r t m e n t , he became comatose. His t e m p e r a t u r e rose to 103 F (39.4 C) and his neck was stiff. There were no focal neurologic signs. G r o s s l y p u r u l e n t fluid was o b t a i n e d on lumbar p u n c t u r e w i t h 350,000 white cells/cu mm, all PMNs. CSF glucose was 35 mg/100 ml w i t h a blood glucose of 157 mg/100 ml. G r a m s t a i n of the C S F d e m o n s t r a t e d gram positive cocci. CSF c u l t u r e e v e n t u a l l y showed coagulase positive Staphylococcus aureus: CSF o b t a i n e d by cister-. nal t a p was cloudy with one w h i t e cell a n d no bacteria, glucose of 30 rag/100 ml and p r o t e i n of 700 mg/100 ml. A m y e l o g r a m d e m o n s t r a t e d a functional block at the level of T5 to T8 b u t no s u b d u r a l or e p i d u r a l abscess_ The pa. t i e n t was t r e a t e d w i t h methicillin, i n t r a t h e c a l l y and intravenously, and was d i s c h a r g e d 20 days l a t e r with no neurologic i m p a i r m e n t .
C a s e N u m b e r O n e . The p a t i e n t was a 21-year-old black m a n w i t h a chief c o m p l a i n t of low back p a i n t h a t b e g a n a f t e r he l i f t e d a h e a v y object. He d e n i e d a n y w e a k n e s s or p a r e s t h e s i a of the legs. There was no h i s t o r y of d r u g abuse. On p h y s i c a l e x a m i n a t i o n t h e p o s i t i v e .findings were l u m b a r t e n d e r n e s s and a t e m p e r a t u r e of 101 F (38.3 C). L a b o r a t o r y studies, including white blood count (WBC), u r i n a l y s i s , and r a d i o g r a p h s of t h e l u m b a r spine, were w i t h i n n o r m a l limits. The p a t i e n t was discharged w i t h o u t t r e a t m e n t . T h r e e days l a t e r he r e t u r n e d c o m p l a i n i n g of fever, chills, and dysuria. A t t h a t time, he a p p e a r e d a c u t e l y ill with a t e m p e r a t u r e of 104 F (40.0 C). His neck was supple. T h e r e were no focal neurologic abnormalities_ Left flank t e n d e r n e s s was present. One hour after a d m i s s i o n the p a t i e n t s u d d e n l y developed g a s p i n g r e s p i r a t i o n s and a d i l a t e d left pupil, followed by c a r d i o r e s p i r a t o r y a r r e s t from which he was r e s u s c i t a t e d . F o l l o w i n g arrest, his pupils r e m a i n e d fixed a n d d i l a t e d and his e x t r e m i t i e s were flaccid and hyporeflexic. The p a t i e n t h a d no spont a n e o u s r e s p i r a t i o n s and no response to deep pain. Lumb a r p u n c t u r e was done after t h e a r r e s t w i t h the r e t u r n of t h i c k pus, w i t h 6300 white cells/cu mm, all polymorpho n u c l e a r l e u k o c y t e s (PMN). C e r e b r o s p i n a l fluid (CSF) glucose was 20 mg/100 ml w i t h a blood glucose of 250 From the Emergency Department, Detroit General Hospital, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226.
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R a l p h C u s h i n g , MD: S p i n a l e p i d u r a l abscess is an uncommon disease but, because of the associated mortality and morbidity, it is e x t r e m e l y i m p o r t a n t for the emergency p h y s i c i a n to recognize t h e e n t i t y as e a r l y as p0Ssible_ The p r e s e n t a t i o n of s p i n a l e p i d u r a l abscess as f r a n k m e n i n g i t i s is most u n u s u a l . Note the similarities and differences between our p a t i e n t s and the followin~ case report: ~H.H., male, age 27 years, h a d suffered from a pain i~ the sacral region two weeks before admission. On the last two days he had t h r e e a t t a c k s of s h i v e r i n g and suffering
May 1976"~]~P
from diffuse h e a d a c h e . . . He h a d sudden p a i n in the left hip which d i s a p p e a r e d e n t i r e l y in a few days. On admission, the 14th d a y of his illness, he looked e x t r e m e l y ill. His t e m p e r a t u r e was 104.4 F r e a c h i n g 105.2 F at midnight. The h e a d a c h e was general, with p a i n in the neck on moving the head, the head and shoulders moved stiffly together- The i n n e r edge of the r i g h t optic disk was hazy but his eyes were otherwise n o r m a l . . . . He lay on his back with the left knee flexed and a t t e m p t s to e x t e n d it completely gave severe pain. The knee j e r k on this side was brisk . . . . The n e x t d a y the sacral t e n d e r n e s s and headache w e r e less b u t t h e r e was p a i n down t h e left thigh. On t h e 21st d a y of his illness he lay quiet, m u t t e r ing occasionally and with the left pupil l a r g e r t h a n t h e right- R e t e n t i o n of u r i n e was complete a n d t h e r e was no control of the rectum. He died in the afternoon." Now the p o s t m o r t e m findings: '*The left psoas muscle was much swollen, and its central p a r t h a d b r o k e n down to a large abscess . . . . The transverse process of the l a s t l u m b a r v e r t e b r a was b a r e and necrosed, and from this point t h e r e was free communication from the psoas abscess to the l u m b a r s p i n a l muscles in which an abscess also existed . . . . There was suppuration of the whole loose connective tissue b e t w e e n the d u r a m a t e r and the bones forming t h e spinal canal. Pus and l y m p h were found inside the theca from its lower end up to t h e inferior e x t r e m i t y of the cervical e n l a r g e ment. The cord itself was n o r m a l to the n a k e d eye. The brain a n d its m e m b r a n e s were h e a l t h y with the exception of a little t u r b u l e n t fluid inside the dura. ''1
+~'~,lll, V ~ l 111~Vlldl
IJl~hlJ;~
F i g . 1. Vertebral venous system (Adapted from G r a n t ' s A t l a s of A n a t o m y . J. C. Boileau Grant, ed 6, Baltimore,
Williams and Wilkins Co, 1972, Fig 390)
Posterior spinal aa.~. : :~:;:: .:.'~ : . ( . :
This i n t e r e s t i n g case report, along w i t h a review of 21 others, was w r i t t e n in 1896. Of t h e 21 cases, 11 died w i t h meningitis a n d v e r t e b r a l osteomyelitis. This, then, represents the n a t u r a l h i s t o r y of u n t r e a t e d s p i n a l e p i d u r a l abscess.
Pathophysiology Spinal e p i d u r a l abscess can develop in several ways: (1) by h e m a t o g e n o u s spread; (2) by direct extension from vertebral osteomyelitis; (3) by direct inoculation. H e m a t o g e n o u s spread is by far the commonest source of e p i d u r a l abscess,2, 3 especially in children. 4 T h e r e a r e two circulatory systems involved in the pathophysiology of spinal disease: the venous plexus of Batson, and the spinal a r t e r i e s (Figures 1 and 2). Batson's veins are located in the e p i d u r a l space (Figure 3), and anastomose with thoracic and a b d o m i n a l veins at each spinal segraent7 D u r i n g V a l s a l v a ' s m a n e u v e r , blood shunts from the thoracic and a b d o m i n a l veins into the p e r i v e r t e b r a l plexus. Batson's veins are p a r t i c u l a r l y i m p o r t a n t in t h e dissemination of c a r c i n o m a of the prostate and breast, accounting for t h e i r frequent m e t a s t a s i s to the spine. In the case of spinal e p i d u r a l abscess, it has been postulated t h a t b a c t e r i a from the u r i n a r y t r a c t invade t h e prostate gland, or the pelvic viscera, and gain e n t r y into the p e r i v e r t e b r a l plexus of Batson, where the e p i d u r a l space is seeded. However, the commonest p a t h o g e n in s p i n a l a b s c e s s is t h e s t a p h y l o c o c c u s , w h i l e t h e Staphylococcal u r i n a r y t r a c t infection is rare. Pyogenic infection reaches the spine most often by systemic dissemination m t h e a r t e r i a l circulation.
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May 1976
\Anterior sp,no~ uu Segmental arteries F i g . 2. Arterial supply of the spinal cord (Adapted from A n a t o m y . Gardner, Gray, and O'Rahilly, ed 3, Saunders,
1969, p 557) Dr. T i n t i n a l l i : The blood-borne o r g a n i s m proliferates on the surface of the dura, u s u a l l y the posterior surface, as the fatty tissue t h e r e offers l i t t l e resistance to spread of the organism. Anteriorly, the d u r a is closely a d h e r e n t to the spinal ligaments. Abscesses occur more commonly at the level of the thoracic and l u m b a r vertebrae, where the v e r t e b r a l c a n a l is l a r g e s t . O n c e e s t a b l i s h e d in t h e e p i d u r a l space, the infection can spread p a r a v e r t e b r a l l y or a l o n g i n t e r m u s c u l a r planes. R u p t u r e into the suba r a c h n o i d space with r e s u l t a n t m e n i n g i t i s is rare. Direct e x t e n s i o n from o s t e o m y e l i t i s occurs in 10% to 40% of a d u l t cases.~, 6 Direct inoculation can occur from l u m b a r p u n c t u r e if p u n c t u r e is done t h r o u g h a burn, cellulitis, or in the presence of otherwise i n a d e q u a t e sterile technique, or from p e n e t r a t i n g t r a u m a . B l u n t t r a u m a m a y be con-
Volume 5 Number 5 Page 335
.•/•ff
Su barachnoid space
Spina~l ~ nerve Vertebral~ body
~~Arachnoid ~.J'C--~Dura mater ~ ~
Epidural space
F i g . 3. Cross section of the spinal cord demonstrating the relationships of the dura mater (Adapted from A n a t o m y .
Gardner, Gray, and O'Rahilly, 1969, ed 3, Saunders, 1969, p 557)
t r i b u t o r y to t h e f o r m a t i o n of spinal e p i d u r a l abscess in t h a t a r e s u l t a n t h e m a t o m a provides an excellent c u l t u r e m e d i u m for t h e growth of bacteria, s Dr. C u s h i n g : The two p a t i e n t s presented today most l i k e l y h a d p r i m a r y staphylococcal b a c t e r e m i a , with t h e development of an e p i d u r a l focus of staphylococcal infection. The abscess t h e n r u p t u r e d across the dura, eventually producing m e n i n g i t i s . The e n t r y of the o r g a n i s m in Case N u m b e r One was p r o b a b l y secondary to i n t r a v e n ous heroin Use, a n historical point well e s t a b l i s h e d after the p a t i e n t ' s death_ In Case N u m b e r Two t h e point of e n t r y of the o r g a n i s m is not evident. The skin, or a n y p a r e n c h y m a l focus of infection, can be the source of bacteremia. The staphylococcus is the commonest c a u s a t i v e organism, b u t the streptococcus and anaerobic or g r a m n e g a t i v e o r g a n i s m s are b e i n g found w i t h i n c r e a s i n g frequency3
R a d i o g r a p h s of the clinically affected a r e a of the spi~ should also be obtained on initial, e v a l u a t i o n . However, unless v e r t e b r a l osteomyelitis is present, or unless the abscess h a s d i s s e c t e d a l o n g t h e psoas musctes, radiQ, g r a p h s are not helpful in the diagnosis of s p i n a l epidural abscess. If, on the basis of p h y s i c a l e x a m i n a t i o n , a spinal abscess is suspected, m y e l o g r a p h y should be performed. A s a m p l e of CSF can be o b t a i n e d at m y e l o g r a p h y or fro~ c i s t e r n a l tap. It is i m p o r t a n t to avoid i n v a s i v e procedures at t h e abscessed a r e a since d i s s e m i n a t i o n of ~nfecti0~ and m e n i n g i t i s could r e s u l t 3 S p i n a l e p i d u r a l abscess is a surgical emergency. Treat, m e n t consists of laminectomy, d r a i n a g e of the abscess, and a d m i n i s t r a t i o n of a p p r o p r i a t e antibiotics. Q U E S T I O N : What do you consider contraindications to lumbar puncture ? Dr. C u s h i n g : A l u m b a r p u n c t u r e is i n d i c a t e d whenever t h e r e is suspicion of c e n t r a l nervous s y s t e m infection. Be. fore one reaches the point of l u m b a r puncture, a history, physical e x a m i n a t i o n , and n-eurologic e v a l u a t i o n should be p e r f o r m e d and skull r a d i o g r a p h s should be obtained. A n a b s o l u t e c o n t r a i n d i c a t i o n to l u m b a r p u n c t u r e is the p r e s e n c e of a b u r n , abscess, or c e l l u l i t i s in t h e area t h r o u g h w h i c h p u n c t u r e is t o be a t t e m p t e d . If papill e d e m a is present, l u m b a r p u n c t u r e should be performed cautiously. A small gauge s p i n a l needle should be used and a m i n i m u m a m o u n t of f l u i d o b t a i n e d . One must weigh the possibility of o b t a i n i n g vital i n f o r m a t i o n from l u m b a r p u n c t u r e versus the possibility of b r a i n hernia. tion as a r e s u l t of the procedure, s L u m b a r p u n c t u r e should be a v o i d e d especially in those p a t i e n t s w i t h focal n e u r o l o g i c a l signs w h e r e a spaceoccupying i n t r a c r a n i a l lesion is s u s p e c t e d 2 In such cases, e l e c t r o e n c e p h a l o g r a p h y , b r a i n scan and flow study, or, a n g l o g r a p h y should be performed before l u m b a r puncture is attempted_ It is especially h a z a r d o u s to perform lure. b a r p u n c t u r e on the p a t i e n t w i t h b r a i n abscess_ CSF find. ings in this i n s t a n c e are not u s u a l l y informative. 1°
Clinical Features
The c o m b i n a t i o n of b a c k p a i n and fever should arouse in the e m e r g e n c y p h y s i c i a n the suspicion of several diagnoses: m e n i n g i t i s , p y e l o n e p h r i t i s , s p i n a l abscess, r e t r o p e r i t o n e a l t u m o r or abscess, v e r t e b r a l body or d i s k space infection, or t r a n s v e r s e myelitis. The clinical picture of spinal abscess progresses from spinal ache, to root pain, to motor w e a k n e s s and f i n a l l y paralysis. I n i t i a l e v a l u a t i o n of the p a t i e n t w i t h back p a i n and fever should include a careful and complete neurological e x a m i n a t i o n . In acute disease, once root p a i n has developed, it m a y t a k e o n l y a few d a y s to p r o g r e s s to paralysis. Root p a i n is i n v a r i a b l y accompanied by e i t h e r deep t e n d o n r e f l e x c h a n g e s or p a r e s t h e s i a s _ T h e dev e l o p m e n t of p a r a l y s i s carries an ominous prognosis. The presence of a n o r m a l w h i t e count should not give t h e p h y s i c i a n a false sense of security. It m a y be that, at first, the abscess was so well localized t h a t a leukocytosis was not affected. The o t h e r p o s s i b i l i t y is t h a t b o t h of these p a t i e n t s were not completely h e a l t h y a n d were unable to produce a w h i t e count response or p r e v e n t diss e m i n a t i o n of infection.
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Q U E S T I O N : How valuable is echoencephalography? Dr. C u s h i n g : E c h o e n c e p h a l o g r a p h y can detect a mid. line shift of t h e t h i r d ventricle. D e p e n d i n g on the skill of the technician, a l a t e r a l shift of as little as 3 m m can be sig. nificant. A d i s a d v a n t a g e of the t e c h n i q u e is t h a t bilateral s u p r a n t e n t o r i a l lesions and i n f r a t e n t o r i a l lesions will go u n d e t e c t e d if t h e r e is no d i s p l a c e m e n t of the t h i r d ventricle. If the e c h o e n c e p h a l o g r a m is positive, the n e x t step is angiography. If negative, the p a t i e n t should be closely monitored and t h e s t u d y r e p e a t e d l a t e r if clinically indicated.// T h e r e are s e v e r a l points of i n f o r m a t i o n to be obtained from a s a m p l e of CSF. The opening pressure, color and t u r b i d i t y should be noted. A g r a m s t a i n should be performed in every case of suspected meningitis. The aliquot 0f spinal fluid should be centrifuged, the s u p e r n a t a n t dis' carded, and the p r e c i p i t a t e r e s u s p e n d e d and-stained. The crystal violet m u s t be freshly filtered before each use or dye crystals will a p p e a r as g r a m positive cocci a n d bacilli over the e n t i r e slide_ The presence of five or more white blood cells in the CSF is a b n o r m a l a n d a cell count of 1000 or g r e a t e r w i t h a predominance of P M N s is h i g h l y suspicioUS
May 1976..U ~ P
of bacterial m e n i n g i t i s . In t h e first few hours of b a c t e r i a l meningitis t h e r e m a y be no cells in the CSF b u t g r a m s t a i n will u s u a l l y r e v e a l the presence of bacteria. A predominance of lymphocytes in t h e CSF is compatible w i t h v i r a l or g r a n u l o m a t o u s m e n i n g i t i s . I n h y p e r a c u t e t u b e r c u louS m e n i n g i t i s , h o w e v e r , p o l y m o r p h o n u c l e a r l e u k o cytes m a y i n i t i a l l y p r e d o m i n a t e .
d e n c e i n c r e a s e s w i t h i n c r e a s i n g age. M e n i n g o c o c c a l m e n i n g i t i s decreases in incidence w i t h i n c r e a s i n g age, a n d in older, d e b i l i t a t e d individuals, the pneumococcus is proba b l y t h e c o m m o n e s t c a u s e of b a c t e r i a l m e n i n g i t i s . Staphylococcal m e n i n g i t i s occurs most commonly second a r y to b a c t e r i a l e n d o c a r d i t i s , 14 or p e n e t r a t i n g h e a d trauma.
CSF p r o t e i n will be e l e v a t e d in all i n f l a m m a t o r y processes. N o r m a l C S F glucose is two-thirds of the blood glucose. A glucose t e s t should a l w a y s be d r a w n at t h e t i m e of lumbar p u n c t u r e for comparison. In b a c t e r i a l and t u b e r c u l o u s meningitis t h e C S F glucose is low unless the p a t i e n t has been p a r t i a l l y treated. W i t h other fungal m e n i n g i d i t e s , the glucose is u s u a l l y low b u t occasionally can be normal. In viral m e n i n g i t i s , glucose is normal, except for m u m p s and herpes, which can occasionally cause a low glucose.
The d r u g of choice for a p r e v i o u s l y h e a l t h y a d u l t with n o n h o s p i t a l acquired p u r u l e n t m e n i n g i t i s is penicillin, one million units every two hours i n t r a v e n o u s l y . An a l t e r n a tive drug is ampicillin, 12 gms i n t r a v e n o u s l y per day, since t h e r e is a 10% chance ofH. influenzae b e i n g the c a u s a t i v e agent. If the p a t i e n t is elderly, t h e n ampicillin, not penicillin, m a y be t h e drug of choice.
Given the following spinal fluid findings, w h a t is the diagnosis: 45 w h i t e cells, 50% PMNs; CSF glucose of 15 rag/100 ml a n d blood glucose of 100 mg/100 ml; CSF p r o t e i n of 60; g r a m s t a i n w i t h no o r g a n i s m s identifiable. The pat i e n t has been stuporous for two days and has never h a d antibiotics_ T h e r e are no focal neurologic findings.
ANSWER: Early bacterial meningitis. Dr. C u s h i n g : Most u n l i k e l y with a r a t h e r even distribution b e t w e e n lymphocytes and PMNs. In e a r l y b a c t e r i a l meningitis, even if t h e r e a r e only a few cells in the CSF, they are p r e d o m i n a n t l y PMNs. In addition, even if t h e r e are no cells in t h e CSF, the g r a m s t a i n will u s u a l l y r e v e a l organisms.
ANSWER: Tuberculous meningitis. Dr. C u s h i n g : Tuberculous or other fungal m e n i n g i t i s is likely even if the acid-fast s t a i n is negative. However, a definitive diagnosis cannot be m a d e in the e m e r g e n c y department.
ANSWER: Viral meningoencephalitis. Dr. C u s h i n g : V i r a l m e n i n g o e n c e p h a l i t i s is possible although a low CSF glucose m a k e s it unlikely. E a r l y aseptic meningitis may present with a polymorphonuclear leukocytosis b u t over the next 8 hours the cellular C S F population will become p r e d o m i n a n t l y lymphocytic_ 12 But in any case, t h e presence of a low CSF glucose m a k e s a v i r a l etiology unlikely.
ANSWER: Mycotic aneurysm. Dr. C u s h i n g : The complication of mycotic a n e u r y s m occurs in 2% to 10% of p a t i e n t s w i t h b a c t e r i a l endocarditis. 13 Red cells are p r e s e n t in t h e CSF and t h e r e are almost a l w a y s focal neurologic findings.
ANSWER: Brain abscess. Dr. C u s h i n g : B r a i n abscess is possible except for t h e finding of low CSF glucose. Unless the abscess has r u p t u r e d into the s u b a r a c h n o i d space and produced m e n i n g i t i s , CSF glucose will be normal. The commonest causes of b a c t e r i a l m e n i n g i t i s in the adult are HemophiIus influenzae, Diplococcus (Streptococcus) pneumoniae, andNeisseria meningitidis_ H. influenzae accounts for less t h a n 10% of a d u l t m e n i n g i t i s b u t its inci-
J ~ F ) May 1976
Q U E S T I O N : W h a t is the role o f chloramphenicol in the treatment o f meningitis ? Dr. C u s h i n g : C h l o r a m p h e n i c o l is the d r u g of choice for t h e t r e a t m e n t of b a c t e r i a l m e n i n g i t i s in t h e p a t i e n t w i t h a n a p h y l a x i s to penicillin. The dose is 4 gm i n t r a venously per day. A m p i c i l l i n r e s i s t a n t H. influenzae is s t i l l u n c o m m o n , b u t some s o u r c e s a d v i s e t h e use of chloramphenicol in suspected h e m o p h i l u s m e n i n g i t i s as i n i t i a l t h e r a p y until sensitivities return. ~s Q U E S T I O N : Is there any role for steroids in the treatment of meningitis ? Dr. Cushing: S t e r o i d s a r e i n d i c a t e d in t h e W a t e r h o u s e - F r i d e r i c h s e n syndrome, m e n i n g i t i s with septic shock, a n d in t u b e r c u l o u s m e n i n g i t i s . The use of s t e r o i d s in p n e u m o c o c c a l m e n i n g i t i s is c o n t r o v e r s i a l a n d I do not r e c o m m e n d it as a routine measure. Q U E S T I O N : Do you advocate prophylactic antibiotic t r e a t m e n t for s k u l l f r a c t u r e s w i t h cerebrospinal C S F rhinorrhea or otorrhea? Dr. C u s h i n g : No. The p a t i e n t should be followed closely a n d t r e a t m e n t i n i t i a t e d if signs of m e n i n g i t i s become evident_ In t h e h e a d injury p a t i e n t , the development of bacter i a l m e n i n g i t i s is r e l a t e d to the presence of d u r a l t e a r a n d C S F fistula. In closed-head injuries, t h e c a u s a t i v e org a n i s m isD. pneumoniae in most cases. 16 In p e n e t r a t i n g , or open, c r a n i a l injuries, the staphylococcus, streptococcus, and g r a m n e g a t i v e o r g a n i s m s a r e commonly the infectious agents. 17 If C S F culture indicates the presence of an uncommon organism, such as a n anaerobe, one should search for a b r a i n abscess or a s m a l l focus of infection in the sinuses or the i n n e r ear. I n v e s t i g a t i o n should e v e n t u a l l y include b r a i n scan and r a d i o g r a p h s of t h e frontal a n d e t h m o i d sinuses, mastoids, petrous bone, and cribriform plate. REFERENCES 1. Makins GH, Abbott FC: On acute primary osteomyelitis of the vertebrae. Ann Surg 23:510-539, 1896. 2. Baker A, Ojemann R, Swartz M, et al: Spinal epidural abscess. N Eng J Med 293:463-468, 1975. 3_ Heusner AP: Non-tuberculous spinal epidural infections. N Eng J Med 239:845-854, 1948. 4. Enberg RN, Kaplan R: Spinal epidural abscess in children. Clin Pediatr 13:247-253, 1974. 5. Batson O: The vertebral vein system.A m J Roent and Rad Ther
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and Nucl Med 78:195-212, 1974. 6. Hancock DO: A study of 49 patients with acute spinal ext r a d u r a l abscess. Paraplegia 10:285-288, 1973. 7. Rosamond E: Epidural abscess complicated by staphylococcal meningitis. J Pediatrics 1:230-238, 1932. 8. Duffy GP: L u m b a r puncture in the presence of raised intracranial pressure. Brit Med J 1:407-409, 1969. 9. Plum F, Petite F: The l u m b a r puncture. N E n g J Med 290:225226, 1974. 10. Brewer N, MacCarty C, Wellman W: Brain abscess: a review of recent experience. A n n Int Med 82:571-576, 1975. 11. Horwitz SR, Halpern S, Leopold G: Brain scans and encephalography in the diagnosis of chronic subdural hematoma. J Neurosurg 40:34%350, 1974.
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12. Feigin R, Shackleford P: Value of repeat l u m b a r puncture i~ the differential diagnosis of meningitis. N E n g J M e d 289"571-573, 1973. 13. Jones HR, Siekert RG, G e r a c h i J E : Neurologic manifestatiea s of bacterial endocarditis. A n n Int Med 71:21-28, 1969. 14. Destaing F, Thierry A, Villand U et al: Meningite a staph. ylocoque: a p r o p o s de deux cas. L y o n Medical 228:577-578, 1972. 15. Shackleford P, Bobinski J, Feigin R, Cherry J: Therapy ot haemophilus influenzae meningitis reconsidered. N E n g J IVied 287:634-638, 1972. 16. H a n d WL, Sanford J: Post-traumatic bacterial meningitis A n n Int Med 72:869-874, 1970. 17. Jones S, Luby JP, Sanford J: Bacterial meningitis complicat. ing cranial-spinal trauma. J Trauma 13:895-900, 1973.
May 1 9 7 6 . J ~ P
Meningitis Missed Judith E. Tintinalli, M D - editor Detroit, Michigan
Tintinalli JE: Meningitis missed. JACEP 5:334-338, May 1976. meningitis, diagnosis; abscess, spinal; lumbar puncture, indications for. INTRODUCTION
mg/100 ml. G r a m stain of the CSF d e m o n s t r a t e d gram positive cocci. The following d a y he died on the medical ward. P o s t m o r t e m d i a g n o s e s w e r e s t a p h y l o c o c c a l lep, t o m e n i n g i t i s a n d lower spinal, s u b d u r a l a n d epidural abscesses.
J u d i t h E. T i n t i n a l l i , MD: The cases for discussion t o d a y are those of two m a l e p a t i e n t s who p r e s e n t e d to t h e e m e r g e n c y d e p a r t m e n t of D e t r o i t G e n e r a l Hospital in t h e s a m e w e e k w i t h c o m p l a i n t s of low back pain. R a l p h D. Cushing, MD, a s s i s t a n t professor of medicine at W a y n e S t a t e U n i v e r s i t y and chief of infectious disease at D e t r o i t G e n e r a l Hospital, will be the discussant.
C a s e N u m b e r T w o . This p a t i e n t was a 58-year-old black m a n who h a d a chief c o m p l a i n t of left-sided back p a i n of s e v e r a l h o u r s ' d u r a t i o n . P h y s i c a l examination and l a b o r a t o r y studies, i n c l u d i n g WBC, urinalysis, and r a d i o g r a p h s of t h e l u m b a r spine, were w i t h i n normal limits. The p a t i e n t was d i s c h a r g e d to the medical clinic for follow-up care.
Case Reports
Three days l a t e r he r e t u r n e d to the e m e r g e n c y departm e n t confused a n d t r e m u l o u s . T h e d i a g n o s i s was del i r i u m t r e m e n s a n d he was t r e a t e d w i t h intravenous fluids, t h i a m i n e and chlordiazepoxide. Twenty-four hours later, while still in the e m e r g e n c y d e p a r t m e n t , he became comatose. His t e m p e r a t u r e rose to 103 F (39.4 C) and his neck was stiff. There were no focal neurologic signs. G r o s s l y p u r u l e n t fluid was o b t a i n e d on lumbar p u n c t u r e w i t h 350,000 white cells/cu mm, all PMNs. CSF glucose was 35 mg/100 ml w i t h a blood glucose of 157 mg/100 ml. G r a m s t a i n of the C S F d e m o n s t r a t e d gram positive cocci. CSF c u l t u r e e v e n t u a l l y showed coagulase positive Staphylococcus aureus: CSF o b t a i n e d by cister-. nal t a p was cloudy with one w h i t e cell a n d no bacteria, glucose of 30 rag/100 ml and p r o t e i n of 700 mg/100 ml. A m y e l o g r a m d e m o n s t r a t e d a functional block at the level of T5 to T8 b u t no s u b d u r a l or e p i d u r a l abscess_ The pa. t i e n t was t r e a t e d w i t h methicillin, i n t r a t h e c a l l y and intravenously, and was d i s c h a r g e d 20 days l a t e r with no neurologic i m p a i r m e n t .
C a s e N u m b e r O n e . The p a t i e n t was a 21-year-old black m a n w i t h a chief c o m p l a i n t of low back p a i n t h a t b e g a n a f t e r he l i f t e d a h e a v y object. He d e n i e d a n y w e a k n e s s or p a r e s t h e s i a of the legs. There was no h i s t o r y of d r u g abuse. On p h y s i c a l e x a m i n a t i o n t h e p o s i t i v e .findings were l u m b a r t e n d e r n e s s and a t e m p e r a t u r e of 101 F (38.3 C). L a b o r a t o r y studies, including white blood count (WBC), u r i n a l y s i s , and r a d i o g r a p h s of t h e l u m b a r spine, were w i t h i n n o r m a l limits. The p a t i e n t was discharged w i t h o u t t r e a t m e n t . T h r e e days l a t e r he r e t u r n e d c o m p l a i n i n g of fever, chills, and dysuria. A t t h a t time, he a p p e a r e d a c u t e l y ill with a t e m p e r a t u r e of 104 F (40.0 C). His neck was supple. T h e r e were no focal neurologic abnormalities_ Left flank t e n d e r n e s s was present. One hour after a d m i s s i o n the p a t i e n t s u d d e n l y developed g a s p i n g r e s p i r a t i o n s and a d i l a t e d left pupil, followed by c a r d i o r e s p i r a t o r y a r r e s t from which he was r e s u s c i t a t e d . F o l l o w i n g arrest, his pupils r e m a i n e d fixed a n d d i l a t e d and his e x t r e m i t i e s were flaccid and hyporeflexic. The p a t i e n t h a d no spont a n e o u s r e s p i r a t i o n s and no response to deep pain. Lumb a r p u n c t u r e was done after t h e a r r e s t w i t h the r e t u r n of t h i c k pus, w i t h 6300 white cells/cu mm, all polymorpho n u c l e a r l e u k o c y t e s (PMN). C e r e b r o s p i n a l fluid (CSF) glucose was 20 mg/100 ml w i t h a blood glucose of 250 From the Emergency Department, Detroit General Hospital, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226.
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R a l p h C u s h i n g , MD: S p i n a l e p i d u r a l abscess is an uncommon disease but, because of the associated mortality and morbidity, it is e x t r e m e l y i m p o r t a n t for the emergency p h y s i c i a n to recognize t h e e n t i t y as e a r l y as p0Ssible_ The p r e s e n t a t i o n of s p i n a l e p i d u r a l abscess as f r a n k m e n i n g i t i s is most u n u s u a l . Note the similarities and differences between our p a t i e n t s and the followin~ case report: ~H.H., male, age 27 years, h a d suffered from a pain i~ the sacral region two weeks before admission. On the last two days he had t h r e e a t t a c k s of s h i v e r i n g and suffering
May 1976"~]~P
from diffuse h e a d a c h e . . . He h a d sudden p a i n in the left hip which d i s a p p e a r e d e n t i r e l y in a few days. On admission, the 14th d a y of his illness, he looked e x t r e m e l y ill. His t e m p e r a t u r e was 104.4 F r e a c h i n g 105.2 F at midnight. The h e a d a c h e was general, with p a i n in the neck on moving the head, the head and shoulders moved stiffly together- The i n n e r edge of the r i g h t optic disk was hazy but his eyes were otherwise n o r m a l . . . . He lay on his back with the left knee flexed and a t t e m p t s to e x t e n d it completely gave severe pain. The knee j e r k on this side was brisk . . . . The n e x t d a y the sacral t e n d e r n e s s and headache w e r e less b u t t h e r e was p a i n down t h e left thigh. On t h e 21st d a y of his illness he lay quiet, m u t t e r ing occasionally and with the left pupil l a r g e r t h a n t h e right- R e t e n t i o n of u r i n e was complete a n d t h e r e was no control of the rectum. He died in the afternoon." Now the p o s t m o r t e m findings: '*The left psoas muscle was much swollen, and its central p a r t h a d b r o k e n down to a large abscess . . . . The transverse process of the l a s t l u m b a r v e r t e b r a was b a r e and necrosed, and from this point t h e r e was free communication from the psoas abscess to the l u m b a r s p i n a l muscles in which an abscess also existed . . . . There was suppuration of the whole loose connective tissue b e t w e e n the d u r a m a t e r and the bones forming t h e spinal canal. Pus and l y m p h were found inside the theca from its lower end up to t h e inferior e x t r e m i t y of the cervical e n l a r g e ment. The cord itself was n o r m a l to the n a k e d eye. The brain a n d its m e m b r a n e s were h e a l t h y with the exception of a little t u r b u l e n t fluid inside the dura. ''1
+~'~,lll, V ~ l 111~Vlldl
IJl~hlJ;~
F i g . 1. Vertebral venous system (Adapted from G r a n t ' s A t l a s of A n a t o m y . J. C. Boileau Grant, ed 6, Baltimore,
Williams and Wilkins Co, 1972, Fig 390)
Posterior spinal aa.~. : :~:;:: .:.'~ : . ( . :
This i n t e r e s t i n g case report, along w i t h a review of 21 others, was w r i t t e n in 1896. Of t h e 21 cases, 11 died w i t h meningitis a n d v e r t e b r a l osteomyelitis. This, then, represents the n a t u r a l h i s t o r y of u n t r e a t e d s p i n a l e p i d u r a l abscess.
Pathophysiology Spinal e p i d u r a l abscess can develop in several ways: (1) by h e m a t o g e n o u s spread; (2) by direct extension from vertebral osteomyelitis; (3) by direct inoculation. H e m a t o g e n o u s spread is by far the commonest source of e p i d u r a l abscess,2, 3 especially in children. 4 T h e r e a r e two circulatory systems involved in the pathophysiology of spinal disease: the venous plexus of Batson, and the spinal a r t e r i e s (Figures 1 and 2). Batson's veins are located in the e p i d u r a l space (Figure 3), and anastomose with thoracic and a b d o m i n a l veins at each spinal segraent7 D u r i n g V a l s a l v a ' s m a n e u v e r , blood shunts from the thoracic and a b d o m i n a l veins into the p e r i v e r t e b r a l plexus. Batson's veins are p a r t i c u l a r l y i m p o r t a n t in t h e dissemination of c a r c i n o m a of the prostate and breast, accounting for t h e i r frequent m e t a s t a s i s to the spine. In the case of spinal e p i d u r a l abscess, it has been postulated t h a t b a c t e r i a from the u r i n a r y t r a c t invade t h e prostate gland, or the pelvic viscera, and gain e n t r y into the p e r i v e r t e b r a l plexus of Batson, where the e p i d u r a l space is seeded. However, the commonest p a t h o g e n in s p i n a l a b s c e s s is t h e s t a p h y l o c o c c u s , w h i l e t h e Staphylococcal u r i n a r y t r a c t infection is rare. Pyogenic infection reaches the spine most often by systemic dissemination m t h e a r t e r i a l circulation.
J~P
May 1976
\Anterior sp,no~ uu Segmental arteries F i g . 2. Arterial supply of the spinal cord (Adapted from A n a t o m y . Gardner, Gray, and O'Rahilly, ed 3, Saunders,
1969, p 557) Dr. T i n t i n a l l i : The blood-borne o r g a n i s m proliferates on the surface of the dura, u s u a l l y the posterior surface, as the fatty tissue t h e r e offers l i t t l e resistance to spread of the organism. Anteriorly, the d u r a is closely a d h e r e n t to the spinal ligaments. Abscesses occur more commonly at the level of the thoracic and l u m b a r vertebrae, where the v e r t e b r a l c a n a l is l a r g e s t . O n c e e s t a b l i s h e d in t h e e p i d u r a l space, the infection can spread p a r a v e r t e b r a l l y or a l o n g i n t e r m u s c u l a r planes. R u p t u r e into the suba r a c h n o i d space with r e s u l t a n t m e n i n g i t i s is rare. Direct e x t e n s i o n from o s t e o m y e l i t i s occurs in 10% to 40% of a d u l t cases.~, 6 Direct inoculation can occur from l u m b a r p u n c t u r e if p u n c t u r e is done t h r o u g h a burn, cellulitis, or in the presence of otherwise i n a d e q u a t e sterile technique, or from p e n e t r a t i n g t r a u m a . B l u n t t r a u m a m a y be con-
Volume 5 Number 5 Page 335
.•/•ff
Su barachnoid space
Spina~l ~ nerve Vertebral~ body
~~Arachnoid ~.J'C--~Dura mater ~ ~
Epidural space
F i g . 3. Cross section of the spinal cord demonstrating the relationships of the dura mater (Adapted from A n a t o m y .
Gardner, Gray, and O'Rahilly, 1969, ed 3, Saunders, 1969, p 557)
t r i b u t o r y to t h e f o r m a t i o n of spinal e p i d u r a l abscess in t h a t a r e s u l t a n t h e m a t o m a provides an excellent c u l t u r e m e d i u m for t h e growth of bacteria, s Dr. C u s h i n g : The two p a t i e n t s presented today most l i k e l y h a d p r i m a r y staphylococcal b a c t e r e m i a , with t h e development of an e p i d u r a l focus of staphylococcal infection. The abscess t h e n r u p t u r e d across the dura, eventually producing m e n i n g i t i s . The e n t r y of the o r g a n i s m in Case N u m b e r One was p r o b a b l y secondary to i n t r a v e n ous heroin Use, a n historical point well e s t a b l i s h e d after the p a t i e n t ' s death_ In Case N u m b e r Two t h e point of e n t r y of the o r g a n i s m is not evident. The skin, or a n y p a r e n c h y m a l focus of infection, can be the source of bacteremia. The staphylococcus is the commonest c a u s a t i v e organism, b u t the streptococcus and anaerobic or g r a m n e g a t i v e o r g a n i s m s are b e i n g found w i t h i n c r e a s i n g frequency3
R a d i o g r a p h s of the clinically affected a r e a of the spi~ should also be obtained on initial, e v a l u a t i o n . However, unless v e r t e b r a l osteomyelitis is present, or unless the abscess h a s d i s s e c t e d a l o n g t h e psoas musctes, radiQ, g r a p h s are not helpful in the diagnosis of s p i n a l epidural abscess. If, on the basis of p h y s i c a l e x a m i n a t i o n , a spinal abscess is suspected, m y e l o g r a p h y should be performed. A s a m p l e of CSF can be o b t a i n e d at m y e l o g r a p h y or fro~ c i s t e r n a l tap. It is i m p o r t a n t to avoid i n v a s i v e procedures at t h e abscessed a r e a since d i s s e m i n a t i o n of ~nfecti0~ and m e n i n g i t i s could r e s u l t 3 S p i n a l e p i d u r a l abscess is a surgical emergency. Treat, m e n t consists of laminectomy, d r a i n a g e of the abscess, and a d m i n i s t r a t i o n of a p p r o p r i a t e antibiotics. Q U E S T I O N : What do you consider contraindications to lumbar puncture ? Dr. C u s h i n g : A l u m b a r p u n c t u r e is i n d i c a t e d whenever t h e r e is suspicion of c e n t r a l nervous s y s t e m infection. Be. fore one reaches the point of l u m b a r puncture, a history, physical e x a m i n a t i o n , and n-eurologic e v a l u a t i o n should be p e r f o r m e d and skull r a d i o g r a p h s should be obtained. A n a b s o l u t e c o n t r a i n d i c a t i o n to l u m b a r p u n c t u r e is the p r e s e n c e of a b u r n , abscess, or c e l l u l i t i s in t h e area t h r o u g h w h i c h p u n c t u r e is t o be a t t e m p t e d . If papill e d e m a is present, l u m b a r p u n c t u r e should be performed cautiously. A small gauge s p i n a l needle should be used and a m i n i m u m a m o u n t of f l u i d o b t a i n e d . One must weigh the possibility of o b t a i n i n g vital i n f o r m a t i o n from l u m b a r p u n c t u r e versus the possibility of b r a i n hernia. tion as a r e s u l t of the procedure, s L u m b a r p u n c t u r e should be a v o i d e d especially in those p a t i e n t s w i t h focal n e u r o l o g i c a l signs w h e r e a spaceoccupying i n t r a c r a n i a l lesion is s u s p e c t e d 2 In such cases, e l e c t r o e n c e p h a l o g r a p h y , b r a i n scan and flow study, or, a n g l o g r a p h y should be performed before l u m b a r puncture is attempted_ It is especially h a z a r d o u s to perform lure. b a r p u n c t u r e on the p a t i e n t w i t h b r a i n abscess_ CSF find. ings in this i n s t a n c e are not u s u a l l y informative. 1°
Clinical Features
The c o m b i n a t i o n of b a c k p a i n and fever should arouse in the e m e r g e n c y p h y s i c i a n the suspicion of several diagnoses: m e n i n g i t i s , p y e l o n e p h r i t i s , s p i n a l abscess, r e t r o p e r i t o n e a l t u m o r or abscess, v e r t e b r a l body or d i s k space infection, or t r a n s v e r s e myelitis. The clinical picture of spinal abscess progresses from spinal ache, to root pain, to motor w e a k n e s s and f i n a l l y paralysis. I n i t i a l e v a l u a t i o n of the p a t i e n t w i t h back p a i n and fever should include a careful and complete neurological e x a m i n a t i o n . In acute disease, once root p a i n has developed, it m a y t a k e o n l y a few d a y s to p r o g r e s s to paralysis. Root p a i n is i n v a r i a b l y accompanied by e i t h e r deep t e n d o n r e f l e x c h a n g e s or p a r e s t h e s i a s _ T h e dev e l o p m e n t of p a r a l y s i s carries an ominous prognosis. The presence of a n o r m a l w h i t e count should not give t h e p h y s i c i a n a false sense of security. It m a y be that, at first, the abscess was so well localized t h a t a leukocytosis was not affected. The o t h e r p o s s i b i l i t y is t h a t b o t h of these p a t i e n t s were not completely h e a l t h y a n d were unable to produce a w h i t e count response or p r e v e n t diss e m i n a t i o n of infection.
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Q U E S T I O N : How valuable is echoencephalography? Dr. C u s h i n g : E c h o e n c e p h a l o g r a p h y can detect a mid. line shift of t h e t h i r d ventricle. D e p e n d i n g on the skill of the technician, a l a t e r a l shift of as little as 3 m m can be sig. nificant. A d i s a d v a n t a g e of the t e c h n i q u e is t h a t bilateral s u p r a n t e n t o r i a l lesions and i n f r a t e n t o r i a l lesions will go u n d e t e c t e d if t h e r e is no d i s p l a c e m e n t of the t h i r d ventricle. If the e c h o e n c e p h a l o g r a m is positive, the n e x t step is angiography. If negative, the p a t i e n t should be closely monitored and t h e s t u d y r e p e a t e d l a t e r if clinically indicated.// T h e r e are s e v e r a l points of i n f o r m a t i o n to be obtained from a s a m p l e of CSF. The opening pressure, color and t u r b i d i t y should be noted. A g r a m s t a i n should be performed in every case of suspected meningitis. The aliquot 0f spinal fluid should be centrifuged, the s u p e r n a t a n t dis' carded, and the p r e c i p i t a t e r e s u s p e n d e d and-stained. The crystal violet m u s t be freshly filtered before each use or dye crystals will a p p e a r as g r a m positive cocci a n d bacilli over the e n t i r e slide_ The presence of five or more white blood cells in the CSF is a b n o r m a l a n d a cell count of 1000 or g r e a t e r w i t h a predominance of P M N s is h i g h l y suspicioUS
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of bacterial m e n i n g i t i s . In t h e first few hours of b a c t e r i a l meningitis t h e r e m a y be no cells in the CSF b u t g r a m s t a i n will u s u a l l y r e v e a l the presence of bacteria. A predominance of lymphocytes in t h e CSF is compatible w i t h v i r a l or g r a n u l o m a t o u s m e n i n g i t i s . I n h y p e r a c u t e t u b e r c u louS m e n i n g i t i s , h o w e v e r , p o l y m o r p h o n u c l e a r l e u k o cytes m a y i n i t i a l l y p r e d o m i n a t e .
d e n c e i n c r e a s e s w i t h i n c r e a s i n g age. M e n i n g o c o c c a l m e n i n g i t i s decreases in incidence w i t h i n c r e a s i n g age, a n d in older, d e b i l i t a t e d individuals, the pneumococcus is proba b l y t h e c o m m o n e s t c a u s e of b a c t e r i a l m e n i n g i t i s . Staphylococcal m e n i n g i t i s occurs most commonly second a r y to b a c t e r i a l e n d o c a r d i t i s , 14 or p e n e t r a t i n g h e a d trauma.
CSF p r o t e i n will be e l e v a t e d in all i n f l a m m a t o r y processes. N o r m a l C S F glucose is two-thirds of the blood glucose. A glucose t e s t should a l w a y s be d r a w n at t h e t i m e of lumbar p u n c t u r e for comparison. In b a c t e r i a l and t u b e r c u l o u s meningitis t h e C S F glucose is low unless the p a t i e n t has been p a r t i a l l y treated. W i t h other fungal m e n i n g i d i t e s , the glucose is u s u a l l y low b u t occasionally can be normal. In viral m e n i n g i t i s , glucose is normal, except for m u m p s and herpes, which can occasionally cause a low glucose.
The d r u g of choice for a p r e v i o u s l y h e a l t h y a d u l t with n o n h o s p i t a l acquired p u r u l e n t m e n i n g i t i s is penicillin, one million units every two hours i n t r a v e n o u s l y . An a l t e r n a tive drug is ampicillin, 12 gms i n t r a v e n o u s l y per day, since t h e r e is a 10% chance ofH. influenzae b e i n g the c a u s a t i v e agent. If the p a t i e n t is elderly, t h e n ampicillin, not penicillin, m a y be t h e drug of choice.
Given the following spinal fluid findings, w h a t is the diagnosis: 45 w h i t e cells, 50% PMNs; CSF glucose of 15 rag/100 ml a n d blood glucose of 100 mg/100 ml; CSF p r o t e i n of 60; g r a m s t a i n w i t h no o r g a n i s m s identifiable. The pat i e n t has been stuporous for two days and has never h a d antibiotics_ T h e r e are no focal neurologic findings.
ANSWER: Early bacterial meningitis. Dr. C u s h i n g : Most u n l i k e l y with a r a t h e r even distribution b e t w e e n lymphocytes and PMNs. In e a r l y b a c t e r i a l meningitis, even if t h e r e a r e only a few cells in the CSF, they are p r e d o m i n a n t l y PMNs. In addition, even if t h e r e are no cells in t h e CSF, the g r a m s t a i n will u s u a l l y r e v e a l organisms.
ANSWER: Tuberculous meningitis. Dr. C u s h i n g : Tuberculous or other fungal m e n i n g i t i s is likely even if the acid-fast s t a i n is negative. However, a definitive diagnosis cannot be m a d e in the e m e r g e n c y department.
ANSWER: Viral meningoencephalitis. Dr. C u s h i n g : V i r a l m e n i n g o e n c e p h a l i t i s is possible although a low CSF glucose m a k e s it unlikely. E a r l y aseptic meningitis may present with a polymorphonuclear leukocytosis b u t over the next 8 hours the cellular C S F population will become p r e d o m i n a n t l y lymphocytic_ 12 But in any case, t h e presence of a low CSF glucose m a k e s a v i r a l etiology unlikely.
ANSWER: Mycotic aneurysm. Dr. C u s h i n g : The complication of mycotic a n e u r y s m occurs in 2% to 10% of p a t i e n t s w i t h b a c t e r i a l endocarditis. 13 Red cells are p r e s e n t in t h e CSF and t h e r e are almost a l w a y s focal neurologic findings.
ANSWER: Brain abscess. Dr. C u s h i n g : B r a i n abscess is possible except for t h e finding of low CSF glucose. Unless the abscess has r u p t u r e d into the s u b a r a c h n o i d space and produced m e n i n g i t i s , CSF glucose will be normal. The commonest causes of b a c t e r i a l m e n i n g i t i s in the adult are HemophiIus influenzae, Diplococcus (Streptococcus) pneumoniae, andNeisseria meningitidis_ H. influenzae accounts for less t h a n 10% of a d u l t m e n i n g i t i s b u t its inci-
J ~ F ) May 1976
Q U E S T I O N : W h a t is the role o f chloramphenicol in the treatment o f meningitis ? Dr. C u s h i n g : C h l o r a m p h e n i c o l is the d r u g of choice for t h e t r e a t m e n t of b a c t e r i a l m e n i n g i t i s in t h e p a t i e n t w i t h a n a p h y l a x i s to penicillin. The dose is 4 gm i n t r a venously per day. A m p i c i l l i n r e s i s t a n t H. influenzae is s t i l l u n c o m m o n , b u t some s o u r c e s a d v i s e t h e use of chloramphenicol in suspected h e m o p h i l u s m e n i n g i t i s as i n i t i a l t h e r a p y until sensitivities return. ~s Q U E S T I O N : Is there any role for steroids in the treatment of meningitis ? Dr. Cushing: S t e r o i d s a r e i n d i c a t e d in t h e W a t e r h o u s e - F r i d e r i c h s e n syndrome, m e n i n g i t i s with septic shock, a n d in t u b e r c u l o u s m e n i n g i t i s . The use of s t e r o i d s in p n e u m o c o c c a l m e n i n g i t i s is c o n t r o v e r s i a l a n d I do not r e c o m m e n d it as a routine measure. Q U E S T I O N : Do you advocate prophylactic antibiotic t r e a t m e n t for s k u l l f r a c t u r e s w i t h cerebrospinal C S F rhinorrhea or otorrhea? Dr. C u s h i n g : No. The p a t i e n t should be followed closely a n d t r e a t m e n t i n i t i a t e d if signs of m e n i n g i t i s become evident_ In t h e h e a d injury p a t i e n t , the development of bacter i a l m e n i n g i t i s is r e l a t e d to the presence of d u r a l t e a r a n d C S F fistula. In closed-head injuries, t h e c a u s a t i v e org a n i s m isD. pneumoniae in most cases. 16 In p e n e t r a t i n g , or open, c r a n i a l injuries, the staphylococcus, streptococcus, and g r a m n e g a t i v e o r g a n i s m s a r e commonly the infectious agents. 17 If C S F culture indicates the presence of an uncommon organism, such as a n anaerobe, one should search for a b r a i n abscess or a s m a l l focus of infection in the sinuses or the i n n e r ear. I n v e s t i g a t i o n should e v e n t u a l l y include b r a i n scan and r a d i o g r a p h s of t h e frontal a n d e t h m o i d sinuses, mastoids, petrous bone, and cribriform plate. REFERENCES 1. Makins GH, Abbott FC: On acute primary osteomyelitis of the vertebrae. Ann Surg 23:510-539, 1896. 2. Baker A, Ojemann R, Swartz M, et al: Spinal epidural abscess. N Eng J Med 293:463-468, 1975. 3_ Heusner AP: Non-tuberculous spinal epidural infections. N Eng J Med 239:845-854, 1948. 4. Enberg RN, Kaplan R: Spinal epidural abscess in children. Clin Pediatr 13:247-253, 1974. 5. Batson O: The vertebral vein system.A m J Roent and Rad Ther
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and Nucl Med 78:195-212, 1974. 6. Hancock DO: A study of 49 patients with acute spinal ext r a d u r a l abscess. Paraplegia 10:285-288, 1973. 7. Rosamond E: Epidural abscess complicated by staphylococcal meningitis. J Pediatrics 1:230-238, 1932. 8. Duffy GP: L u m b a r puncture in the presence of raised intracranial pressure. Brit Med J 1:407-409, 1969. 9. Plum F, Petite F: The l u m b a r puncture. N E n g J Med 290:225226, 1974. 10. Brewer N, MacCarty C, Wellman W: Brain abscess: a review of recent experience. A n n Int Med 82:571-576, 1975. 11. Horwitz SR, Halpern S, Leopold G: Brain scans and encephalography in the diagnosis of chronic subdural hematoma. J Neurosurg 40:34%350, 1974.
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12. Feigin R, Shackleford P: Value of repeat l u m b a r puncture i~ the differential diagnosis of meningitis. N E n g J M e d 289"571-573, 1973. 13. Jones HR, Siekert RG, G e r a c h i J E : Neurologic manifestatiea s of bacterial endocarditis. A n n Int Med 71:21-28, 1969. 14. Destaing F, Thierry A, Villand U et al: Meningite a staph. ylocoque: a p r o p o s de deux cas. L y o n Medical 228:577-578, 1972. 15. Shackleford P, Bobinski J, Feigin R, Cherry J: Therapy ot haemophilus influenzae meningitis reconsidered. N E n g J IVied 287:634-638, 1972. 16. H a n d WL, Sanford J: Post-traumatic bacterial meningitis A n n Int Med 72:869-874, 1970. 17. Jones S, Luby JP, Sanford J: Bacterial meningitis complicat. ing cranial-spinal trauma. J Trauma 13:895-900, 1973.
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