Discussion

The patient’s medical history, examination findings, and test results suggest a diagnosis of meningitis. This patient’s case demonstrates that a normal complete blood count  should never be used alone to rule out a serious infection; even if the patient’s white blood cell (WBC) count is normal, the percentage of polymorphonuclear neutrophils may be elevated at >70%.  Lumbar puncture was performed and revealed normal protein and glucose levels with 45 WBC/hpf consisting mostly of lymphocytes.

In the setting of a positive lumbar puncture, computed tomography (CT) of the brain should be performed to rule out brain abscess, which can cause cerebrospinal fluid pleocytosis. The Swedish guidelines for CT before lumbar puncture include an indication for CT if symptoms last >4 days.2

The patient underwent CT of the brain (Figure), which demonstrated sphenoid sinusitis with osteomyelitis and a small epidural brain abscess.  The next best step in treatment is to admit the patient and refer for neurosurgical consultation.

Although bacterial sinusitis is a common condition, it occurs far less frequently than viral sinusitis and is often overdiagnosed and overtreated unnecessarily with antibiotics. In this case, the patient has a form of complicated sinusitis, which occurs most often in children. The patient’s pediatrician made the correct diagnosis, avoided unnecessary imaging, and chose a good first-line antibiotic.  Unfortunately, this case ended up being one of treatment failure. 

Fortunately, complications of sinusitis are rare; when they do occur, they are more common with frontal or sphenoid sinusitis as seen in this case.  In addition to meningitis, osteomyelitis, and brain abscess, other complications of sinusitis include orbital cellulitis, cavernous venous sinus thrombosis, and Pott puffy tumor. See the table below for more information on sinusitis.  

Key takeaways from this case:

  • For meningitis, the jolt sign is very sensitive but only about 50% specific. To perform this examination, have the patient to rotate his or her head rapidly from side to side and ask if the movement worsens the pain significantly.  In patients who cannot cooperate and have not had a recent neck injury, manually rotate their head for them. 
  • Suspect treatment failure, complicated disease, or an incorrect diagnosis if there is no improvement in an infection after 48 hours of appropriate antibiotic therapy. 
  • Most patients do not need to undergo CT prior to lumbar puncture. Unnecessary CT is associated with delays to treatment, radiation exposure, and increased healthcare cost.  Clinicians should refer to the Swedish guidelines to determine appropriate use of CT prior to lumbar puncture.2 These guidelines include the significant criterion of symptom duration >4 days, which is clinically relevant as most cases of meningitis present with symptom duration <4 days.  A more indolent presentation should raise suspicion for other conditions that may mimic meningitis, especially brain abscess.

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

References

  1. Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. EMresource.org. 2017;5.
  2. Glimaker M, Sjolin J, Akesson S, Naucler P. Lumbar puncture performed promptly or after neuroimaging in acute bacterial meningitis in adults: a prospective national cohort study evaluating different guidelines. Clin Infect Dis. 2018;66(3):321-328.