Review Question - QID 206231

The patient presents with petechial rash and Kernig's sign consistent with likely meningococcal meningitis. Blood cultures should be obtained prior to initiation of antimicrobial therapy.

Meningococcal meningitis is common in college students and others living in close quarters, such as military recruits. Symptoms include headache, fever, neck stiffness, photophobia, and altered mental status. Petechial rash is present in over half of patients with meningococcal disease, though Haemophilus influenzae and pneumococcus may present with petechial rash as well.

Bamberger reviews management of meningitis. Kernig's sign, in which extension of the knee while both the knee and thigh are flexed produces pain, is poorly sensitive but highly specific for bacterial meningitis. The cardinal features of meningitis, fever, neck stiffness, and altered mental status, are present in 99 to 100% of patients with disease.

Kimmel reviews prevention of meningococcal meningitis. The FDA recommends that the meningococcal vaccine be given to 11 and 12 year-olds, adolescents entering high school, and college freshmen living in dormitories. Prophylactic rifampin, ciprofloxacin, or ceftriaxone should be given to household and close contacts of affected patients.

Illustration A demonstrates a Gram stain of meningococci from a culture of cerebral spinal fluid. Meningococci are Gram negative diplococci.

Incorrect Answers:
Answer 1 and 4: Imaging of the head should be performed in patients with signs of central nervous system changes or new onset seizures. CT is preferred to MRI.
Answers 2 and 5: Appropriate empiric therapy for meningitis in a healthy adult is vancomycin and ceftriaxone.
Remember: Blood cultures should always be obtained prior to administration of antimicrobial therapy when bacterial infection is suspected, unless they would cause a substantial delay in antibiotic administration.