The conclusion to the story…
The patient continues to recover on the way to the hospital, recalling more and more information. When you get to the ED, the patient is transferred over to a ED bed. CT, MRI, and labs are drawn and before you leave the patient is completely back to normal, asking about the event.
The next day you are notified by the infection control officer that the patient was admitted with meningitis.
Meningitis is a dangerous infection and resulting inflammation of the meninges, a surrounding layer of the brain. It can be caused by multiple sources: viral, bacterial, micro-organisms and even some drugs will all cause meningitis.
The three layers surrounding the brain make up the meninges: the pia mater, arachnoid mater, and dura mater. Along with cerebrospinal fluid, these insulate the protect the brain inside the skull. Regardless of type, the meninges may become infected either through the bloodstream or through direct contact through mucous membranes or unbroken skin. The inflammatory response and subsequent symptoms are a result of the body’s immune system attacking the intruder in the central nervous system. As a result of the release of cytokines, the blood brain barrier before permeable, resulting in cerebral edema. The edema and decreased blood pressure from the infection cause hypoperfusion to the brain, resulting automated cell death (apoptosis)
The presenting symptoms almost usually include a severe headache, sudden high fever, and nuchal rigidity (stiff or sore neck) and occasionally altered mental status, but the likelihood of the first three symptoms appearing together is only around 45%. Other symptoms include photophobia and phonophobia (inability to tolerate loud noises). Meningococcal meningitis can be distinguished from other sources by the presence of a petechial rash. As in our case, seizures may occur when ICP rises or an area of the brain becomes inflamed.
Bacterial meningitis is extremely common in newborns in the first week of life, with the common cause being a type of strep that inhibits the vagina as well as the E. coli bacteria. In adults, 80% of all cases are caused by two different bacteria. Viral meningitis is most often caused by enteroviruses, herpes simplex type II, vericella zoster (commonly called chickenpox), mumps, HIV, and LCMV (a rodent borne virus). Drugs such as NSAIDS and certain antibiotics may cause meningitis, as well as cancer.
SHOCKER! I never considered infection either. My differential included all the usual suspects, including a long shot of drug use despite lack of evidence to the same. The treatment modality in the prehospital should focus on the management of the symptoms since we can not correct this in the field. Patients may present with hypotension, seizures, high fever, and altered mental status. Fluid resuscitation is a must in any case where an infection is present with hypotension, and we should manage seizures using an anticonvulsant. Should fluid alone fail to control the blood pressure, certain vasopressors like dopamine may be used to maintain a mean arterial pressure (MAP) of between 65 mmHg and 90 mmHg. The airway should be aggressively managed if the patient is close to unconsciousness or is in danger of respiratory failure.