From the Research
The appropriate inpatient workup for a 26-year-old patient with new onset urticarial rash, weakness, and nuchal rigidity should focus on ruling out meningitis, particularly meningococcal meningitis, as the constellation of symptoms suggests a serious central nervous system infection. Begin with immediate blood cultures, complete blood count, comprehensive metabolic panel, and C-reactive protein/ESR to assess for systemic inflammation, as suggested by general medical principles and not specifically addressed in 1, 2, 3, 4, or 5. Perform a lumbar puncture to analyze cerebrospinal fluid for cell count, protein, glucose, Gram stain, and culture. Order a head CT scan before lumbar puncture if there are concerns about increased intracranial pressure. Include a skin biopsy of the urticarial lesions to evaluate for vasculitis or other dermatologic conditions. Empiric antibiotic therapy should be initiated immediately with ceftriaxone 2g IV every 12 hours plus vancomycin 15-20 mg/kg IV every 8-12 hours, pending culture results. Add acyclovir 10 mg/kg IV every 8 hours if viral encephalitis is suspected. The nuchal rigidity (neck stiffness) is a classic sign of meningeal irritation, while the combination with rash and weakness raises concern for meningococcemia or other bacterial meningitis, which is a life-threatening condition that requires urgent treatment, as delay could lead to rapid deterioration, septic shock, or death, although not directly discussed in the provided studies 1, 2, 3, 4, 5. Isolation precautions should be implemented until meningococcal disease is ruled out. Key considerations in the workup and treatment are based on the clinical presentation and the potential for severe outcomes if not promptly addressed, prioritizing the patient's morbidity, mortality, and quality of life. Given the acute presentation and potential severity, the most recent and highest quality studies may not directly apply, but the principles of urgent evaluation and treatment for potential life-threatening conditions guide the approach. In this scenario, while 3 discusses anaphylaxis in cold-induced urticaria and 2 provides an overview of acute and chronic urticaria, the immediate concern for meningitis and sepsis takes precedence, necessitating a focused and rapid diagnostic and therapeutic approach.