What is the proper workup for an elderly patient with headache, mildly compromised coordination, and low-grade fever that progressed to vomiting and hyperpyrexia over 4 days?

From the Guidelines

The proper workup for an elderly patient with headache, mildly compromised coordination, and low-grade fever that progressed to vomiting and hyperpyrexia over 4 days should prioritize ruling out bacterial meningitis, with a focus on prompt cerebrospinal fluid (CSF) analysis and empiric antimicrobial therapy initiation within one hour of suspicion, as recommended by the ESCMID guideline 1. The initial evaluation should include a complete neurological examination, vital signs monitoring, and laboratory tests such as complete blood count, comprehensive metabolic panel, blood cultures, and inflammatory markers (ESR, CRP).

• Key considerations in the diagnostic workup include:
  • Neuroimaging with CT or MRI of the brain to rule out mass lesions or increased intracranial pressure, particularly in patients with severely altered mental status, focal neurologic deficits, new-onset seizures, or a severe immunocompromised state 1.
  • Lumbar puncture for CSF analysis, which remains the principal contributor to the final diagnosis of bacterial meningitis, examining for cell count, protein, glucose, Gram stain, culture, viral PCR, and cryptococcal antigen 1.
• Empiric antimicrobial therapy should be initiated promptly, typically with broad-spectrum antibiotics such as ceftriaxone and vancomycin, and antiviral agents like acyclovir, pending culture results 1.
• Supportive care, including antipyretics like acetaminophen and antiemetics such as ondansetron, should be provided to manage symptoms like fever and vomiting. The patient requires close monitoring in a hospital setting with frequent neurological checks and vital sign monitoring, as the constellation of symptoms suggests a potentially life-threatening central nervous system infection, which carries high mortality if not promptly diagnosed and treated, particularly in elderly patients who may present with atypical symptoms and have less physiological reserve 1.

From the Research

Proper Workup for Elderly Patient with Headache and Fever

The proper workup for an elderly patient with headache, mildly compromised coordination, and low-grade fever that progressed to vomiting and hyperpyrexia over 4 days involves a thorough diagnostic approach.

• The patient's symptoms, such as headache, fever, and vomiting, could be indicative of meningitis, a serious infection that requires prompt diagnosis and treatment 2, 3.
• A lumbar puncture (LP) is a crucial diagnostic tool in this scenario, as it allows for the analysis of cerebrospinal fluid (CSF) to determine the presence of infection or inflammation 2.
• However, before performing an LP, a computed tomography (CT) scan of the head may be necessary to rule out any space-occupying lesions or other abnormalities that could contraindicate the procedure 4.
• The clinical features that are associated with an abnormal finding on CT of the head include an age of at least 60 years, immunocompromise, a history of central nervous system disease, and a history of seizure within one week before presentation 4.
• If the CT scan is normal, an LP can be performed to collect CSF for analysis, including cell count, protein level, and glucose level, as well as culture and polymerase chain reaction (PCR) to identify the causative organism 2, 3.

Diagnostic Considerations

• The diagnosis of meningitis is based on the analysis of CSF, and the results must be interpreted in the context of the patient's clinical presentation 2, 3.
• The presence of blood in the CSF can be a reliable predictor of subarachnoid hemorrhage, but it takes several hours to develop, and traumatic tap or subarachnoid hemorrhage can artificially increase the white blood cell count and protein level, confounding the diagnosis 2.
• The white blood cell differential may be misleading early in the course of meningitis, and culture is the gold standard for determining the causative organism, although PCR is much faster and more sensitive in some circumstances 2, 3.

Management and Treatment

• The management and treatment of the patient will depend on the diagnosis and the severity of the symptoms, and may involve antibiotics, antiviral medications, or other treatments as needed.
• It is essential to monitor the patient's condition closely and adjust the treatment plan as necessary to ensure the best possible outcome.