What is the workup for an 18-year-old female with fever, chills, neck pain, headache, sore throat, and congestion?

Emergency Department Workup for an 18-Year-Old Female with Fever, Chills, Neck Pain, Headache, Sore Throat, and Congestion

Bacterial meningitis should be the primary concern and requires immediate lumbar puncture for diagnosis, unless contraindications are present, as these symptoms strongly suggest possible meningitis despite the absence of the complete classic triad.1

Initial Assessment

• Evaluate for the presence of fever, headache, neck stiffness, altered mental status, and rash, as these are common manifestations of bacterial meningitis, though classic signs may be absent in many cases 1, 2
• Document vital signs with particular attention to fever, which is present in 77-97% of adult meningitis cases 1, 2
• Assess for neck stiffness, which has low sensitivity (65-83% in adults) but is an important clinical sign when present 1, 2
• Evaluate for altered mental status, which occurs in 30-69% of adult meningitis cases 1, 2
• Check for the presence of rash, particularly petechial or purpuric, which is indicative of meningococcal infection in over 90% of cases when present 1

Diagnostic Workup

Immediate Actions

• Arrange rapid admission to hospital via emergency ambulance if meningitis is suspected in the community setting 1
• Do not rely on Kernig's sign and Brudzinski's sign for diagnosis as they have low sensitivity (Kernig 11%, Brudzinski 9% in adults) 1, 2
• Consider that the classic triad of fever, neck stiffness, and altered mental status is present in less than 50% of bacterial meningitis cases 1

Laboratory Tests

• Complete blood count with differential to assess for leukocytosis 3
• Blood cultures before initiating antibiotics 3
• Cerebrospinal fluid (CSF) examination via lumbar puncture is essential unless contraindications are present 1
• CSF should be tested for:
  • Cell count and differential
  • Protein and glucose levels
  • Gram stain and culture
  • PCR for viral pathogens (enterovirus, HSV-1, HSV-2, VZV) 1

Imaging

• Brain imaging (CT or MRI) should be performed before lumbar puncture if the patient presents with:
  • Altered mental status
  • Focal neurological deficits
  • Papilledema
  • History of immunocompromising conditions or CNS disease 3

Differential Diagnosis

Bacterial Meningitis

• Consider this diagnosis even without the complete classic triad of symptoms 1
• Most common causative organisms in this age group are Neisseria meningitidis and Streptococcus pneumoniae 3

Viral Meningitis

• Patients present with meningism (neck stiffness, headache, photophobia) 1
• May have additional non-specific symptoms such as diarrhea, vomiting, muscle pain, and sore throat 1, 4
• Most common viral causes are enteroviruses and herpes viruses (HSV-2 and VZV) 1

Influenza

• Characterized by abrupt onset of fever, myalgia, headache, rhinitis, sore throat, and cough 5
• Diagnosis should be made clinically, and antiviral therapy should be considered 5

COVID-19

• May present with fever, cough, and respiratory symptoms 1
• Can have neurological manifestations in some cases 1

Lyme Disease with Meningitis

• Consider in endemic areas, especially with history of tick exposure 1
• May present with more severe initial symptoms when coinfection with Babesia or Anaplasma is present 1

Management Approach

• If bacterial meningitis is suspected, do not delay treatment waiting for laboratory confirmation 3
• In countries where ceftriaxone-resistant S. pneumoniae exceeds 1%, empiric therapy should include vancomycin and ceftriaxone 3
• For suspected viral meningitis, CSF PCR testing for enteroviruses, HSV-1, HSV-2, and VZV is recommended 1
• For influenza-like symptoms, consider oseltamivir if within 48 hours of symptom onset, especially in high-risk patients 6, 5

Important Considerations

• Bacterial meningitis can present with non-specific symptoms, and absence of classic signs should not rule out the diagnosis 1, 4
• The sensitivity of clinical signs alone is poor for diagnosing meningitis, necessitating CSF examination 2
• Headache associated with aseptic meningitis is typically severe, bilateral, and may be of abrupt onset 7
• Early recognition and treatment of bacterial meningitis is crucial to reduce mortality and neurological sequelae 3, 8