What is the best course of action for a patient with sudden onset of high fever, severe headache, and vomiting?

Management of Acute Febrile Illness with Severe Headache and Vomiting

This patient requires immediate hospital admission with urgent diagnostic workup to exclude life-threatening infections, particularly meningitis, malaria, and tick-borne rickettsial diseases, followed by empirical antimicrobial therapy if indicated. 1, 2

Immediate Actions Required

Hospital Admission Criteria Met

• All patients with suspected meningitis or severe systemic infection must be referred to hospital for urgent evaluation and consideration of lumbar puncture. 1
• Rapid admission via emergency transport should be arranged so the patient arrives within one hour of assessment. 1
• This patient meets multiple criteria: high fever (39.2°C), severe headache (10/10 retroorbital to frontal), vomiting, and body malaise requiring immediate evaluation. 1, 2

Critical Initial Assessment

• Document presence or absence of headache, altered mental status, neck stiffness, fever, rash, seizures, and signs of shock immediately. 1
• Current examination shows: fever (37.8°C on admission), negative Brudzinski and Kernig signs, no neck stiffness, no rash, stable vital signs (BP 100/70, HR 65). 1
• Do not rely on Kernig's and Brudzinski's signs to exclude meningitis—these have low sensitivity (up to 5%) despite high specificity. 1, 2

Differential Diagnosis Priority

High-Risk Conditions to Exclude

Bacterial Meningitis:

• The classic triad of neck stiffness, fever, and altered consciousness is present in less than 50% of bacterial meningitis cases. 1
• Individual symptoms (fever, vomiting, headache) are poor discriminators when taken independently, but combinations increase suspicion. 1
• Absence of neck stiffness does not exclude meningitis, particularly in early presentation. 1, 2

Malaria (if travel history present):

• Malaria imported to non-endemic settings is frequently overlooked initially, and delayed diagnosis causes preventable deaths. 1
• Acute onset fever with headache, myalgias, and vomiting are classic presenting features. 1
• Thrombocytopenia and elevated bilirubin would support this diagnosis. 1
• Blood smear for malaria parasites must be obtained immediately if any travel history to endemic areas exists. 1

Tick-Borne Rickettsial Diseases (Ehrlichiosis/Anaplasmosis):

• Characterized by fever (96%), headache (72%), malaise (77%), with prominent gastrointestinal symptoms including vomiting. 2
• Rash occurs in only one-third of patients and may appear late or be absent—absence does not exclude diagnosis. 2
• Laboratory findings typically show leukopenia, thrombocytopenia, and elevated hepatic transaminases. 2

Mandatory Diagnostic Workup

Laboratory Investigations

• Complete blood count with differential to evaluate for leukopenia, thrombocytopenia, or lymphocytosis. 2
• Complete metabolic panel including liver function tests (transaminases), renal function, and electrolytes (especially sodium). 2
• Blood cultures before antibiotics. 1
• Malaria blood smear and rapid diagnostic test if any travel history to endemic areas. 1
• Procalcitonin may help distinguish bacterial from viral etiology but should not delay treatment. 1

Lumbar Puncture Considerations

• Lumbar puncture is mandatory for suspected meningitis unless contraindicated. 1
• Contraindications include signs of increased intracranial pressure, focal neurological deficits, or coagulopathy. 1
• CT head before LP if: altered mental status, focal neurological signs, new-onset seizures, or papilledema. 1

Epidemiological History Critical

• Detailed travel history including recent trips to malaria-endemic or tick-endemic areas. 1, 2
• Tick exposure, outdoor activities, time of year, contact with sick persons. 2
• Vaccination status (COVID, influenza, meningococcal). 1

Empirical Treatment Algorithm

If Meningitis Cannot Be Excluded:

• Do not delay antibiotics while awaiting lumbar puncture or imaging if bacterial meningitis is suspected. 1
• Empirical antibiotics should cover Streptococcus pneumoniae, Neisseria meningitidis, and Listeria (if >50 years or immunocompromised). 1
• Standard regimen: Ceftriaxone 2g IV every 12 hours plus Vancomycin 15-20mg/kg IV every 8-12 hours. 1
• Add Ampicillin 2g IV every 4 hours if age >50 years or immunocompromised (Listeria coverage). 1

If Rickettsial Disease Suspected:

• Doxycycline 100mg twice daily is the drug of choice for all tick-borne rickettsial diseases in patients of all ages and should be started immediately. 2
• Treatment decisions should never be delayed while waiting for laboratory confirmation—delayed treatment leads to severe disease, long-term sequelae, or death. 2
• Start empirically if: endemic area exposure, tick exposure history, fever with headache and thrombocytopenia/leukopenia. 2

If Malaria Suspected:

• For severe malaria (altered consciousness, high parasitemia >5%, shock): intravenous artesunate is mandatory with ICU admission. 1
• For uncomplicated malaria: oral artemisinin-based combination therapy (ACT). 1
• Parasitemia should be checked every 12 hours until decline detected, then every 24 hours until negative. 1

Supportive Care Measures

Symptomatic Management

• Adequate hydration with intravenous fluids given poor oral intake and vomiting. 2
• Antipyretics (acetaminophen or ibuprofen) for fever control and comfort. 2
• Antiemetics for persistent vomiting (ondansetron 4-8mg IV). 1
• Monitor urine output and fluid balance. 1

Monitoring Parameters

• Vital signs every 4 hours minimum, more frequently if unstable. 2
• Neurological status assessment every 4-6 hours. 1
• Fluid intake/output monitoring. 1
• Temperature curve documentation. 1

Critical Red Flags Requiring Escalation

Immediate ICU Consultation If:

• Persistent hypotension (systolic BP <90 mmHg) despite fluid resuscitation. 2
• Altered mental status, confusion, or declining Glasgow Coma Scale. 2
• Respiratory distress or oxygen saturation <92%. 2
• Petechial or purpuric rash suggesting meningococcemia or severe rickettsiosis. 2
• Seizure activity. 1
• Signs of increased intracranial pressure. 1

Common Pitfalls to Avoid

Clinical Decision Errors

• Assuming absence of neck stiffness excludes meningitis—many cases present without classic meningeal signs, especially early in disease course. 1, 2
• Waiting for laboratory confirmation before starting doxycycline in suspected rickettsial disease—this delay increases mortality. 2
• Dismissing malaria without travel history—obtain detailed travel history including layovers and brief exposures. 1
• Ignoring possibility of co-infections—ticks can transmit multiple pathogens simultaneously (Borrelia, Ehrlichia, Anaplasma, Babesiosis). 2
• Relying on Kernig's or Brudzinski's signs which have very low sensitivity. 1, 2

Management Errors

• Discharging patient with persistent high fever and severe symptoms without adequate workup. 1
• Delaying lumbar puncture unnecessarily when no contraindications exist. 1
• Failing to obtain blood cultures before starting antibiotics. 1
• Not considering empirical doxycycline in endemic areas or with tick exposure history. 2

Disposition Decision

This patient requires hospital admission based on:

• Severity of symptoms (10/10 headache, high fever, persistent vomiting). 1
• Need for diagnostic lumbar puncture and close monitoring. 1
• Risk of rapid deterioration if serious infection present. 1, 2
• Inability to maintain oral intake due to vomiting. 1
• Need for intravenous antibiotics if bacterial infection confirmed. 1

Admission to general medical ward is appropriate if hemodynamically stable with close monitoring; ICU admission if any red flags develop. 1, 2