What is the best course of treatment for a patient with a history of fever, now afebrile, presenting with unnecessary screaming and visual hallucinations?

Management of History of Fever with Visual Hallucinations and Screaming

This patient requires urgent evaluation for meningitis or other central nervous system infection with immediate lumbar puncture, particularly if under 18 months of age, regardless of current afebrile status. 1

Immediate Risk Stratification and Critical Actions

Rule Out Life-Threatening CNS Infection First

Perform lumbar puncture immediately if ANY of the following are present:

• Excessive drowsiness or irritability 2, 1
• Systemically ill appearance 2, 1
• Incomplete recovery or altered mental status after one hour 2, 1
• Age less than 12-18 months (almost always indicated) 2, 1
• Signs of meningism 2, 1

Critical pitfall: Bacterial meningitis can present atypically with sudden onset of severe behavioral disturbance and visual hallucinations, closely mimicking substance abuse or primary psychiatric illness, even without fever or neck rigidity. 2 The absence of fever does NOT exclude serious CNS infection—both case reports in the literature demonstrated pyogenic meningitis presenting with wildly disturbed behavior and visual hallucinations without typical features like fever or neck rigidity. 2

Immediate Bedside Testing

• Check blood glucose immediately with glucose oxidase strip, especially if patient appears unrousable or continues screaming. 2, 1
• Assess vital signs and general appearance for toxic appearance or signs of systemic illness. 3, 1

Diagnostic Workup Algorithm

Primary Evaluation (Do Not Delay)

If lumbar puncture is indicated based on above criteria:

• Administer broad-spectrum antibiotics FIRST if LP will be delayed for any reason (including CT imaging). 2
• If immediate CT is available and patient is comatose, CT may be performed before LP, but give antibiotics first. 2
• Never withhold antibiotics while awaiting investigation results. 2

Additional Diagnostic Considerations

Laboratory testing should be targeted based on clinical presentation:

• Leucocytosis is an important clue to CNS infection even without fever. 2
• Routine metabolic panels are NOT indicated unless specific clinical suspicion exists. 2
• Do NOT routinely perform EEG, blood urea, serum electrolytes, or serum calcium in straightforward cases. 2, 1

Imaging considerations:

• CT or MRI may be indicated if focal neurological findings are present or if LP is contraindicated. 2
• Chest radiograph should be performed if respiratory signs are present. 3

Age-Specific Considerations

For children under 1 year:

• Lumbar puncture is almost always indicated to rule out meningitis. 4, 1
• Do not delay LP in this age group. 1

For older children and adults:

• Age under 10 years at onset of hallucinations suggests medical (not psychiatric) etiology. 1
• First episode of hallucinations (no previous identical episodes) suggests medical etiology. 1

Management During Evaluation

Symptomatic treatment:

• Administer paracetamol (acetaminophen) for comfort if fever recurs, not for seizure prevention. 3, 4
• Avoid physical cooling methods (fanning, cold bathing, tepid sponging) as they cause discomfort. 2, 3
• Ensure adequate hydration. 2, 3

Do NOT:

• Dismiss this presentation as purely psychiatric without excluding infectious causes first. 1
• Delay definitive evaluation based on current afebrile status—the history of fever is sufficient concern. 2

Disposition

Hospitalize if:

• Signs of serious infection, meningitis, or systemic illness are present. 1
• Patient has not returned to baseline mental status. 2
• Diagnostic workup reveals concerning findings requiring inpatient management. 2

Documentation Requirements

Document the following key elements: 2, 3

• Accurate description of behavioral disturbance and hallucinations
• Temperature history and current vital signs
• Presence or absence of meningeal signs
• Neurodevelopmental/mental status when recovered
• Results of lumbar puncture if performed