What is the appropriate diagnosis and treatment for a patient presenting with body aches, green phlegm, and photophobia (light sensitivity)?

Diagnosis: Bacterial Meningitis

This patient requires immediate evaluation for bacterial meningitis, which classically presents with fever, headache, photophobia, and myalgias (body aches), with or without productive cough. 1

Clinical Presentation Analysis

The triad of symptoms strongly suggests meningitis:

• Photophobia (light sensitivity) is a cardinal feature of meningeal irritation and occurs in the majority of bacterial meningitis cases 1
• Body aches (myalgias) represent systemic inflammatory response and are commonly reported in bacterial meningitis 1
• Green phlegm may indicate concurrent respiratory infection, which can be a portal of entry for meningeal pathogens like Streptococcus pneumoniae 1

The combination of photophobia with systemic symptoms (fever implied by body aches) has high specificity for meningitis rather than isolated ocular conditions 1.

Immediate Diagnostic Workup Required

Perform lumbar puncture immediately after ruling out contraindications (papilledema, focal neurologic deficits suggesting mass effect): 1

• Obtain CSF for cell count, glucose, protein, Gram stain, and bacterial culture 1
• Blood cultures should be drawn before antibiotics 1
• Complete blood count and comprehensive metabolic panel 1

Do not delay antibiotics while awaiting lumbar puncture if there are contraindications to LP or if the procedure will be delayed. 1

Empiric Treatment Protocol

Initiate empiric intravenous antibiotics immediately—within 1 hour of presentation—before diagnostic confirmation: 1

• Ceftriaxone 2g IV every 12 hours PLUS Vancomycin 15-20 mg/kg IV every 8-12 hours for adults 1
• Add Ampicillin 2g IV every 4 hours if patient is >50 years old or immunocompromised (to cover Listeria monocytogenes) 1
• Dexamethasone 10mg IV every 6 hours should be given with or just before the first antibiotic dose to reduce mortality and neurologic sequelae 1

The green phlegm suggests possible pneumococcal etiology, making the ceftriaxone-vancomycin combination critical given rising pneumococcal resistance 1.

Critical Differential Considerations

While bacterial meningitis is the primary concern, consider these alternatives if initial workup is negative:

• Psittacosis presents with fever, photophobia, cough, and myalgia but is less common and requires specific exposure history (birds) 1
• Rickettsial infection (Rickettsia typhi) can cause fever, myalgias, headaches, and photophobia with meningoencephalitis 2
• Viral meningitis has similar presentation but typically less severe and CSF shows lymphocytic pleocytosis 1, 3

Common Pitfalls to Avoid

Do not attribute photophobia solely to ocular causes (conjunctivitis, keratitis) when systemic symptoms are present. Bacterial keratitis presents with pain, redness, and photophobia but would have visible corneal infiltrates on examination and lacks the systemic body aches 1. The absence of eye discharge or visible corneal pathology makes isolated ocular infection unlikely 1.

Do not wait for classic meningeal signs (neck stiffness, Kernig's sign) to be present before treating. These signs may be absent in early disease or in certain populations 1.

Do not delay antibiotics for imaging studies unless there are clear signs of increased intracranial pressure requiring CT before LP. 1

Monitoring and Follow-up

• Reassess clinical status every 4-6 hours initially 1
• Adjust antibiotics based on culture results and sensitivities 1
• Continue dexamethasone for 4 days if pneumococcal meningitis is confirmed 1
• Monitor for complications including seizures, cerebral edema, and septic shock 1