What is the plan and treatment for an adult patient with no significant medical history presenting with upper respiratory symptoms and photophobia (light sensitivity)?

Urgent Evaluation for Meningitis Required

The combination of upper respiratory symptoms with photophobia (light sensitivity) is a red flag for meningitis and requires immediate evaluation with lumbar puncture if meningeal signs are present, as this presentation can indicate life-threatening bacterial meningitis that demands urgent antibiotic therapy to prevent mortality and severe neurologic morbidity.

Immediate Assessment Priority

Rule Out Meningitis First

• Perform meningeal sign assessment immediately: Check for nuchal rigidity (neck stiffness), Kernig's sign, and Brudzinski's sign, as photophobia combined with respiratory symptoms can indicate meningococcal meningitis or viral meningitis 1
• Assess for fever, severe headache, altered mental status, and petechial rash: These findings alongside photophobia constitute a medical emergency requiring immediate hospital transfer 2
• If meningeal signs are present: Obtain blood cultures and initiate empiric antibiotics (ceftriaxone 2g IV) immediately before lumbar puncture if any delay in performing LP is anticipated, as mortality increases significantly with delayed treatment 2

Critical Pitfall to Avoid

The presence of photophobia should never be dismissed as simple viral conjunctivitis when accompanied by respiratory symptoms. This combination warrants aggressive evaluation for central nervous system infection, as early meningitis can present with nonspecific upper respiratory prodrome before classic meningeal signs fully develop 1.

If Meningitis is Excluded: Differentiate Respiratory Conditions

Step 1: Assess for Pneumonia

Suspect pneumonia if any of the following are present 3:

• New focal chest signs on auscultation
• Dyspnea or tachypnea (respiratory rate >25/min)
• Pulse rate >100 bpm
• Fever persisting >4 days
• Dull percussion note or pleural rub

If pneumonia is suspected: Obtain chest radiograph to confirm diagnosis, as this is the gold standard and necessary before initiating antibiotic therapy 3

Step 2: Consider Allergic Rhinitis with Conjunctivitis

Photophobia may indicate allergic conjunctivitis when the following features are present 3:

• Clear rhinorrhea (not purulent)
• Nasal congestion with itchy nose or sneezing
• Red and watery eyes (not purulent discharge)
• Pale discoloration of nasal mucosa on examination

Step 3: Rule Out Chronic Lung Disease Exacerbation

Consider lung function testing if ≥2 of the following are present 3:

• Wheezing on examination
• Prolonged expiration
• History of smoking
• Symptoms of allergy
• Previous consultations for wheezing or cough

This is critical because up to 45% of patients with acute cough >2 weeks actually have underlying asthma or COPD rather than simple upper respiratory infection 3, 1.

Treatment Based on Diagnosis

If Allergic Rhinitis with Conjunctivitis (Most Likely if Meningitis Excluded)

Recommend intranasal corticosteroids as first-line therapy for patients whose symptoms affect quality of life 3

Add oral second-generation antihistamines (e.g., cetirizine, loratadine, fexofenadine) for primary complaints of sneezing, itching, and eye symptoms 3

Consider combination therapy if monotherapy provides inadequate response after 2-4 weeks 3

If Simple Viral Upper Respiratory Infection

Provide symptomatic management only 4:

• No antibiotics indicated, as most viral URIs resolve spontaneously within 1-2 weeks
• Purulent nasal discharge alone does not predict bacterial infection and does not benefit from antibiotics
• Reassess if fever >38°C persists beyond 3 days total from symptom onset, as this suggests bacterial superinfection

If Pneumonia Confirmed

Initiate antibiotic therapy immediately 2:

• First-line: Amoxicillin 1g three times daily for 5-7 days
• Alternative: Doxycycline 100mg twice daily if penicillin allergy
• Hospital admission consideration for elderly patients, tachypnea, tachycardia, or confusion

If COPD/Asthma Exacerbation

Prescribe inhaled bronchodilators (long-acting anticholinergics or long-acting β-agonists) for symptomatic relief 2

Consider antibiotics only if ≥2 Anthonisen criteria present 4:

• Increased breathlessness beyond baseline
• Increased sputum volume
• Development of purulent sputum

Red Flags Requiring Immediate Action

• Photophobia with fever and headache: Meningitis until proven otherwise 2, 1
• Focal chest signs with dyspnea: Pneumonia requiring chest X-ray 3
• Fever >4 days duration: Bacterial infection likely, not simple viral URI 3
• Tachypnea (>25/min) or tachycardia (>100 bpm): Severe infection requiring urgent evaluation 2, 1

Follow-Up Timing

Reassess within 48-72 hours if symptoms worsen or fail to improve 2:

• Clinical improvement should be expected within 3 days of appropriate therapy
• Persistent or worsening photophobia warrants ophthalmology referral to exclude uveitis or keratitis
• Development of new focal neurologic signs requires immediate neuroimaging