What is the appropriate management for a patient presenting with fever, vomiting, cough, and headache for 4 days?

Management of Fever, Vomiting, Cough, and Headache for 4 Days

This patient requires immediate hospital referral via emergency ambulance to arrive within 1 hour, with empiric antibiotics (ceftriaxone 2g IV plus vancomycin 15-20 mg/kg IV) administered immediately after obtaining blood cultures, as the combination of fever, headache, and vomiting for 4 days raises serious concern for bacterial meningitis or severe pneumonia. 1, 2

Immediate Risk Stratification

The 4-day duration of fever fundamentally changes the clinical approach—this is NOT a simple viral upper respiratory infection until proven otherwise. 3, 4

Critical red flags requiring immediate action:

• Fever persisting beyond 3 days without improvement 3
• Headache with vomiting suggests increased intracranial pressure or meningitis 1, 2
• The classic triad of fever, headache, and neck stiffness occurs in less than 50% of bacterial meningitis cases, so absence of neck stiffness does NOT exclude meningitis 1, 2
• Elderly patients are more likely to have altered consciousness and less likely to have neck stiffness or fever 1

Pre-Hospital Assessment and Transport

Document immediately:

• Presence or absence of neck stiffness, altered mental status, rash (especially petechial), seizures, and signs of shock (hypotension, poor capillary refill) 1, 2
• Travel history within the past year to malaria-endemic areas, as fever with chills increases likelihood ratio for malaria to 5.1 3
• HIV risk factors, as B symptoms (fever, night sweats, weight loss) with cough can represent HIV seroconversion illness 4

Do NOT rely on Kernig's or Brudzinski's signs—these have poor sensitivity and should not guide clinical decision-making. 1, 2

Arrange rapid emergency ambulance transport to ensure hospital arrival within 1 hour of initial assessment. 1, 2

Hospital Management Algorithm

Step 1: Immediate Resuscitation (Within First Hour)

Fluid resuscitation:

• Administer aggressive IV crystalloid boluses (250-500 mL) to restore intravascular volume and correct hypotension and tachycardia 2
• Begin fluid resuscitation immediately when sepsis is suspected, even before confirming diagnosis 2
• Target normalization of heart rate, blood pressure, capillary refill time, urine output, and mental status 2

Step 2: Blood Cultures and Empiric Antibiotics

Obtain at least 2-3 sets of blood cultures from separate anatomical sites BEFORE antibiotics, but do not delay treatment beyond a few minutes. 3, 2

Empiric antibiotic regimen (administer within 1 hour):

• Ceftriaxone 2g IV PLUS vancomycin 15-20 mg/kg IV immediately after blood cultures 2
• This covers Streptococcus pneumoniae (including resistant strains), Neisseria meningitidis, and other common bacterial pathogens 2
• Add ampicillin 2g IV every 4 hours if patient is >50 years old, immunocompromised, or has risk factors for Listeria monocytogenes 2
• Add dexamethasone 10mg IV before or with the first antibiotic dose if bacterial meningitis is suspected, as this reduces neurological complications 2

Critical pitfall to avoid: Never delay antibiotics waiting for lumbar puncture or neuroimaging—this significantly increases mortality. 2

Step 3: Diagnostic Workup

Laboratory testing:

• Complete blood count with differential to assess for leukopenia, thrombocytopenia (occurs in 70-79% of malaria cases), or leukocytosis 3, 2
• Metabolic panel to assess for hyponatremia, renal dysfunction, and electrolyte abnormalities 2
• Lactate level—lactate >4 mmol/L indicates high risk for fatal outcome 2
• Inflammatory markers (C-reactive protein, procalcitonin) to assess severity 2
• Thick and thin blood films (Giemsa stained) stat if any travel to endemic areas within the past year, as this remains the gold standard for diagnosing malaria 3
• HIV testing with antigen and antibody tests, as acute HIV can present with fever, cough, and constitutional symptoms 4

Imaging:

• Chest X-ray to evaluate for pneumonia, given the cough 2
• CT head without contrast is mandatory before lumbar puncture if the patient has altered mental status, focal neurological signs, or immunocompromised state 2

Lumbar puncture:

• Perform LP urgently once CT clears the patient, ideally within 4 hours of starting antibiotics to maximize culture yield 2
• CSF analysis should include cell count with differential, glucose, protein, Gram stain, bacterial culture, and viral PCR panel 2

Step 4: Differential Diagnosis Considerations

Infectious causes requiring specific evaluation:

• Bacterial meningitis: The combination of fever, headache, and vomiting strongly suggests this diagnosis 1, 2
• Pneumonia: Cough with fever requires chest X-ray evaluation 2
• Malaria: Any travel history to endemic areas mandates thick and thin blood films 3
• Tuberculosis: Chronic cough with B symptoms requires TB workup regardless of chest radiograph findings 4
• Influenza: If presenting within 48 hours of symptom onset with severe symptoms, consider oseltamivir 75 mg orally twice daily for 5 days 4, 5

Non-infectious causes to consider:

• Lymphoma evaluation if fever, night sweats, and weight loss persist without infectious etiology identified 4

Step 5: Admission and Monitoring

ICU admission criteria:

• Persistent hypotension despite fluid resuscitation 2
• Altered consciousness or Glasgow Coma Scale deterioration 2
• Oxygen saturation <92% 3, 2
• Evidence of organ dysfunction 3, 2
• Severe thrombocytopenia 3
• Seizures 3

Monitor for signs of clinical deterioration—patients with meningitis can deteriorate rapidly even if initially appearing stable. 2

Supportive Care

• Administer ibuprofen or paracetamol for fever control and symptom relief 3
• Ensure adequate hydration 3
• Implement infection control measures: provide tissues, ensure hand hygiene, consider masking the patient if tolerated, and maintain 3-foot separation from others 4

Common Pitfalls to Avoid

1. Never assume prolonged symptoms automatically indicate bacterial infection—but 4 days of fever with headache and vomiting requires aggressive evaluation 3
2. Do not underestimate severity based on initial vital signs—patients with sepsis can deteriorate rapidly 2
3. Missing malaria in any patient with travel history is a critical error 3
4. Delaying blood cultures to start antibiotics significantly reduces diagnostic yield, but antibiotics should not be delayed beyond a few minutes 3, 2
5. Prescribing antibiotics empirically for presumed viral infection without proper evaluation leads to unnecessary adverse effects, but this patient's 4-day duration and symptom constellation warrant empiric therapy 3