What is the appropriate management for a 65-year-old woman presenting with fever, headache, altered mental status (irrelevant speech), left eye ptosis, and a recent right femur fracture?

Management of 65-Year-Old Woman with Fever, Headache, Altered Mental Status, Left Eye Ptosis, and Right Femur Fracture

This patient requires immediate empirical treatment for bacterial meningoencephalitis with ceftriaxone, vancomycin, and acyclovir, along with urgent neuroimaging before lumbar puncture, while simultaneously addressing the femur fracture and investigating the ptosis as a potential focal neurological sign indicating brainstem involvement. 1

Immediate Life-Threatening Priorities

Airway and Hemodynamic Stabilization

• Assess airway protection immediately - consider intubation if Glasgow Coma Score is less than 8 or the patient cannot protect their airway due to altered mental status 1
• Provide supplemental oxygen if saturation is less than 92% or there is respiratory distress 1
• Initiate aggressive IV crystalloid fluid resuscitation to correct any hypotension and normalize vital signs, capillary refill, urine output, and mental status 1

Empirical Antimicrobial Therapy - Start Immediately

Do not delay antibiotics while waiting for neuroimaging or lumbar puncture, as delay significantly increases mortality 1

• Ceftriaxone 2g IV every 12 hours for coverage of Streptococcus pneumoniae, Streptococcus viridans, and other respiratory pathogens 1
• Vancomycin 15-20 mg/kg IV every 8-12 hours for coverage of resistant S. pneumoniae and Staphylococcus aureus 1
• Add Acyclovir for presumptive HSV encephalitis because encephalitis cannot be ruled out based on clinical presentation alone 1, 2
• Add Ampicillin (this patient is >50 years old) for Listeria coverage 2
• Consider Dexamethasone if bacterial meningitis is suspected 2

Diagnostic Approach - Structured Algorithm

Step 1: Urgent Neuroimaging BEFORE Lumbar Puncture

CT head without contrast must be performed immediately before lumbar puncture because the patient has focal deficits (left eye ptosis) and altered consciousness, which may indicate increased intracranial pressure or mass lesions 1

• The American College of Radiology recommends neuroimaging before LP when focal deficits or decreased consciousness are present, with relevant abnormal results in approximately 11% of cases 1, 2
• Look specifically for cerebral abscess, which may show ring enhancement and diffusion restriction 1
• Assess for signs of increased intracranial pressure, mass effect, or herniation 1

Step 2: MRI Brain with Contrast Within 48 Hours

• If CT is negative but clinical suspicion remains high, perform MRI brain with and without contrast within 48 hours 1, 2
• Look for T2/FLAIR hyperintensities in brainstem, cerebellum, basal ganglia, thalamus, or spinal cord suggesting encephalitis 2
• MRI is superior for detecting cerebral abscesses and brainstem lesions that could explain the ptosis 1

Step 3: Lumbar Puncture (After Neuroimaging)

• Draw at least 3 sets of blood cultures before antibiotics if possible, but do not delay therapy more than a few minutes 1
• Perform LP after neuroimaging is cleared 1
• Send CSF for cell count, protein, glucose, Gram stain, bacterial culture, HSV PCR, and other viral studies 3

Critical Differential Diagnosis

Primary Concern: Bacterial Meningoencephalitis

The combination of fever, altered mental status (irrelevant talk), and focal neurological sign (left eye ptosis) strongly suggests bacterial meningoencephalitis or cerebral abscess 1

• The classic triad of fever, neck stiffness, and altered consciousness appears in less than 50% of bacterial meningitis cases 3, 1, 2
• Do not wait for neck stiffness or the complete triad - its absence does not exclude meningitis 3, 4
• Focal neurological signs like ptosis suggest either brainstem involvement or increased intracranial pressure 1

Secondary Consideration: HSV Encephalitis

• Mental status changes occurring early in the disease course are more common in encephalitis than meningitis 3, 2
• Altered behavior, confusion, and speech disturbances (irrelevant talk) are characteristic of HSV encephalitis 3
• Fever may be low-grade rather than high in some HSV encephalitis cases 3

Evaluate the Left Eye Ptosis Specifically

• Ptosis with altered mental status and fever suggests brainstem pathology - either from direct infection (brainstem encephalitis), abscess, or increased intracranial pressure affecting cranial nerve III 5
• Midbrain hemorrhage or ischemia affecting the oculomotor complex can cause bilateral ptosis and ophthalmoplegia 5
• Document whether ptosis is unilateral or bilateral, and assess for other cranial nerve deficits or eye movement abnormalities 5

Management of the Right Femur Fracture

Timing of Orthopedic Intervention

• Defer surgical fixation of the femur fracture until the CNS infection is controlled and the patient is neurologically stable 1
• The femur fracture is not immediately life-threatening compared to the CNS infection 1
• Provide adequate analgesia and immobilization of the fracture 1
• Consult orthopedic surgery for definitive management planning once infection is treated 1

Consider Fat Embolism Syndrome

• Although less likely given the acute presentation with fever, fat embolism from the femur fracture could theoretically contribute to altered mental status 6
• However, the presence of fever and focal neurological signs makes infection far more likely 1

ICU Admission and Monitoring

Admit to ICU immediately due to:

• Decreased consciousness indicating encephalitis, meningitis, or cerebral abscess 1
• Risk of progressive neurological deterioration 1
• Need for close monitoring of intracranial pressure and neurological status 1
• Potential need for airway protection 1

Monitoring Parameters

• Serial neurological examinations every 1-2 hours 1
• Consider intracranial pressure monitoring if there is diffuse cerebral edema, hydrocephalus, or impending herniation 1
• Monitor for seizures - consider EEG if mental status does not improve or if subclinical seizures are suspected 2

Specialist Consultations

Immediate Consultations Required

• Neurology - for management of suspected meningoencephalitis and evaluation of focal neurological signs 1
• Infectious Disease - for antimicrobial management and diagnostic workup 1
• Neurosurgery - urgent consultation if cerebral abscess is confirmed, especially if diameter >2.5cm, significant mass effect, or progressive neurological deterioration despite antibiotics 1
• Orthopedic Surgery - for femur fracture management planning once patient is stable 1

Critical Pitfalls to Avoid

• Do not wait for the classic triad of meningitis (fever, neck stiffness, altered consciousness) as it appears in less than 50% of cases 3, 1, 2, 4
• Do not rely on Kernig's or Brudzinski's signs - they have extremely poor sensitivity (9% in adults) and should not be used to exclude meningitis 3, 4
• Do not delay antibiotics while waiting for lumbar puncture or neuroimaging - this significantly increases mortality 1, 2
• Do not underestimate severity based on initial vital signs - patients with sepsis and neurological compromise can deteriorate rapidly 1
• Do not perform LP before neuroimaging in a patient with focal deficits and altered consciousness due to risk of herniation 1, 2
• Do not dismiss the ptosis as unrelated - it is a focal neurological sign that may indicate brainstem involvement or increased intracranial pressure 1, 5