What is the appropriate emergent evaluation and management for an 82‑year‑old woman presenting with new headache, ear pain, and photophobia?

Emergent Evaluation for Suspected Bacterial Meningitis in an 82-Year-Old Woman

This 82-year-old woman presenting with headache, ear pain, and photophobia requires immediate evaluation for bacterial meningitis, which carries a 20-30% mortality rate and demands treatment within 1 hour of presentation. 1

Immediate Clinical Assessment

Perform a focused neurological examination immediately to identify red-flag features that mandate imaging before lumbar puncture:

• Assess for altered consciousness or focal neurological deficits (weakness, numbness, diplopia, dysarthria), as these indicate potential mass effect and herniation risk 1, 2
• Examine for nuchal rigidity (neck stiffness or limited neck flexion), which is a classic meningeal sign but may be absent in up to 30% of bacterial meningitis cases 3, 1, 2
• Document fever presence, recognizing that bacterial meningitis can present without fever in elderly patients 1, 4
• Perform fundoscopy to assess for papilledema, which suggests increased intracranial pressure 2, 4

The combination of headache, photophobia, and ear pain in an elderly patient is particularly concerning because otitis is present in 27% of community-acquired bacterial meningitis cases, with Streptococcus pneumoniae accounting for 88% of otogenic meningitis 5.

Emergent Imaging Decision Algorithm

If ANY of the following are present, obtain non-contrast head CT immediately BEFORE lumbar puncture: 1

• Altered consciousness or reduced Glasgow Coma Scale
• Focal neurological signs or symptoms
• Papilledema on fundoscopy
• New-onset seizure

The European Society of Clinical Microbiology and Infectious Diseases strongly recommends CT before LP when neurologic signs such as nuchal rigidity or altered consciousness are present, as this approach has 90% specificity for identifying dangerous mass effect 1.

If the neurological examination is completely normal, proceed directly to lumbar puncture without imaging, as the yield of CT in this scenario is extremely low (0.2% abnormality rate, equivalent to asymptomatic volunteers) 2.

Critical Time-Sensitive Management

Initiate empiric antibiotics within 1 hour of presentation, even before imaging or lumbar puncture if there will be any delay: 1

• Ceftriaxone 2g IV plus vancomycin 15-20 mg/kg IV for suspected pneumococcal meningitis (the most likely pathogen given her ear pain) 1
• Add dexamethasone 10mg IV before or with the first antibiotic dose to reduce mortality and neurological sequelae 1

Do not delay antibiotics waiting for imaging or LP results—treatment delay directly increases mortality in bacterial meningitis 1.

Lumbar Puncture Execution

If CT is negative or not indicated, proceed immediately to lumbar puncture: 1

• Measure opening pressure (expect >25 cm H₂O in bacterial meningitis) 1
• Send CSF for: cell count with differential, glucose, protein, Gram stain, bacterial culture, and PCR for S. pneumoniae 3, 1
• Obtain simultaneous serum glucose to calculate CSF/blood glucose ratio (expect <0.4 in bacterial meningitis, typically 0.27) 1

Expected CSF findings in bacterial meningitis: 1

• Polymorphonucleocyte (neutrophil) predominance
• Elevated protein (usually >45 mg/dL)
• Low glucose (CSF/blood ratio <0.4)
• Elevated opening pressure (>25 cm H₂O)

Otolaryngology Consultation

Given the ear pain, consult ENT emergently to evaluate for otitis media or mastoiditis as the source of meningitis 5. In otogenic meningitis cases, an ENT specialist is consulted in 82% of episodes, and ear surgery (myringotomy, mastoidectomy) is performed in 55% of those consultations 5. While ear surgery's impact on outcome remains uncertain, identifying and managing the infectious source is standard practice 5, 6, 7.

Common Pitfalls to Avoid

• Do not perform LP before imaging in patients with meningeal signs, as this risks cerebral herniation if mass effect is present 1
• Do not assume absence of fever rules out meningitis—elderly patients and those with aseptic meningitis may be afebrile 1, 4
• Do not dismiss ear pain as unrelated—otogenic meningitis accounts for more than one-quarter of community-acquired bacterial meningitis cases 5
• Do not wait for LP results to start antibiotics—every hour of delay increases mortality 1

Alternative Diagnoses to Consider After Stabilization

If initial workup is negative for bacterial meningitis, consider:

• Viral (aseptic) meningitis: CSF shows lymphocytic pleocytosis rather than neutrophilic; test for enteroviruses, HSV-1, HSV-2, and VZV by PCR 3
• Migraine with aura: Would require recurrent episodes with specific ICHD-3 criteria (photophobia, phonophobia, nausea), but new-onset headache after age 50 is a red flag 3, 2
• Giant cell arteritis: Consider if scalp tenderness or jaw claudication present; obtain ESR/CRP, though ESR can be normal in 10-36% of cases 2

However, in this acute presentation with the triad of headache, ear pain, and photophobia in an elderly patient, bacterial meningitis must be ruled out first before considering benign diagnoses 1, 4, 8.