When to refer a patient with mild fever, mild nuchal rigidity, and eye pain?

From the Guidelines

Referral Guidelines for Patients with Mild Fever, Mild Nuchal Rigidity, and Eye Pain

Patients with mild fever, mild nuchal rigidity, and eye pain should be referred to a specialist immediately if they exhibit symptoms that could indicate a serious underlying condition such as subarachnoid hemorrhage (aSAH) or meningitis, as these conditions can be life-threatening if not promptly diagnosed and treated 1.

• Severe Headache: If the patient develops a severe headache, often described as the "worst headache of my life," which is a classic presentation of aSAH, referral is warranted without delay 1.
• Photophobia or Blurred Vision: Worsening eye pain, photophobia, or blurred vision despite treatment with over-the-counter analgesics for 48-72 hours also necessitates referral 1.
• Confusion, Seizures, or Focal Neurological Deficits: The development of confusion, seizures, or focal neurological deficits indicates a potential serious condition such as meningitis or aSAH, requiring immediate specialist evaluation 1.
• Persistence or Worsening of Symptoms: If the patient's symptoms persist or worsen over time, despite appropriate initial management, referral to a specialist is necessary to rule out more serious conditions 1.

A thorough ophthalmologic and neurologic examination should be performed prior to referral to rule out other potential causes of eye pain and nuchal rigidity, such as optic neuritis or other infections 1. Given the potential for misdiagnosis of serious conditions like aSAH, which can have a high misdiagnosis rate leading to significant morbidity and mortality 1, a high index of suspicion and prompt referral are crucial in the management of these patients.

From the Research

Referral Criteria

When to refer a patient with mild fever, mild nuchal rigidity, and eye pain depends on various factors, including the presence of other symptoms and the patient's medical history.

• The presence of mild nuchal rigidity may indicate meningitis, but the sensitivity of this symptom is relatively low (40%-60%) 2.
• Combining several examinations for the detection of meningeal signs may decrease the risk of misdiagnosis 2.
• A patient with a history of idiopathic multicentric Castleman disease who is being treated with tocilizumab may be at increased risk of developing meningitis-retention syndrome 3.
• In pediatric patients, fever is a common complaint, and most patients with fever do not require hospitalization 4.
• In patients with aneurysmal subarachnoid hemorrhage, fever is commonly observed, and it has been associated with the occurrence of delayed cerebral ischemia and worse outcomes 5.

Symptom Persistence

• Some patients may experience persistence of symptoms, such as pain and dermatological manifestations, for weeks or months after the onset of fever 6.
• Prognostic factors for symptom persistence include the duration of fever, platelet count, and the presence of petechiae/bruises or abdominal pain/hepatomegaly 6.

Referral Decision

• A referral decision should be based on a thorough evaluation of the patient's symptoms, medical history, and laboratory results.
• Patients with mild fever, mild nuchal rigidity, and eye pain who have a history of idiopathic multicentric Castleman disease or aneurysmal subarachnoid hemorrhage, or who have persistent symptoms, may require closer monitoring and referral to a specialist 2, 3, 5, 6.