A case presentation

1. CASE PRESENTATION ON
ACUTE PYOGENIC MENINGITIS
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2. A female patient of 49 yrs old was admitted in hospital with
following complaints:
C/O : Altered sensorium since 4am(yesterday) associated with
vomiting.
Had one episode of seizures at morning 6am.
O/E : patient is unconscious , reacting for painful stimuli
PR-110/min.
BP-70/80mmHg
TEMP-980 F
SP O2- 96% with room air
RR-20/min.
Heart-s1s2 + ,lungs-BAE +, P/A- soft,
CNS-NAD
2

3. 3
SOCIAL HISTORY:
Marital status : married
Smoking : No
Alcohol : No
Diet :Mixed
Past medical history : hypertension
Past medication history : not available
Surgical history : Nil
Family history : Nil
Previous allergies : Nil
Neck stiffness –present
Brudzinski sign positive
CT brain done at outside hospital which showed normal study

4. 4
Parameter Day 1 Day 2 Day 3 Day 4 Day 5 Day 6
BP(mmHg) 140/80 136/76 112/76 158/66 134/76 142/88
PR(BPM) 74 80 78 74 70 78
RR(CPM) 18 20 20 20 20 20
TEMP(F) N N N N N N
SPO2 % 97% 98% 98% 98% 98% 97%
VITALS:

5. PARAMETERS NORMAL VALUES DAY 1
TLC 5000-11000cells/mm3 10900
RBC 4.5-5.5mil/mm3 5.20
Hb 12.0-15.5mg/dL 12.7
HCT
34.9-44.5%
40
PLATELET 1.5-4.4lakhs/mm3 3.87
LYMPHOCYTES 20-40% 21
BLOOD-NH3 10-47umol/l 41
ALP 44-147 IU/L 120
GGT 9-48U/L 12
CREATININE 0.8-1.25mg/dl 1.24
URIC ACID 0.18-0.48mmol/L 8.8
SGPT 7-56 units/L 15
APTT Control 30-40seconds 28.8
LAB PARAMETERS
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6. PARAMETERS Normal Ranges Lab values
Total bilirubin 0.0-1.4mg/dl 0.83
Direct bilirubin 0.0-0.3mg/dl 0.24
Total proteins 6-8g/dl 8.6
Sr. albumin 3.5-5.5g/dl 4.5
Sr.Globulin 2-3.5g/dl 4.1
Na+ 135-155mmol/L 133
K+ 3.5-5.5mmol/L 3.81
Cl- 95-105mmol/L 83.3
Ca2+ 8.5-10.5mg/dL 10.3
PT 11-14seconds 10.4
INR Below 1.1 1.2
aptt 30-40seconds 24.5
T 3 80-180ng/dL 47.52
T4 0.7-1.9ng/dL 0.5
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7.  OTHERS:
CSF: Protein -53.70 (15-45mg/ dL)
Glucose -45 (50-80 mg/ dL)
chlorides -112(110 to 125 mEq/L)
2D ECHO- Grade-II diastolic dysfunction , NO RWMA
Malaria detection by QBC method-
p.falciparum
p.vivax -ve
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8. SOAP NOTE
SUBJECTIVE EVIDENCE:
Altered sensorium since 4am(yesterday) associated with vomiting.
Had one episode of seizures at morning 6am.
OBJECTIV EVEIDENCE
• Abnormal ALP, Uric acid, total proteins, serum globulin, chloride, aPTT,
INR,T3 and T4.
• CSF: Protein -53.70 (15-45mg/ dL)
Glucose -45 (50-80 mg/ dL)
chlorides -112

9. 9
ASSESSMENT
From subjective and objective evidence it was diagnosed as
Acute pyogenic Meningitis
Acute bacterial meningitis is rapidly progressive bacterial infection of the
meninges and subarachnoid space. Findings typically include headache, fever,
and nuchal rigidity and confusion(elders).Some patients may also have
seizures.
In middle-aged adults and in the elderly, the most common cause of bacterial
meningitis is S. pneumonia, less commonly is N. meningitidis

10. CORE
CONDITION
• Altered sensorium associated with one episode of vomiting,
• one episode of seizure this morning.
• Abnormal ALP, Uric acid, total proteins, serum globulin, chloride,
aPTT, INR,T3 and T4
OUTCOMES:
• To decrease presenting complaints.
• To improve quality of life.
• To prevent further complications like cerebral edema.
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11. REGIMEN
• Empiric antimicrobial therapy should be instituted as soon as possible to
eradicate the causative organism(cephalosporins, vancomycin (Vancocin),
rifampin (Rifadin), carbapenems, and fluoroquinolones)-
Ceftriaxone-4g IV every 12hrs
Cefotaxime-2g IV every 12 hrs
vancomycin 10-15mg/kg every 12 hrs
• Antimicrobial therapy should last at least 48 to 72 hours or until the
diagnosis of bacterial meningitis can be ruled out.
• Dexamethasone can be given as Adjunctive Treatment for Meningitis in
addition to antibiotics.The recommended IV dose is 0.15 mg/kg every 6
hours for 2 to 4 days, initiated 10 to 20 minutes prior to or concomitant with
but not after, the first dose of antimicrobials.
• Cephalosporins(3rd generation) and vancomycin is mostly preferred if
meningitis is caused by S.pneumonia and N. meningitidis.
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12. DRUG DOSE FREQ Day
1
Day 2 Day
3
Day 4 Day 5 Day 6
Inj.Monocef
(Ceftriaxone)
2gm
(IM)
BD      
Inj. Levipil
(levetiracetam)
1gm TID      
Inj.Pan
(pantoprazole)
40 mg OD      
Inj.Zofer
(ondansetron)
4 mg TID      
Mvi
(vit. Supplement)
10ml OD    
Inj.Vancomycin 1 g BD      
DRUG CHART
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T.Thyronorm 100mcg OD      
Tab.Dolo 650mg SOS      
Tab.Cinod
(clinidipine)
5mg OD      
Inj.Decadran
(dexamethaso
ne)
8mg TID    
Syp.Calcimax 5ml OD      

14. EVALUATION:
•Patient should be evaluated for CSF culture to check
the presence of any micro-organisms growth
•Should be evaluated for signs of seizures
•Patient clinical status improvement should be
checked
•Monitor renal function tests while using
vancomycin.
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15. PRIME
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PHARMACEUTICAL RELATED PROBLEMS:
Nil
RISK FACTORS:
Dexamethasone-abnormal vision, conjunctivitis, depression.
Levetiracetam - headache, dizziness, abnormal behaviour.
Ondansetron-headache, prolonged QT interval.
Vancomycin- hypotension, cardiac arrest.

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INTERACTIONS
Monitor Closely
• dexamethasone + ondansetron-
dexamethasone will decrease the level or effect of ondansetron by
affecting hepatic/intestinal enzyme CYP3A4 metabolism.
Minor
• levetiracetam + acetaminophen-
levetiracetam decreases levels of acetaminophen by increasing metabolism.
• dexamethasone + pantoprazole-
dexamethasone will decrease the level or effect of pantoprazole by affecting
hepatic/intestinal enzyme CYP3A4 metabolism.
MISMATCH:
Nil
EFFICACY RELATED PROBLEMS:
Nil

17. DISCHARGE MEDICATIONS:
T.monocef-o 200 mg BD X 5days
T.Pan 40mg OD BBF
T.Dolo 650mg SOS for headache
T.Thyamine 100mg OD-2Pm
T.Levipil 500mg BD-8am & 8pm
T.Cinod 5mg OD
Syp.zincovit 5ml BD
Syp.calcimax 5ml OD
T.Tryptomer 10mg at 9pm
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18. PATIENT COUNSELLING:
Wash your hands. Careful hand-washing helps prevent the spread of
germs. Wash hands often, especially before eating and after using the
toilet, spending time in a crowded public place or petting animals.
Practice good hygiene. Don't share drinks, foods, straws, eating utensils,
or toothbrushes with anyone else.
• Stay healthy. Maintain your immune system by getting enough rest,
exercising regularly, and eating a healthy diet with plenty of fresh fruits,
vegetables and whole grains.
• Cover your mouth. When you need to cough or sneeze, be sure to cover
your mouth and nose.
• Take plenty amounts of fluids.
• Do physical activities as tolerated.
• Consume fresh fruits and vegetables.
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19. Regarding the medications-
• Report diarrhea (if severe) while using antibiotics.
• Monitor renal function tests regularly
Vaccines:
• Haemophilus influenzae type b (Hib) vaccine.
• Pneumococcal conjugate vaccine (PCV13).
• Pneumococcal polysaccharide vaccine (PPSV23)
• Meningococcal conjugate vaccine
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20. References
• IDSA (Infectious Diseases Society Of America) guidelines for the
management of bacterial meningitis.
• Dipiro
• Medscape
• Micromedex
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