Case 1

Case Background

• A 7 year old healthy child went camping with his scouting team at a lake, where he swam for a long time. 7 days later, he developed a severe headache, high fever, nausea, vomiting, photophobia and meningismus.

What will be your next step?

A. Empiric broad spectrum antibiotics + Anti epileptics

B. Acyclovir + Anti epilepticsC. Send for immediate Blood cultureD. Lumbar puncture E. Wait and watch + Careful Mannitol InfusionF. Order CT Scan

A.

• No response after days 2 and 3, patient becomes comatose, has seizures, needs airway protection:– Continue Antibiotic therapy for days 4 and 5– Go back to do list and restart!

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B.

• No Response after days 2 and 3, patient becomes comatose, has seizures, needs airway protection :– Continue Anti Virals for Days 4 and 5– Go back to first step and restart!

- 5

C.

• Methicillin Resistant, Coagulase Negative Staphylococcus cultured.

• Start:– IV Cefepime– IV Quinupristine/Dalfopristine– IV Vancomycin– IV Linezolid– Resend blood for culture - 5

Resend Culture

• No growth• Go back to starting list

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IV Drugs.

• No response after days 2 and 3:– Continue Antibiotic therapy for days 4 and 5– Go back to do list and restart!

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D.

• High intracranial pressure observed during LP

• WBC = 15,000/microlit• Protein = (very high)• Glucose = (very low)• More Slides• Provisional Diagnosis• Next step + 10

More Slides

Next step

• Start:– Amphotericin B– Fluconazole– Anti TB drugs– Albendazole + Ivermectin– Piperacillin/Tazobactam– Meropenem or Imipenem/Cilastatin

Amphotericin B.

• CORRECT drug choice• Patient becomes comatose• Respiratory failure• Intubated and put on ventilator• No response to empirical

antibiotic/antiviral/antifungal therapy• Death on day 3!

• Provisional diagnosis? + 10

Other Drugs.

• INCORRECT drug choice• Patient becomes comatose• Respiratory failure• Intubated and put on ventilator• No response to empirical

antibiotic/antiviral/antifungal therapy• Death on day 3!

• Provisional diagnosis? - 5

E.

• Patient becomes comatose• Respiratory failure• Intubated and put on ventilator• No response to empirical

antibiotic/antiviral/antifungal therapy• Death on day 5!

• Provisional diagnosis? - 5

F.

• Back to List of options

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Continuing Drugs

• On Day 6 patient has severe seizures, becomes comatose.

• Transferred to ICU.• Further deterioration Death!

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Provisional Diagnosis

• Correct

• Incorrect

• Back to work up

Incorrect• Incorrect Diagnosis: You missed, he hit!

- 10

Correct

• Early Diagnosis! Patient may have a chance if properly treated!

• Choose treatment

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