Infection · Moderate
This case is fictional and exists for study. It describes no real patient.
22 years · female
A 22-year-old female university student presents to the emergency department with a 12-hour history of severe generalized headache, high fever, photophobia, and neck stiffness. Her flatmate reports that she became increasingly lethargic and confused over the past 2 hours. On examination, her temperature is 39.2°C, heart rate is 118 bpm, and blood pressure is 102/64 mmHg. She has marked nuchal rigidity and a positive Kernig's sign. Physical examination reveals a non-blanching petechial and purpuric rash over her lower limbs and abdomen. Her Glasgow Coma Scale (GCS) score is 14 (E4 V4 M6). There are no focal neurological deficits or papilloedema on fundoscopy.
Vital signs
- HR
- 118 bpm
- BP
- 102/64 mmHg
- RR
- 24/min
- Temp
- 39.2 °C
- SpO₂
- 96%
Examination findings
- Marked nuchal rigidity and positive Kernig's sign
- Non-blanching petechial and purpuric rash on lower limbs and abdomen
- Glasgow Coma Scale score of 14 (E4 V4 M6)
- No papilloedema or focal neurological signs
Investigations
| White Blood Cells (WBC) | 18.5 10^9/L | reference: 4.0-11.0 |
| C-Reactive Protein (CRP) | 180 mg/L | reference: <5 |
| Platelets | 110 10^9/L | reference: 150-400 |
Question 1 of 3
Which of the following is the most appropriate next step in the management of this patient?
In suspected bacterial meningitis (especially with a non-blanching rash suggestive of Neisseria meningitidis), immediate administration of IV antibiotics (such as ceftriaxone) is the critical initial management step. Antibiotic administration must not be delayed for lumbar puncture or neuroimaging. CT head is not indicated prior to LP in this patient as there are no focal neurological deficits, new-onset seizures, papilloedema, or severe drop in GCS (<12). Dexamethasone is an adjunct to antibiotics and is never given alone — and it is not indicated in this patient. NICE advises strongly suspecting meningococcal disease when features of bacterial meningitis are combined with a non-blanching petechial or purpuric rash, and advises against routinely giving corticosteroids in meningococcal disease. Where dexamethasone is indicated in bacterial meningitis it is given with or just before the first antibiotic dose, never delaying antibiotics, and is continued only if pneumococcus or Haemophilus influenzae type b is confirmed.
Teaching point: Empiric parenteral antibiotics should be administered immediately in suspected acute bacterial meningitis without delaying for diagnostics.
Question 2 of 3
A lumbar puncture is subsequently performed. Which set of cerebrospinal fluid (CSF) analysis results is most characteristic of acute bacterial meningitis?
Bacterial meningitis typically presents with turbid/cloudy CSF, neutrophil-predominant pleocytosis, high protein content (>1.0 g/L), and a low CSF-to-blood glucose ratio (<0.4). Option B describes typical viral meningitis (clear CSF, lymphocytosis, normal glucose). Option A describes typical fungal or tuberculous meningitis. Option C describes subarachnoid haemorrhage.
Teaching point: Bacterial meningitis CSF shows cloudy appearance, high neutrophils, elevated protein, and low CSF:blood glucose ratio.
Question 3 of 3
Regarding infection control and prophylaxis for contacts, which single action is most appropriate?
Close household contacts or prolonged direct contacts of a patient with suspected meningococcal disease should receive post-exposure chemoprophylaxis with single-dose oral ciprofloxacin (or rifampicin) to eradicate nasopharyngeal carriage. Casual contacts (e.g., classroom peers or healthcare workers without direct respiratory droplet exposure) do not require prophylaxis or isolation. Amoxicillin is not used for meningococcal prophylaxis.
Teaching point: Close contacts of patients with suspected meningococcal disease require post-exposure prophylaxis with oral ciprofloxacin or rifampicin.
Key learning points
- Suspected bacterial meningitis with a non-blanching rash requires immediate IV antibiotic treatment without delaying for lumbar puncture or CT.
- Bacterial meningitis CSF shows turbid appearance, elevated neutrophils, high protein (>1.0 g/L), and low CSF:plasma glucose ratio (<0.4).
- Close contacts of patients with meningococcal infection require chemoprophylaxis with single-dose oral ciprofloxacin or rifampicin.
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