Headache OSCE - Meningitis

Diagnosis: Meningitis

Case Overview

  • Age/Sex: 27-year-old male
  • Occupation: Personal trainer / fitness instructor
  • Setting: Emergency department, brought by friend after collapse during training
  • Chief complaint: "Bad headache"

Patient Script

Who I Am

I'm 27, I work as a personal trainer and I keep very fit — I was coaching a class earlier today.

What Brings Me In

I've got a really bad headache that started suddenly and I felt hot and dizzy; I started to feel confused and one of my clients called an ambulance.

My Story

The headache started yesterday evening as a bad, throbbing pain at the front and back of my head, but it got a lot worse overnight. By this morning I had a high temperature and felt really weak. While I was coaching today it got so bad I felt light-headed and sort of "out of it" and I threw up once. My friend noticed I was squinting a lot at the lights and I complained the lights hurt my eyes. I also felt my neck was stiff when I tried to look up. I felt worse and more confused over the last few hours and collapsed briefly on the gym floor — I was conscious but very shaky.

I remember bumping my head on a goalpost playing football two days ago, but it didn’t seem like much — no loss of consciousness then. I had a couple of beers last night after work. I had a mild sore throat and some runny nose earlier this week that I thought was just a cold; the symptoms went away. I woke up today feeling feverish and the headache was terrible.

My Medical Background

  • Past medical history: no chronic illnesses, no surgeries
  • Medications: occasional ibuprofen or paracetamol when needed
  • Allergies: none known
  • Social: non-smoker, drinks socially (2–4 drinks on a night out), exercises daily, lives with two roommates
  • Family history: father alive, well; no bleeding disorders or serious infections in the family

What I Think & Worry About

  • I think I might have picked up a bug from a client or from the gym.
  • I’m really worried I might be seriously sick — I don’t want anything that could make me worse or keep me from working.
  • I’m worried about how quickly this happened and I want to know if this is something dangerous.

If You Ask Me About Other Symptoms...

  • Fever/chills: "Yes — I feel very hot and was shivering last night and this morning."
  • Nausea/vomiting: "I vomited once this morning."
  • Neck/neck pain: "My neck feels very stiff — it hurts when I try to look up."
  • Vision/photophobia: "I’m really bothered by bright lights — they hurt my eyes."
  • Rash: "I noticed some small red spots on my chest and leg this morning, I thought maybe they were from sweating or from the gym — they didn’t itch much."
  • Recent travel or sick contacts: "No travel; a couple of clients have been sniffly this week but nobody very sick."
  • Focal weakness/tingling: "No numbness or weakness, just very tired and a bit confused."
  • Substance use: "Had a beer last night, that’s all."
  • Head injury: "Like I said, I hit my head playing football two days ago but it felt fine after."

Clinical Summary

Examination

  • General: appears unwell, diaphoretic, mildly disoriented to exact time (alert but confused), lying curled up complaining of severe headache
  • Temperature: 39.4°C
  • Heart rate: 110 bpm, regular
  • Blood pressure: 110/70 mmHg
  • Respiratory rate: 22/min
  • Oxygen saturation: 98% on room air
  • GCS: 14 (eye 4, verbal 4, motor 6) — slight confusion
  • HEENT: photophobia present, pupils equal and reactive; no focal retinal hemorrhages; no obvious penetrating head injury
  • Neck: marked nuchal rigidity; positive Kernig and Brudzinski signs
  • Skin: multiple small petechial non-blanching spots on trunk and lower limbs (more visible on trunk) — patient noticed them this morning
  • Neurological: no focal limb weakness, reflexes symmetric, normal sensation; cranial nerves grossly intact
  • Cardiovascular/Respiratory/Abdomen: unremarkable on brief exam

Investigations

  • Bloods: WBC 18.2 x10^9/L (neutrophils 15.4 x10^9/L), CRP 180 mg/L, Na 138 mmol/L, K 4.1 mmol/L, glucose 6.5 mmol/L
  • Blood cultures: taken (pending)
  • CT head (non-contrast): no acute intracranial hemorrhage, no mass effect, no focal lesion (performed prior to LP because of recent head impact and confusion)
  • Lumbar puncture:
    • Opening pressure: 280 mmH2O (elevated)
    • CSF appearance: cloudy
    • CSF WBC: 8000 cells/µL (90% neutrophils)
    • CSF glucose: 1.8 mmol/L (serum glucose 6.5 mmol/L) — low CSF:serum ratio
    • CSF protein: 2.0 g/L (elevated)
    • Gram stain: gram-negative diplococci seen
    • CSF culture: pending

Diagnosis

  • Primary diagnosis: Acute bacterial meningitis, most consistent with Neisseria meningitidis (meningococcal meningitis)

    • Supporting evidence: acute onset severe headache, high fever, photophobia, neck stiffness, altered mental status, petechial non-blanching rash, elevated WBC and CRP, CSF with high opening pressure, neutrophilic pleocytosis, low glucose, high protein, and gram-negative diplococci on Gram stain.

  • Important differentials:

    • Viral meningitis: less likely due to neutrophil-dominant CSF, low CSF glucose, and Gram stain positive for bacteria.
    • Subarachnoid hemorrhage: sudden severe headache possible, but CT head was normal and CSF findings inconsistent with SAH.
    • Severe migraine or cluster headache: unlikely given fever, neck stiffness, systemic inflammatory markers, and abnormal CSF.
    • Severe sinusitis with headache: may cause headache and fever but would not explain meningism, CSF findings, or petechial rash.

Management

  • Immediate actions already taken:
    • Blood cultures obtained prior to antibiotics
    • Urgent non-contrast CT head performed because of recent head injury and altered mental state
    • Lumbar puncture performed after CT (LP not delayed further)
  • Empirical antimicrobial therapy:
    • Start IV ceftriaxone 2 g every 12 hours (or cefotaxime if preferred) immediately
    • Consider adding IV vancomycin until susceptibilities known if local resistance patterns warrant (local guidelines dependent)
  • Adjunctive therapy:
    • IV dexamethasone 10 mg IV (given before or with the first dose of antibiotics if bacterial meningitis suspected)
  • Infection control and public health:
    • Implement droplet precautions immediately
    • Notify local public health and infection control (possible meningococcal case)
    • Give chemoprophylaxis to close contacts (e.g., rifampicin or ciprofloxacin as per local guidelines)
  • Supportive care:
    • Monitor in high-dependency or ICU setting for at least first 24–48 hours (hemodynamic monitoring, frequent neuro observations)
    • Manage fever and pain (paracetamol), IV fluids as needed
    • Consider seizure precautions and treat seizures if they occur
  • Further steps:
    • Adjust antibiotics according to CSF culture and sensitivities
    • Continue monitoring for complications (raised intracranial pressure, septic shock, hearing loss) and involve ENT/ID/ICU as needed

Key Learning Points

  • Suspect bacterial meningitis in a patient with acute severe headache, fever, photophobia, and neck stiffness; presence of petechial rash strongly suggests meningococcal infection and is a red flag for rapid deterioration.

  • Do blood cultures and start empirical IV antibiotics promptly; if there is any delay to LP for imaging or other reasons, give antibiotics first — do not wait for LP to start treatment when bacterial meningitis is suspected.

  • Implement droplet precautions and arrange public health notification and prophylaxis for close contacts early in suspected meningococcal disease.

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