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Clinical Focus
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| THE | WINTER SEASON SPECIAL
Case Report
Bring home the bacterial infection
A globe-trotting chef returns from working in Thailand with persistent headache, fever and vomiting.
Dr Lucy Heyworth Basic physician trainee in Sydney, NSW.
MAI, a 51-year-old Thai chef and restaurant owner, presents with a five-day history of headache associated with fever, lethargy, nausea and vomiting.
Two days prior, she returned to Australia from Chiang Mai, Thailand, where she had been working in one of her restaurants for the past three months.
She has a past medical history of thalassaemia minor, takes no regular medications and has no known drug allergies. She is usually very well and a non-smoker, with no history of drug or alcohol use and one sexual partner, her Australian husband, for the past 30 years.
Assessment
On examination, Mai is afebrile and other vital signs are within normal limits. Neurological examination is unremarkable, with no neck stiffness and negative Kernig’ s and Brudzinski’ s signs. There is no evident rash, and other systems examinations are unremarkable.
Mai is managed for a presumptive viral illness with analgesia, rest and oral rehydration. However, she re-presents two days later with persistent headache, ongoing subjective fevers and vomiting.
Once again, she is afebrile with otherwise normal vital signs. Physical examination is largely unremarkable, but she now appears lethargic and irritable. Mai’ s husband reports it is uncharacteristic for her to be so ill. The GP considers meningitis as a highly likely differential diagnosis and refers Mai to ED for further assessment.
Investigations
Preliminary investigations reveal normal FBC, electrolytes, renal and liver functions, and negative dengue serology. CRP is 15mg / L( normal: less than 5). CT brain is unremarkable. In the ED, her headache is refractory to opioid analgesia, so a lumbar puncture is performed for further diagnostic evaluation. CSF is clear, but opening pressure is increased at 40cmH2O( normal: 5-25).
Empiric IV ceftriaxone and aciclovir are commenced to cover for meningitis given the clinical presentation and high opening pressure.
CSF biochemistry and cell count are
A
consistent with a bacterial meningitis, with glucose of 0.5mmol / L( normal: 2.2-3.9), protein of 1.45g / L( normal: 0.15-0.40) and WCC of 470 /µ L( normal: 0-5). The meningitis / encephalitis multiplex PCR is negative. This panel includes Escherichia coli K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis, Streptococcus agalactiae, S. pneumoniae, CMV, enterovirus, HSV1 and HSV2, human herpesvirus 6, human parechovirus, varicella – zoster virus, Cryptococcus neoformans / gattii. Gram stain reveals Gram-positive cocci in pairs( see figure A), and CSF culture isolates S. suis( see figure B).
Progress
Further history reveals that, two weeks before symptom onset, Mai had been handling raw pork with her bare hands at her restaurant in Thailand. While her hands were clean, some small open wounds were present. She also reports left-sided ear fullness,
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