Figure C. MRI of the brain showed scattered trace sulcal hyperintensities over the bilateral cerebral hemispheres. |
What is the most likely diagnosis?
a Mpox b Syphilis c Hand, foot and mouth disease d Chickenpox
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with slight decreased hearing since the headache commenced. Given S. suis meningitis is associated with a high rate of sensorineural hearing loss( SNHL), an audiometry test is performed, which is consistent with left-sided mild SNHL. 1 She is commenced on high-dose prednisolone and weaned over two weeks. IV vancomycin is also added as the S. suis demonstrates ceftriaxone resistance.
Additionally, Mai undergoes an MRI of the brain, which demonstrates trace sulcus hyperintensities bilaterally, suggestive of leptomeningitis( see figure C).
Mai’ s headache resolves within a few days of starting IV antibiotics. She remains afebrile throughout her admission.
At outpatient follow-up a month later, she reports her hearing is back to baseline.
Discussion
S. suis is the most common cause of meningitis in pork-consuming and pig-rearing countries in South-East Asia. 1 Multiplex PCR is commonly used to identify a causative organism in meningitis, but a negative result does not exclude non-target pathogens, as shown by this case.
Given the high morbidity and mortality of
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bacterial meningitis, delay in diagnosis and initiation of antibiotics can be associated with significant adverse clinical outcomes.
A meta-analysis of 913 patients with S. suis meningitis found that 53 % experienced SNHL compared with 14 % reported in 696 cases of S. pneumoniae and N. meningitidis meningitis. 1, 2
Corticosteroids in combination with antibiotics are more effective than antibiotic therapy only in reducing the risk of SNHL associated with meningitis. 3 Clinicians should therefore be vigilant with hearing assessments and have a low threshold for early steroid administration to minimise its risk.
As S. suis is a zoonotic infection, the overuse of different antimicrobials in pig farming poses a risk of inducing greater antimicrobial resistance in human cases. Widespread resistance to tetracyclines and macrolides and intermediate susceptibility to penicillin( 45.4 %) have been reported in S. suis in Thai pigs. 4
Headache and fever are not uncommon complaints in returned travellers. This case highlights the need for a high index of suspicion for red flags even in the absence of classical features, such as neck stiffness or photophobia. 5
References on request from kate. kelso @ adg. com. au
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ANSWER The answer is c. While most cases of hand, foot and mouth disease( HFMD) occur in infants and children, sporadic cases and epidemics principally affecting older children and adults are documented, and adult cases have increasingly been described in the past decade. 1, 2
Multiple enterovirus serotypes can cause HFMD, with coxsackievirus A being the most common.
Many adult cases present typically with a febrile illness and vesicular eruption on the hands, feet and oral mucosa. Subsequent desquamation of the palms and soles is common. Atypical cases are also reported in adults, presenting with pseudo-purpuric lesions, affecting other‘ non-typical’ areas such as the scalp, face, limbs and trunk. Fever and malaise may be prominent, and strawberry tongue has been reported as the key oral manifestation in some. Severe CNS and cardiac manifestations in immunocompetent adults have also been reported. 2-4
The diagnosis is typically clinical, but when the clinical clues are unclear or atypical, samples for cultures or nucleic acid amplification from the throat, stool and vesicular fluid may aid diagnosis. 4
Treatment is supportive and symptomatic, with preventive measures to contain the risk of spread.
Mpox is less likely in this case, given the lack of risk exposure, the absence of umbilication of skin lesions, and the lack of anogenital or perioral lesions. The rash of secondary syphilis is more likely to be associated with sexual risk factors, be diffuse and involve the trunk, and is associated with lymphadenopathy. The childhood history of varicella and distribution and non-pruritic nature of the rash makes chickenpox less likely.
In this case, review of the recent family history revealed that Mike’ s partner had noted a few small macular spots on her daughter’ s hands and feet during her illness, but did not think of HMFD because these were not vesicular.
Dr Kate Kelso is a GP and medical editor at Australian Doctor. References on request from kate. kelso @ adg. com. au
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