Case in the Spotlight 20 - answer & discussion

Clinical presentation


A 28 year old man presents to the ED with a headache. He has been feeling hot and cold, has a dry cough, mildly sore throat, and has a headache and photophobia. He has a stiff neck, and generalised muscle aches. He feels terrible generally, with some nausea. He has had no vomiting or diarrhoea, and no urinary symptoms.
 

Physical examination.

Temp 37.9 HR 110 BP 120/80
No anaemia, jaundice or rash
Ears normal. Mild pharyngitis. He can get his chin to his chest, prefers the lights off. His chest sounds clear, abdomen non tender.
 

Investigations.
 

Wcc 13.9
CRP 130
U&E and LFT both normal
Urine clear

You are asked to consent the patient for a Lumbar Puncture

Can you find an online resource e.g video that instructs re LP?
 

Example

http://educationresource.bhs.org.au/hmo_2_3skills

What complications will you inform the patient about?

  • Headache (up to 10%)
  • Pain during the procedure
  •  Infection (rare)
  • Bleeding complications (rare)
  • Failure of the procedure
  • Failure of the procedure to provide final diagnosis

The lumbar puncture is performed without complications. The CSF looks clear, and indeed you phone the lab re the sample being on its way, and they phone you a short while later to confirm that the sample is completely normal.

What now?
 

Influenza swabs were sent, but the results will not be available for days.


 CXR

The CXR demonstrates right lower lobe patchy consolidation, consistent with pneumonia.
It would be appropriate to send off Atypical Pneumonia serology, and this case was based on a patient who was about to have an LP, but had not yet had a CXR.
 

We have seen several cases like this. In fact, on occasions a LP was performed after the CXR, and the results were normal.
 

  • There are reported cases of Strep pneumonia causing pneumonia and meningitis in the same patient.

http://www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html
 

  • A longer duration of therapy is needed if there is concomitant extra-pulmonary infection such as meningitis

http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf+html

Never perform a LP without first getting a Chest X-ray