Presenter: Jim Pile, MD, Cleveland Clinic
Summary: The following three infectious diagnoses are relatively uncommon but important not to miss as they are associated with high mortality, especially when diagnosis and treatment are delayed. Remembering these key points can help you make the diagnosis:
- Bacterial meningitis: Many patients do not have the classic triad—fever, nuchal rigidity, and altered mental status—but nearly all have at least one of these signs, and most have headache. The jolt accentuation test—horizontal movement of the head causing exacerbation of the headache—is more sensitive than nuchal rigidity in these cases. Diagnosis is confirmed by lumbar puncture. It appears safe to not to perform head CT in patients
- Spinal epidural abscess: Risk factors include DM, IV drug use, hemodialysis, UTI, trauma, epidural anesthesia, trauma/surgery. Presentation is acute to indolent and usually consists of four stages: central back pain, radicular pain, neurologic deficits, paralysis; fever variable. Checking ESR can be helpful as it is elevated in most cases. MRI is imaging study of choice. Initial management includes antibiotics to coverage Staph Aureus and gram negative rods and surgery consultation.
- Necrotizing soft tissue infection: Risk factors include DM, IV drug use, trauma/surgery, ETOH, immunosuppression (Type I); muscle trauma, skin integrity deficits (Type II). Clinical suspicion is paramount. Specific clues include: pain out of proportion, anesthesia, systemic toxicity, rapid progression, bullae/crepitus, and failure to respond to antibiotics. Initial management includes initiation of B-lactam/lactamase inhibitor or carbapenem plus clindamycin and MRSA coverage, imaging and prompt surgical consultation (as delayed/inadequate surgery associated with poor prognosis.
Clinical suspicion is key to diagnosis of bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections, and delays in diagnosis and treatment are associated with increased mortality.TH