MEDizzy - A 21-year-old male college student is brought to the ED by

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A 21-year-old male college student is brought to the ED by his friends after developing fever, neck stiffness, confusion, and severe sensitivity to light. Vital signs on admission are as follows: Temperature = 105°F, RR = 20, BP = 120/75, pulse = 92, and pulse oximetry 99% on room air. Examination reveals a confused male patient with nuchal rigidity. A fundoscopic examination shows bilateral blurring of the optic disk margins and retinal venous engorgement. Which of the following is the next best step in management?

ExplanationCT scan. The suspected diagnosis here is meningitis, and a CT scan should be performed first to rule out mass effect before a lumbar puncture is performed. He has a high fever, as well as other symptoms/signs of meningitis (including the most sensitive test for meningitis: the jolt accentuation sign, in which a patient’s headache intensifies after a quick head jolt). Kernig and Brudzinski signs are not sensitive, but they are fairly specific. Once a diagnosis of meningitis is suspected and a lumbar puncture needs to be performed, a CT scan should be performed in patients thought to be at high risk for cerebral herniation. Risk factors include papilledema, previous CNS disease, a seizure in that past week, immunosuppression, altered mental status, and focal neurologic signs. (C) This patient has both papilledema and immunosuppression (methotrexate), and therefore a CT scan should be performed before a lumbar puncture to assess the risk for cerebral herniation during lumbar puncture. (B) An MRI provides better visualization of the brain, however it is costly and time-consuming. Because the purpose here is to rule out mass effect, a CT scan can do this adequately and quickly. (D, E) It is most appropriate to administer empiric antibiotics (and antivirals if HSV encephalitis is suspected) shortly after blood and CSF cultures are sent, however the lumbar puncture has not been performed yet.