Course 1
Case 6
Case report 1-6E: A 16-year-old boy with fever and meningeal syndrome
Family history: Father was treated for duodenal ulcer, mother has got cervicobrachial
syndrome, sister is healthy.
Personal history: No severe illness before, only common colds. Vaccinated according
schedule. Operations: appendectomy in 10ys of age. Sport injuries – fracture of the left
forearm, fractures of right hand fingers. No regular medication, sometimes vitamins. No
known allergy.
Social history: Lives with parents, student of the 1st year of high school. Active ice-hockey
player training 4 times a week. No alcohol, no smoking, no drugs.
Epidemiological data: No known source of infection, no travel abroad in the last year.
Current illness: Three days of sore throat, with no fever, was training ice-hockey normally.
Yesterday in the afternoon headache ant backache, fever 38,5 oC. At night he vomited,
complained of severe headache, had fever 39 oC, small red spots occured on the skin of hands
and legs. Since the morning is very sleepy. The emergency service took him to the hospital.
Physical examination (only significant or pathological findings are listed):
T 39,2oC, patient somnolent, if wakened up can answer his name correctly, no more response.
Neck stiffness 3 fingers, Lassegue + 60 degree bilat., other signs not examined. Small
petechiae up to 3 mm on the skin of hands and legs. Skin turgor normal. Eyes – isocoric
pupills, normal response to light. Throat slightly inflammed, dry tongue. No submandibular
lymphadenopathy. Eupnoic, normal lung and heart sounds, HR 90/min, reg., BP 100/60,
oxygen saturation 97%. No pathology on the abdomen.
Laboratory results:
ESR 20/40
Blood count: leukocytes 20.000/μl, erythrocytes 5.02 mil/μl,, hemoglobin 160 g/l, hematocrit
0.49, thrombocytes 120.000/μl
Serum: glucose 6.6 mmol/l, urea 7.0 mmol/l, creatinine 67 μmol/l, Na 140 mmol/l, K 4.2
mmol/l, Cl 101 mmol/l, CRP 250 mg/l.
Coagulation: Quick 19.2 s, INR 1.5, APTT 67 s, R 2.1, D-dimers 2.000 (high), antitrombin III
60% (decreased)
CSF: turbid, polymorphonuclears 8.200/3μl, protein 4.5 g/l, glucose 0.8mmol/l, lactate
7mol/l
Questions:
1. What type of meningitis is concerned?
2. What is the likely etiology?
3. What tests can detect the etiological agent?
4. What is the mechanism of fever?
5. Why is the patient uncouscious?
6. What kind of coagulation disorder is associated with the disease?
Pathology:
Inflammation of the central nervous system
Pathophysiology:
Waterhouse-Friderichsen syndrome