Case of the Month
February 2005

12-year-old male — severe headache

At 0923 hours Aid 21 is called to see a 12-year-old boy who is complaining of listlessness and severe headache. On arrival you find the patient to indeed be listless and poorly responsive to voice. He has been complaining of a severe headache and also has a high temperature (his skin feels very hot) for the past 36 hours. He is lying on his side with his neck and back held in a stiff position. What is striking is the presence of small red slightly raised lesions on much of his body. His mother states that these appeared in the past 6 hours.

Lesions observed on patient's skin

You ask for a paramedic response because of the boy's "SICK" appearance. You apply a nonrebreathing mask at 10 L/min, acquire a full set of vital signs, and prepare for transport.

Further examination reveals the following:

Appearance	—	listless, poorly responsive to voice
Work of Breathing	—	44/min
Circulation to Skin	—	HR – 122 weak; skin is hot, dry, and mottled with small, raised, red lesions
BP	—	80/palp
HEENT	—	Pupils-normal and reactive to light
Chest	—	Unremarkable
Lungs	—	Bilateral breath sounds present, clear
Adb	—	soft and supple, without complaint
Ext	—	without complaint or injury
Pulse Ox	—	91%

As you are waiting for the medics to arrive you collect a SAMPLE history.

S	—	Severe headache high temperature; small, raised, red lesions
A	—	No known medical allergies
M	—	He takes no medications other than Tylenol for a fever
P	—	No significant medical history
L	—	Ate dinner last night
E	—	Returned home from a church function from out of the country

The paramedics arrive and immediately start an intravenous line and begin transporting the boy to a local hospital. While at the scene, one of the paramedics shares with you that the boy probably has meningitis.

Once you return to your station you notify your supervisor about the possible exposure to meningitis. Your supervisor discusses the matter with the infection control officer who in turn contacts the hospital ED and learns that the probable diagnosis is meningococcal meningitis. It is recommended that you take a single 500 mg dose of ciprofloxacin.

Meningococcal Meningitis
Meningococcal meningitis is an infection caused by the bacterium Neisseria meningitidis, also known as meningococcus. It causes inflammation of the membranes surrounding the brain and spinal cord. Sepsis is a common side effect of bacterial meningitis with a fatality rate of 15%. Meningococcal meningitis is a true emergency. Fortunately this type of meningitis is unusual. There have been 20 cases in Seattle and King County in the past 2 years.

The lesson learned from this case: Once the EMTs decided this was a reportable exposure they properly initiated their department’s exposure control plan and received necessary care. Both EMTs returned work next shift without loss of time. Meningococcal meningitis is the only form of meningitis that requires post-exposure prophylaxis with an antibiotic.

View more information on meningococcal meningitis — Centers for Disease Control (external link)