Case: 76-year-old Woman with Headache – Follow Up

by Roy Strowd, MD

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    00:00 So let's go back to our case, the case of our 76-year-old woman with headache, again with insulin-dependent diabetes who came in with 1-2 days of severe headache and confusion and a fever to 101.9. Well, remember on exam that she was sleepy and altered, she had neck stiffness with flexion and extension evidence of meningitis, and her laboratory studies showed a leukocytosis to 21,000. The spinal tap for this patient, and this is new information, reveals significantly elevated white blood cells, 5000 white blood cells. That is substantially high. And a 95% polymorphonuclear predominant pleocytosis. This sounds like a bacterial process. The protein is substantially elevated, there is inflammation going on in the nervous system, and glucose is 108 but much lower than what we see in the systemic circulation at 185 in our patient with diabetes. So again, we wondered what's the diagnosis. We knew that her diabetes was important, that the acute onset suggests a bacterial process, that the temperature and headache point us to a CNS infection, that her altered mental status is common with many of these infections and certainly can be seen in severe meningitis, and the neck flexion indicates meningismus. The new information that we got from her spinal tap strongly supports a bacterial process and we need to begin antibiotics immediately. So what was her diagnosis? Well it wasn't viral, it didn't look like fungal, parasitic doesn't have this pattern on the spinal tap. This sounds like a bacterial process. She has significantly elevated white blood cells, there is a pleomorphonuclear predominance, low glucose, and elevated protein. This is our signature for a bacterial meningitis. So again, I want you to know how to look at the spinal tap and I want you to have a recipe for approaching these patients quickly in the emergency department or right when you read that vignette. You're going to look at the white blood cells and think about pleocytosis. You're going to think about the differential and know that polymorphonuclear cells indicate bacterial and lymphocytes suggest fungal or viral, low glucose is seen in fungal and bacterial processes and elevated protein means inflammation. This is the recipe for looking at just about every spinal tap.

    About the Lecture

    The lecture Case: 76-year-old Woman with Headache – Follow Up by Roy Strowd, MD is from the course CNS Infections​.

    Included Quiz Questions

    1. Predominance of PMNs
    2. Low white blood cell count
    3. Normal opening pressure
    4. Low protein levels
    5. Normal glucose

    Author of lecture Case: 76-year-old Woman with Headache – Follow Up

     Roy Strowd, MD

    Roy Strowd, MD

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