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Dangerous Fever in Adult
1
Tipa Chakorn, MD. Emergency Medicine Unit
Department of Medicine, Siriraj Hospital
• Dangerous for whom?
– Patient
– Medical personnel
– Hospital
– Community
• Causes of dangerous fever?
– Infectious cause
– Non-infectious cause
5
• Dangerous condition
– Life threatening or mortality
– Morbidity
• Treatable or preventable condition
• Common condition
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• Common disease in Thailand
• High mortality and morbidity
– Overall mortality 20-27%
– Old age 40%
• Morbidity and mortality can preventable
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• Classic triad
– Fever
– Stiffness of neck
– Alteration of consciousness
• Gold standard: Culture positive in CSF
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Netherlands: October 1998-September 2002
– 696 patients with Community-acquired acute bacterial
meningitis
– Sensitivity of classic triad 44%
– At least 2 of 4: Classic triad + headache = 95%
– Overall mortality rate 21%
(S.pneumonae>N.meningitides)
Songklanagarind Hospital, Thailand
• Retrospective study: Jan 1982-Dec 2001
• 180 episodes in 161 cases
• Both community and nosocomial bacterial
meningitis
• Classic triad of symptoms: 62.5%
• 100% had at least 1 of 3 finding
Southeast Asian J Trop Med Public Health.2004;35:886-92 12
Meta-analysis
• Pooled sensitivity for headache =50%
[95% CI, 32%-68%]
• Nausea/vomiting, 30% [95% CI, 22%-38%])
• The absence of fever, neck stiffness, and
altered mental status effectively eliminates meningitis (sensitivity= 99%-100%)
14JAMA 1999;282(2):175-81
สรปไดวา1. เนองจากเปนโรคทมอตราการเสยชวตสง ดงนน ควร
เลอกใชการวนจฉยทมความไวสงกอน
2. การใช Classic triad ครบทง 3 ขอในการวนจฉยโรค ไมมความไวเพยงพอ
3. ผปวยทมอาการ 2 ใน 4 ของไข ปวดศรษะ คอแขง หรอความรสกตวเปลยนแปลง มโอกาสสงทจะเปนโรคน
4. โอกาสทผปวยโรคนจะไมมไข หรอ คอแขง หรอ ความรสกตวเปลยนแปลงมนอยมาก
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• First described in 1880: Yugoslav
• Kernig; 1882
• 1st performed in patient sitting positionextend knee
Mechanism
• Flexion of neck-> spinal cord moves upward about 1
cm in lumbar region -> pain causes resistance to
further movement
• The stretch can be mechanical relieved by flexion at
hip and knee
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• Do not check for meningitis by flexing the neck in
an unconscious patient unless head and neck
trauma has been excluded
• In caution with posterior fossa mass lesion
• False negative: Localized inflame/low inflam
meningtis
• False positive: Other disease of spinal cord, RA,
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Signs Sensitivity Specificity
Kernig’s sign 5% 95%
Nuchal rigidity 30% 68%
Jolt accentuation 97% 60%
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15%
9%Brudzinski’s sign
• ไมมการตรวจรางกายทไว และมความจ าเพาะกบโรคเยอหมสมองอกเสบ
• การใชการตรวจรางกายหลายๆ อยางพรอมกนจะชวยเพมความไวในการวนจฉยโรคนได
• ในผสงอาย การตรวจตางๆเหลานมความไว ลดลง
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CT brain: benefit or risk?
• Consciousness
• Papilledema
• Neurological deficit
• Delay LP
• Delay treatment
• Increase mortality
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Brain Herniation?
Evidence based
LP in 200 cases with known ICP
– No adverse effect of diagnostic LP
LP in 103 patients with ICP
– 4 deaths in 6-40 hours after LP
– No herniation found at autopsy
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Prospective study
• 301 adults with suspected meningitis
• 235 CT scan were done
• Compare baseline characteristic between
normal and abnormal CT brain
N Engl J Med 2001;345:1727-33.
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Asociations between baseline clinical characteristics and abnormal finding
on CT of the Head in 235 adults with suspected meningitis
30Q J Med 2005; 98:291–298
Retrospective case record study: Canada
• 123 cases of adult acute bacterial meningitis
• Jan 1990-March 2002
• Association between mortality and door to
ATB time
LP data
• Opening Pressure
– Important data
– Only in lateral decubitus (not position usually done under radiology)
• Xanthochromia
– Yellow/orange color of centrifuged CSF
– RBC lysis – oxyhemoglobin, bilirubin
– Blood in subarachnoid space at least 2-4 hrs
– More likely due to blood in CSF and less likely traumatic tap
CSF analysis
Correction factors for traumatic tap
– “Trauma” and RBCs increase protein and with
an increase in RBCs come an increase in
WBCs
– True CSF protein = subtract 1 mg/dL protein for
every 1000 RBC/mm3
– 1 WBC/mm3 for every 700 RBC/mm3
CSF Findings
Normal Bacterial Viral Fungal TB
WBC
(TNC)
0-5 100-10,000 5-3000 5-500 5-500
Cell type >50% PMN >50% lymphs
>50% lymphs
>50% lymphs
Protein 50-80 mg/dL
>200 Nl/slight increase
Nl/slight increase
Increase
Glucose 70-80 mg/dL
>60% serum
<40, <60% of serum glucose
Normal normal <40 or nl
Gm stain 60% + Neg 50% indiaink + crypto
AFB + 25-35%
Pressure 75-200 mm Hg
Inc Nl Inc Nl/inc
Limitation
• Post treatment
– Culture may be negative after few hours
– Decreased positive Gram stain
• Follow up LP
– Mostly recommend few days after treatment if
the clinical does not response well
– CSF sugar: 1st change
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Recommendation
• A delay more than 3 hours for receiving
antibiotics was associated with 3 month
mortality
• Rapid administration of ATB in ED
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• Most common
– S.pneumoniae
– N.meningitidis
– H. influenzae
– Listeria monocytogenes: Aging > 50 years
Micro-organism
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First large report in Vietnam in 2002
– May have benefit in S.pneumoniae
– Should start previous or in the same time of ATB
– Decrease mortality rate
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• Overall mortality
– Adult
• Severe hearing loss
• Short term neurological sequenle
• Long term sequenle
• Causative species
• Timing
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