Dangerous Fever in Adult

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Tipa Chakorn, MD. Emergency Medicine Unit

Department of Medicine, Siriraj Hospital

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• Dangerous for whom?

– Patient

– Medical personnel

– Hospital

– Community

• Causes of dangerous fever?

– Infectious cause

– Non-infectious cause

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• 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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N Engl J Med 2004;351:1849-59.10

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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

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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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• Kernig’s sign

• Brudzinski’s sign

• Nuchal rigidity

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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?

Complication of meningitis

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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

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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

31Q J Med 2005; 98:291–298

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• Considered with indication

• Antibiotics should be started before CT

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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

CSF analysis

• Gram stain

• AFB stain

• Culture

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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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41Q J Med 2005; 98:291–298

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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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4444Q J Med 2005; 98:291–298

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• Most common

– S.pneumoniae

– N.meningitidis

– H. influenzae

– Listeria monocytogenes: Aging > 50 years

Micro-organism

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Siriraj Hospital, 1993

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Songklanagarind Hospital

1982-2001

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Empirical ATB

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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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All age group

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Mortality in adult

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Causative species

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Timing

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