R/O Meningitis... What's your practice?

Discussion in 'Emergency Medicine' started by pinipig523, Aug 17, 2012.

  1. pinipig523

    pinipig523 I like my job!
    10+ Year Member

    Joined:
    Jan 7, 2004
    Messages:
    1,320
    Likes Received:
    22
    Status:
    Attending Physician
    Another attending and I had a discussion the other day regarding meningitis rule out. I usually do:

    Gram Stain neg and WBC <4 and pt looks well, dc home.

    Otherwise I admit for rule out and culture results.

    What do you guys do or do you guys have other comments or suggestions?

    Thanks all, much appreciated.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  2. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
    10+ Year Member

    Joined:
    Aug 21, 2007
    Messages:
    3,744
    Likes Received:
    2,975
    Status:
    Attending Physician
    I use the same thought process. Looks good and cell count negative? Home.

    All others, admit.
     
  3. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    I agree with sending home a negative tap/non-sick patient. I do not try and adjust-up my WBC cut-off for bloody taps. I know some suggest it, but the data wasn't strong enough for me to be comfortable with that risk.
     
  4. la gringa

    la gringa Senior Member
    10+ Year Member

    Joined:
    Oct 14, 2004
    Messages:
    847
    Likes Received:
    13
    Status:
    Attending Physician
    half of the hospitalists will admit, the other half scream "but it's viiiiral!" if it's all lymphs and no organisms.
     
  5. dchristismi

    dchristismi Gin and Tonic
    15+ Year Member

    Joined:
    Dec 4, 2003
    Messages:
    1,010
    Likes Received:
    386
    Status:
    Attending Physician
    ...unless under 4 weeks, then automatic admit.
    But I don't think that's where you were going.

    We're seeing a lot of Influenza here now, so a flu swab (even though the sensitivity is lousy) may also change the dispo. Still if I tap someone and it's negative (And they don't have other factors going on and they don't look "sick"), they go home.
     
  6. 8654Marine

    2+ Year Member

    Joined:
    Feb 6, 2012
    Messages:
    189
    Likes Received:
    2
    Status:
    Attending Physician
    Yes, most viral meningitis are benign, bu some of our worst M&M's are from viral meningitis.

    We've had Herpes encephalitis/meningitis w/ deaths. Esp, in the young.

    We've had some really sick enterovirus meningitis.

    I tapped a vacationing Mass man in Maine who succumbed to EEE.

    "viral" doesn't mean benign.

    If they are/look sick, they come in, full court press.
     
  7. DrMom

    DrMom Official Mom of SDN
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Apr 24, 2002
    Messages:
    43,317
    Likes Received:
    20
    Status:
    Attending Physician
    I think this is the big key.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  8. blackavar

    10+ Year Member

    Joined:
    Dec 25, 2005
    Messages:
    68
    Likes Received:
    1
    Status:
    Resident [Any Field]
    Anyone have any recommendations for reading on viral meningitis? Viral meningitis with someone who looks sick seems like an easy sell for me to admit...but any data on the stable "healthy sick" looking viral meningitis?

    I remember a 19 yo I tapped last year in the peds ED, he looked okay, not great, but sick enough for us to tap...came up viral meningitis, I think like 45 WBC, with 90% lymphs, the attending wanted to send him home, but I used a "well, he's not quite tolerating PO and he's still a little tachy (95)" and we ended up admitting him and he did fine upstairs.
     
  9. Rendar5

    15+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,980
    Likes Received:
    600
    Status:
    Attending Physician
    If they're sick enough to tap, they're sick enough to admit in my mind. LP is a r/o meningitis test, not a r/o bacterial meningitis test.
    Now a CSF culture is a bacterial meningitis r/o test, so if they're doing ok and have no growth at 24 hours, that's a different story; but that is not an ED test, that is a floor test.
     
  10. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
    Moderator Physician Faculty Verified Expert 10+ Year Member

    Joined:
    Aug 2, 2006
    Messages:
    9,663
    Likes Received:
    5,850
    Status:
    Attending Physician
    More often than not, if they "look sick", fever, headache, possibly a rash, and are at my shop, they've got murine typhus, not meningitis.

    Although I'm sure some of them may have West Nile.
     
  11. Interpolfanclub

    10+ Year Member

    Joined:
    Apr 11, 2006
    Messages:
    147
    Likes Received:
    18
    Status:
    Attending Physician
    There is no way I would ever, ever send this home. I've been out of residency several years and this is crazy talk. I do not use the WBC or a lymph predominance to determine viral or bacterial meningitis. I can't remember the paper, but there are bacterial meningitis cases where the tap looked viral. I admit people to the hospital for less, why roll the dice on a 19 year old with a weird tap? You may be lucky and get away with this a few times but if you screw up once and the person really dose have bacterial meningitis, they (and you) are hosed.

    And what is a 19 year old doing in a peds ED?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  12. Daiphon

    Daiphon Semper Ubi Sub Ubi
    Physician Verified Expert 15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    989
    Likes Received:
    259
    Status:
    Attending Physician
    Agree. "Viral" meningitis, even if it truly is, gets admitted by me for at least obs and the day 1 culture result... I've had a few "negative gram stains" that looked good but ended up with positive Cx.

    If you look sick enough for me to tap, then you're sick enough to stay.

    Cheers!
    -d

    Sent from my DROID BIONIC using Tapatalk
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  13. blackavar

    10+ Year Member

    Joined:
    Dec 25, 2005
    Messages:
    68
    Likes Received:
    1
    Status:
    Resident [Any Field]
    That was my inclination as well. This was a pediatric attending working in the peds ER, not a emergency medicine trained person, and not a pediatric attending with a peds EM fellowship, just a straight up pediatric attending. I wasn't sure if he knew something I didn't or had some EBM to fall back on that I didn't know.

    Our peds ED takes patients up to 25 years old, usually under 20 just goes to them, 20-25 depends on what they're here for and triage kinda decides based on which way the wind is blowing.
     
  14. Groove

    Groove Member
    Physician Lifetime Donor Verified Account 10+ Year Member

    Joined:
    May 3, 2004
    Messages:
    1,440
    Likes Received:
    765
    Status:
    Attending Physician
    I admit every meningitis, bacterial or viral. I don't have the cahoonas to send a meningitis case home. Even viral should meet just about any 23h obs criteria. Look at all the crazy viral encephalopathies and meningitis cases we've had over the past few years. It freaked the public out. Hell, it freaked me out.
     
  15. la gringa

    la gringa Senior Member
    10+ Year Member

    Joined:
    Oct 14, 2004
    Messages:
    847
    Likes Received:
    13
    Status:
    Attending Physician
    i'm not saying i agree w/ the hospitalist... but if they "consult" and dc the pt home... what can i do?
     
  16. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
    10+ Year Member

    Joined:
    Aug 21, 2007
    Messages:
    3,744
    Likes Received:
    2,975
    Status:
    Attending Physician

    I think that you meant "cojones", but I like "cahoonas" waaay better. :)
     
  17. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Verified Expert Verified Account 15+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,710
    Likes Received:
    4,333
    I've seen people here on SDN speak with authority about sending home viral meningitis, "because, if I had to admit all of them, there would be no room". Really? Yes, I am admitting all of them.

    That's the thing - even the "benign" viral meningitides might not be. Bacterial meningitis - bad juju. Viral meningitis that leads to viral encephalopathy? The above mentioned EEE, WEE, St. Louis virus, dengue, herpes, West Nile, enteroviruses (Cocksackie A) - and more - have a mortality rate; the mantra (or dogma) of "bacterial meningitis - won't feel like it, but will kill you, viral meningitis - won't kill you, but will feel like you are dead alive" doesn't completely hold up.

    Again, as cultures can grow out bacteria while the cell count has a heavy lymphocytic predominance, this shows that it isn't always what it looks like. To send home someone with something infectious in their CSF is foolhardy.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  18. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    ...
     
    #18 WilcoWorld, Aug 18, 2012
    Last edited: Aug 18, 2012
  19. StevieStud

    2+ Year Member

    Joined:
    Jul 26, 2011
    Messages:
    150
    Likes Received:
    0
    100% automatic admit
     
  20. Birdstrike

    7+ Year Member

    Joined:
    Dec 19, 2010
    Messages:
    4,844
    Likes Received:
    3,724
    .
     
    #20 Birdstrike, Aug 18, 2012
    Last edited: Aug 23, 2012
  21. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
    Moderator Physician Faculty Verified Expert 10+ Year Member

    Joined:
    Aug 2, 2006
    Messages:
    9,663
    Likes Received:
    5,850
    Status:
    Attending Physician
    Then why were they supervising you?
     
  22. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Verified Expert Verified Account 15+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,710
    Likes Received:
    4,333
    When I was a resident, the Peds ED had a few attendings that were straight peds, including the best guy there. The others would just fill in holes.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  23. Rendar5

    15+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,980
    Likes Received:
    600
    Status:
    Attending Physician
    Same here. The last year of my residency shifted to where there would always be a peds ED attending on at all times, and sometimes there would be extra coverage by a straight peds doc. That year we were technically only allowed to present to the peds ED guy (the peds residents could present to either).
     
  24. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
    Moderator Physician Faculty Verified Expert 10+ Year Member

    Joined:
    Aug 2, 2006
    Messages:
    9,663
    Likes Received:
    5,850
    Status:
    Attending Physician
    Those are the current ACGME guidelines, from here

    Not to say this hasn't changed relatively recently, but to my understanding this is what they want, and if a significant proportion of training is done outside these guidelines, they start making little marks on the residency file.

    Of course, we have some pediatric attendings who also grandfathered the EM boards way back when as well.
     
  25. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Verified Expert Verified Account 15+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,710
    Likes Received:
    4,333
    I finished residency 6 years ago.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  26. KiloAxe

    7+ Year Member

    Joined:
    Sep 20, 2006
    Messages:
    44
    Likes Received:
    0
    Status:
    Attending Physician
    My thought is, we admit people for a heck of alot less. Failure to thrive, recurrent chest pain that is too 'high risk', etc. it's not like meningitis is even that common and can't imagine getting pushback trying to admit one that appears viral
     
  27. Apollyon

    Apollyon Screw the GST
    Physician Lifetime Donor Verified Expert Verified Account 15+ Year Member

    Joined:
    Nov 24, 2002
    Messages:
    19,710
    Likes Received:
    4,333
    ...and yet...
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  28. KidDr

    KidDr Senior Member
    7+ Year Member

    Joined:
    Jul 16, 2004
    Messages:
    320
    Likes Received:
    1
    Status:
    Attending Physician
    PEM here--I admit all kids (any age) with CSF pleocytosis, and almost everyone gets a dose of Cefotaxime or Ceftriaxone 50 mg/kg, pending culture results. If <4 weeks of age with CSF pleocytosis, I start Ampicillin, Cefotaxime, and Acyclovir. I'm in an area with a lot of Lyme disease, so I end up sending Lyme PCR and antibody screen from the CSF quite a bit, in addition to the viral stuff (HSV PCR in the infants or those with risk factors/other findings suspicious for HSV, EBV PCR in all age groups, etc). I can remember 3 cases of lyme meningitis ultimately diagnosed in school-aged kids I've admitted with CSF pleocytosis. Definitely not a diagnosis that I want to miss.
     
    #28 KidDr, Aug 20, 2012
    Last edited: Aug 21, 2012
  29. OP
    OP
    pinipig523

    pinipig523 I like my job!
    10+ Year Member

    Joined:
    Jan 7, 2004
    Messages:
    1,320
    Likes Received:
    22
    Status:
    Attending Physician
    You guys are all awesome... thanks!

    IF they're sick enough to tap, they're staying. I got it... some attendings were telling me that's how they practiced, that's how I'll do it from now on.

    Thanks!
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  30. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    I just want to make sure I understand- those who say that if they're sick enough to tap, they're staying - you're admitting patients with totally negative taps?
     
  31. ERDude

    7+ Year Member

    Joined:
    Jun 9, 2010
    Messages:
    73
    Likes Received:
    15
    Status:
    Attending Physician
    This also confused me.

    When I have fever/headache/etc patient that I decide to LP, if the CSF comes back negative and they end up looking pretty good after a couple liters of fluid/antipyretics/zofran and a pep-talk...I don't admit that.

    As a related aside, when I was moonlighting towards the end of my 3rd year I had a young girl (like 7 or 8) come in with c/o fever and headache. Looked kind of ill/uncomfortable but not toxic. She had absolutely no other c/o. I went straight ahead with full court press, abx upfront, got the blood, did the LP (which she handled like a champ)....CSF negative, and, oh wait - I still don't have that UA back. Of course she had a raging pyelo (LE+, Nitrite +, >30 wbc). It was moonlighting nerves that made me do that, but now when I see young females with fever/headache who don't have rash or look toxic, I definitely eval for pyelo and see how they look after fluids/meds before going down the LP road.
     
  32. Rendar5

    15+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,980
    Likes Received:
    600
    Status:
    Attending Physician
    No, if they're sick enough to warrant a tap and it comes back with a viral meningitis picture, then it's a sick enough viral meningitis to admit, despite any protests from a hospitalist.
     
  33. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    I understand that, but I'm not wondering about what you do with lymphocytic predominance. I'm asking about a negative CSF analysis, as in <5 WBC's, no organisms, normal protein and normal glucose?
     
  34. bad virus

    7+ Year Member

    Joined:
    Oct 14, 2008
    Messages:
    691
    Likes Received:
    6
    Status:
    Pre-Medical
    Speaking of which. Everyone in my house has GI Upset and diarrhea accompanied by pure chills x3days. No thermometer but they feel hot. Everyone woke up with a stiff neck this morning including my self. I can barely look around and no change in sleep style. Other than feeling cold in the middle of summer without the AC i feel like a champ. The other 5 look like hell.

    Could it be Mingengitis [SIC]?
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  35. Rendar5

    15+ Year Member

    Joined:
    Nov 12, 2003
    Messages:
    6,980
    Likes Received:
    600
    Status:
    Attending Physician
    I dunno guess it depends on whatever else is ailing them. If they're altered and febrile, I'd admit, if they're headache and febrile, then I'll get rid of their headache and send em out.
     
  36. Daiphon

    Daiphon Semper Ubi Sub Ubi
    Physician Verified Expert 15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    989
    Likes Received:
    259
    Status:
    Attending Physician
    Bingo.

    Sent from my DROID BIONIC using Tapatalk
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  37. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    That makes perfect sense to me. If they're altered, I'll admit them. I guess I should've clarified that I'm considering an otherwise well patient who is getting the LP to rule out meningitis because they're febrile and have a chief complaint of headache - not someone with fever and AMS.

    So, do the above posters not think that headache + fever is an indication for LP or are you admitting every headache + fever that you tap? (Exclude febrile patients with strep + headache, pneumonia + headache, pyelonephritis + headache, etc)

    I'm not trying to be argumentative - if I'm tapping too many or admitting too few, that's something I'd like to know.
     
  38. Daiphon

    Daiphon Semper Ubi Sub Ubi
    Physician Verified Expert 15+ Year Member

    Joined:
    Nov 6, 2003
    Messages:
    989
    Likes Received:
    259
    Status:
    Attending Physician
    Ok. My practice is:
    Do I think meningoencephalitis is likely ( e.g. fever + headache without other identifiable etiology)?

    No = no tap
    Yes = tap

    Tap results:
    Stone cold normal = probably discharge (unless something else feels off, or in the case of peds, sketchy parents / followup)
    Any abnormality = admit for abx pending Cx results.

    Savvy?
    -d

    Sent from my DROID BIONIC using Tapatalk
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  39. WilcoWorld

    WilcoWorld Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2004
    Messages:
    2,967
    Likes Received:
    1,644
    Yep, sounds perfectly reasonable. Gotta love (sarcasm) how it only takes 30+ posts to understand someone on the internet.
     
  40. Zanegray

    7+ Year Member

    Joined:
    Nov 3, 2008
    Messages:
    164
    Likes Received:
    0
    Status:
    Attending Physician
    Funny, this week I had a pt with fever to 103 for 6 days, ha and neck pain. No other sx except mild sinus pressure. Sent by urgent care for r/o meningitis. I did a septic w/u although by the time he got to me fever had broken and he looked pretty good.

    Discused lp with pt and his wife and they reluctantly agreed. I made a joke about west Nile (haven't been bitten by any Mosquitos have you? ) and the nurse says no, but he had a tick bite.... But got it off right away. What? Any rashes? You know like a big target? No no nothing like that, got it right off doc. So I proceed with LP which is negative. Then, as he's getting dressed he notes an 8 cm target rash on his inner right thigh. Doh.

    Good ole Lyme:luck:
     
  41. turkeyjerky

    Physician 10+ Year Member

    Joined:
    Sep 27, 2008
    Messages:
    1,759
    Likes Received:
    142
    Status:
    Resident [Any Field]
    Anyone use the bacterial meningitis score (the nigrovic score) in kids? Absence of seizures, CSF protein less than 80, negative gram stain, CSF ANC less than 1000 and peripheral ANC less than 10000. supposed to be >99% sensitive for bacterial meningitis in kids 2 mo to 18 yrs.

    Although, I can't imagine who's gonna send home a kid w/ 900 PMNs in his CSF
     
  42. future_dr_house

    10+ Year Member

    Joined:
    Sep 8, 2006
    Messages:
    919
    Likes Received:
    30
    Status:
    Resident [Any Field]
    Interesting. I haven't heard of that scoring system and will have to read more. But in principle, that discussion all comes down to what is the acceptable miss rate of meningitis in ages 2-18 that you've tapped. Let's say it was 99% sensitive. Are you comfortable sending home 1% of true meningitis? I'm guessing that's around 3-4 cases in a career roughly where you've just thrown some serious lawyer dice. You have to also consider what our baseline miss rate is for meningitis anyways. If this is equivalent then maybe it's reasonable but it'd have to be the most fool proof study validated by an RCT on a large scale, relevant population and account for both bacterial and viral meningitis for it to change my practice.
     

Share This Page