Meningitis Related to Otitis Media Case Study

Shawna Watson

Patient Profile and Background Information

 

 S.F. is a 62-year-old white female who presented to the Emergency Department with complaint of upper back pain, headache, left earache with drainage, and a non–productive cough for the past 12 hours. She stated she had new onset of nausea, vomiting, and fatigue on the morning of admission. She stated she had a three-day history of upper respiratory tract symptoms of nasal congestion and discharge that cleared just before the onset of back pain, headache and earache. She was in her usual state of good health before the onset of symptoms. S.F.’s initial oral temperature was 99.6 F. Based upon her presenting symptoms a preliminary diagnosis of otitis media with possible bacterial meningitis was established.

The medical history for S.F. includes osteoarthritis, and GERD. Her past surgical history includes bilateral cataract surgery and a cholecystectomy. She has no history of prescription medications and took OTC medications for osteoarthritis and GERD.

Social history assessment reveals she is divorced, lives alone, and works at Wal-Mart and Hallmark. She is a social drinker of beer and alcohol, but denies smoking and illicit drug use. Family history includes diabetes mellitus and cerebrovascular accident.

Question 1: What are the general risk factors for bacterial meningitis and those found in S. F.’s background information? (3 points)

Question 2: What are the likely pathophysiological mechanisms for bacterial meningitis in this patient? (3 points)

 

Originally, S.F. presented with an oral temperature of 99.6 F. One hour after admission, her oral temperature was 101.5 F. Initial vital signs were: BP: 128/72; HR: 122; RR: 28; and oxygen saturation (O2 Sat) 100% on NC 2L/min.

Initial physical assessment revealed that she was alert, lying in a supine position upon a stretcher, eyes open and watching her surroundings. Her facial features were relaxed. Her gaze was midline, her pupils equal, round and reactive to light. Her oral mucous membranes were pink and moist. Her right ear had a normal tympanic membrane, but her left ear had congestion in the external auditory canal with some purulent drainage and the tympanic membrane was not visualized. Her respirations were even and unlabored and her lungs were clear to auscultation bilaterally. Her heart rate was regular in rhythm and S1 and S2 present with no rubs or murmurs discerned. Her abdomen was soft, non-distended and nontender.

A well healed abdominal scar was noted. Assessment of her extremities revealed no clubbing, no cyanosis and no edema. Her skin was dry and warm to the touch.

Diagnostic Data

 S.F.’s initial serum complete blood count (CBC) with differential is shown is table 1.

Table 1

S.F.’s Initial Serum CBC/Differential Results

Test Results Normal Range

WBC (K/microL) 19.30 3.8-11.0

RBC (mil/ul) 4.28 3.8-5.1

Hemoglobin (gm/dL) 13.30 11-16

Hematocrit (%) 39.30 34-47

Platelet (K/microL) 259.00 150-450

Neutrophils % 93% 50-81%

Neutrophils Absolute 18.30 1.8-7

Blood cultures, a nasal swab for culture and a left ear swab for culture were collected. A lumbar puncture was performed to collect CSF for culture and to confirm or rule out bacterial meningitis. Her CSF was turbid, not clear. Analysis of the CSF is provided in table 2.

Table 2

S.F.’s CSF Analysis

Test Result Normal Range

WBC (K/microL) 766 0-6

Neutrophil Count 88 0

Lymphocyte Count 4 0

Monocyte Count 8 ≤ 10

Glucose 2 Varies

Protein 760 15-45

Question 3: What is your interpretation of these key diagnostic laboratory values in relation to this patient’s diagnosis? (3 points)

 

While resting after her lumbar puncture, S.F. exhibited signs of confusion, slurred speech, and altered mental status. Her rapid onset altered mental status can be directly attributed to her developing and worsening hydrocephalus, which is related to the overwhelming inflammatory process. Additionally, her oral temperature rose from 99.6 F to 103.8 F in a matter of hours. Vital signs were: BP: 95/55; HR: 131; RR: 31; and O2 Sat 93% on NC 2L/min. She was rapidly intubated and placed on a mechanicalventilator to protect her airway. Her initial post intubation ABG was pH: 7.38; pCO2: 38; pO2: 218;HCO3: 25; and O2 Sat 100% with FiO2 80%. Post intubation chest x-ray revealed hyper-expanded lungs with an extensive left peri-hilar infiltrate.

Neurological Evaluation

S. F. was ventilated, but not sedated. She did not respond to verbal stimuli or follow any verbal commands. She did not open her eyes to painful stimuli. A loud clap in each ear caused only minor response; she did not pull away or furrow her brow. Visual inspection of eyes revealed conjugate gaze, up and to her left. Pupils were equal and sluggishly reactive to light. Doll’s eyes response was present. Threat response was present, as was her corneal reflex. Oral gag reflex was present. Carina gag reflex was present and elicited with endotracheal tube (ETT) suctioning. Noxious stimuli to left upper extremity nail bed elicited delayed, sluggish response involving only large muscle groups of shoulder and upper arm. Noxious stimuli to right upper extremity elicited no response, even with repeated attempts. Noxious stimuli to bilateral lower extremities elicited delayed, sluggish contraction of quadriceps muscles only. Brudzinski sign was evaluated by the neurosurgeon and was present. With repeated stimulation of bilateral lower extremities, patient exhibited sluggish decerebrate posturing. No seizure activity has been reported, and was confirmed via EEG. A non-contrast CAT scan of the brain was completed which illustrated diffuse generalized edema. MRI of the brain was suggestive for early hydrocephalus. A repeat serum WBC count was 36,000. She was evaluated for neurosurgery for hydrocephalus.

Question 4: What is S.F.’s Glasgow Coma Score and your interpretation of the neurological evaluation? Both should be supported by the physical exam data. (2 points)

 

Clinical Course: Medical/Collaborative Management

 

The Infectious Disease (ID) physician immediately started treating S.F. with IV Rocephin, vancomycin, Zyvox, and dexamethasone. She also received a dose of acyclovir, an antiviral medication. He stated that her presenting symptoms, meningoencephalitis, and preliminary culture results were consistent with group A streptococcal meningitis. Her preliminary ear culture was indicative of Staph aureus. He also initiated penicillin G, 24 units over 24 hours as her preliminary blood and CSF culture results demonstrated penicillin sensitivity. The penicillin infusion will run continuously over several days. He also initiated oral vancomycin as a prophylactic against the potential development of Clostridium difficile.

Culture results were received 24 and 48 hours after collection and confirmed ORSA colonization in her nares, and heavy ORSA growth in her left ear. Multiple blood culture collections and her CSF culture confirmed Group A Beta Hemolytic Streptococcus. Sputum and urine cultures were negative.

Question 5: What is the specific action and rationale for using each of the ordered medications? (6 points)

 

S.F. underwent a surgical craniotomy with insertion of a ventriculostomy drain to manage her hydrocephalus. Her ventriculostomy drain was configured with a transducer for continuous ICP reading. Cerebral perfusion pressure (CPP) was monitored via calculations of Mean Arterial Pressure (MAP) minus the ICP. Continuous vasopressin and norepinephrine infusions were utilized and titrated to maintain the MAP between 90 and 110 so the CPP could be maintained between 70 and 90 for adequate cerebral perfusion. An echocardiogram confirmed no infectious vegetation present on the cardiac valves.

Question 6: How does cerebral edema and increased intracranial pressure impact cerebral perfusion in this patient? Include discussion of the 4 stages of increasing ICP. (5 points)

Temperature control had been a challenge early in her MSICU admission, but by day three her temperature could be controlled with cool environment and acetaminophen without the need for cooling blankets, ice packs or fans. Her WBC count was still elevated in the 28,000-30,000 range but could be partially attributed to her high dose steroid therapy. Tapering of her steroid dose began on day four and her WBC count decreased to 25,000. Her neurological condition did not change. A repeat CAT scan of the brain demonstrated persistent generalized edema. A repeat MRI was not yet indicated per her neurologist and infectious disease physician. Repeat blood, urine, and sputum cultures were collected on day six. The results were the same.

The two managing physicians from neurology and pulmonary/critical care, met with family on day eight to discuss the plan of care for S.F. If current care was going to continue, a tracheostomy and feeding tube would need to be considered by family. A follow-up EEG confirmed encephalopathy, no seizure activity, and low underlying brain electrical activity. The extensive infections and poor neurological status of S.F. were reviewed in detail. On day seven, the patient started exhibiting spontaneous movement in response to her two favorite musical CDs, Elvis and Credence Clearwater Revival. Based on this new activity, family was hopeful for continued improvement and wanted to proceed with the tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube.

The physicians were reluctant to proceed with the procedures. They again stated her poor prognosis for significant recovery. An MRI of the brain was ordered and revealed a two-centimeter empyema in her left posterior fossa with mass effect. There was downward descent of the cerebral tonsils with tonsillar herniation.

Question 7: What are the effects of an empyema in brain tissue? (2 points)

Rehabilitation Techniques

S.F. was essentially in an encephalopathic coma and nonresponsive. Physical therapy was utilized daily for range of motion exercises. S.F. offered no resistance to the exercises. Bilateral multipodusboots were applied every two hours to counteract foot drop. After the two-hour application, the boots were removed for a two hour rest period, but her heels were floated to prevent breakdown related to pressure. S.F. was rotated side to side every two hours and a wedge was utilized to prop her at a 30 degree angle. Repositioning was part of her Ventilator-Associated Pneumonia (VAP) prevention protocol and to serve as pulmonary toilet.

Clinical Course: Nursing Interventions

 

Core nursing interventions involved in the care of S.F. included ventilator management, medication administration, nutrition via continuous tube feed, temperature control enhanced via continuous rectal monitoring, neurological assessments, integumentary protection, documentation, physician coordination and liaison between physicians and family. Main family contact and visitation consisted of her brother and his wife, and her best friend. Nursing maintained communication with family and best friend; all were fully aware of her poor prognosis and potential for decline.

Question 8: Based on the patient’s health status, what do you perceive as the two most important nursing diagnoses? What are the related medical and nursing interventions for each diagnosis? (4 points)

Evaluation and Resolution of Patient Care

The neurologist and critical care physicians met with family on day nine to discuss the results of the MRI. A terminal wean was proposed and the family accepted. With family and best friend present, the patient was removed from the ventilator at 1400 and comfort measures were initiated. Antibiotics were discontinued. Continuous temperature monitoring was discontinued. Steroid therapy was continued to prevent discomfort from rapid cessation, but tapered down again. Nutrition and hydration continued. Analgesics and anxiolytics were available if family thought they were indicated. Family stayed with the patient and nursing provided comfort care for them as well as the patient. The brother and his wife left at 2000, with goal to return by 0800 the following morning, day ten. The patient expired at 0720 on day ten.

 

Question 9: Reflecting on the case, what could have been done differently that may have produced a more positive outcome for S.F.? (2 points)

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• 1505889156-Meningitis Related to Otitis Media Case Study.docx