8/ Cultures eventually grow strep pneumo 🦠. 🩸 cultures also growing strep pneumo. Patient is already on ceftriaxone and vancomycin. Do you add steroids?
9/ Steroids have been advocated in meningitis due to some studies showing: 👉 Lower mortality w/ strep pneumo 👉 Lower chance of hearing loss This is postulated to be due to its effects reducing inflammatory cytokines in the CSF
10/ Unfortunately, steroids should be given BEFORE or WITH antibiotics, and this patient had received antibiotics in ED, so these were not started at this point, given no additional benefit if given AFTER antibiotics. So if you suspect meningitis, give steroids!
11/ Despite ongoing drainage, patient with this repeat CT 😫😱:
12/ Note the tonsillar herniation and persistent 🧠💧. We attempted to lower the drainage level, but then the patient developed hygromas!! MRI completed also showed purulent subarachnoid material and severe ventriculitis (DWI shown):
13/ For more on DWI, I recommend you check out this tweet, but also follow @teachplaygrub if you do not already! x.com/teachplaygrub/…
13/ For more on DWI, I recommend you check out this tweet, but also follow @teachplaygrub if you do not already! x.com/teachplaygrub/…
@teachplaygrub 14/ Many days later, the patient then has CSF cultures come back positive again with Strep pneumo 😯😖. What do you do?
@teachplaygrub 15/ We exchanged the EVD and started IT vancomycin given there are case reports of it’s success in the literature (see: e-jnc.org/m/journal/view…) but alas, the patient did not recover and family opted for hospice care
@teachplaygrub 16/ What about source? Strep pneumo is the 1️⃣ cause of 🧠🦠 in US, though lower than pre-💉! Strep pneumo lives in the mucus layer of the upper respiratory tract and can be a colonizer. It can cause otitis/mastoiditis/sinusitis and can be passed in droplet form to others.
@teachplaygrub 17/ Remember, N. Meningitis is the one you need to take 💊prophylaxis for if you are exposed! However, droplet precautions should continue while the patient is hospitalized! 😷
@teachplaygrub 18/ Take 🏡 points: 👉 If you suspect meningitis, give steroids before or with antibiotics 👉 Strep pneumo is the most common 🦠 👉 Strep pneumo can live in the respiratory tract and be a colonizer, causing trouble in specific people 👉 IT vanco can be used for refractory cases
@teachplaygrub End/ Thank you for getting this far! Other thoughts, comments, questions, opinions or corrections? @caseyalbin @JimmySuhMD @JimSiegler @MicieliA_MD @a_charidimou @EricLawson90 @CajalButterfly @Capt_Ammonia @DrAtulRamesh1 @RamaniBalu1 @DSandsmarkMDPhD