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Review Question - QID 101496

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QID 101496 (Type "101496" in App Search)
A 17-year-old male presents with seizure. He was feeling under the weather for the past 3 days. His mother reported that his symptoms began with a headache and malaise and progressed to severe nausea and vomiting. He was also rubbing his neck. Past surgical history is significant for a splenectomy after a car accident. Vital signs are stable with the exception of a temperature of 39°C (102°F). On physical exam, he is post-ictal but has no focal neurological deficits. Lumbar puncture is significant for low glucose, high protein, and an elevated white blood cell count with a polymorphonuclear neutrophil predominance. Gram stain shows the following in Figure A. What features describe the pathogen responsible for this patient's illness?
  • A

Obligate intracellular

6%

19/294

Maltose fermenter

61%

178/294

Facultative intracellular

14%

41/294

Negative Quellung reaction

7%

21/294

Grow best on Eaton's agar

6%

18/294

  • A

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This patient has signs and symptoms of meningitis as a result of Neisseria meningitidis. This bacterium can be differentiated from Neisseria gonorrhoeae by the fact that it is a maltose fermenter. In contrast, N. gonorrhoeae is unable to ferment maltose.

N. meningitidis is a common cause of meningitis, especially in teens or college students. Asplenic patients are also at higher risk of of this encapsulated microbe. One potential route of infection begins in the pharynx and moves to the choroid plexus and meninges. N. meningitidis may also cause acute primary adrenal insufficiency due to adrenal hemorrhage associated with patients who are septic. This condition can lead to disseminated intravascular coagulation and endotoxic shock.

Bamberger discusses the diagnosis, management, and prevention of meningitis. Clinical signs and symptoms are unreliable to distinguish the more deadly bacterial meningitis from the more common viral meningitis. Lumbar puncture, therefore, is indicated but should never delay the initiation of empiric antibiotic therapy. Concomitant therapy with dexamethasone also has been shown to improve morbidity but only with Streptococcal pneumoniae infection.

Campsall et al. discuss meningococcal infection. Meningococcus should be considered and investigated promptly as a potentially etiologic pathogen in any patient with meningitis, or sepsis accompanied by a petechial rash.

Figure A depicts a gram stain of gram negative cocci in pairs as seen in meningoccal infection. Illustration A represents the classic meningococcal petechial rash.

Incorrect Answers:
Answer 1: N. meningitidis is an extracellular pathogen. Examples of obligate intracellular pathogens are Rickettsia and Chlamydia.

Answer 3: N. meningitidis is an extracellular pathogen. Examples of facultative intracellular pathogens are salmonella, N. gonorrhoeae, Brucella, Mycobacteriium, Listeria, Francisella, and Legionella.

Answer 4: Encapsulated bacteria like N. meningitidis would have a positive Quellung reaction.

Answer 5: Eaton's agar is the special culture requirement for M. pneumoniae.

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