Dr. Christenson presents a case of a middle aged male who presents with fungal meningitis likely related to tooth infection.
Learning points:
1. How do we manage this patient's respiratory failure?
--Noninvasive mechanical ventilation:
NIV has been shown to benefit those with COPD exacerbations, cardiogenic pulmonary edema, neuromuscular disease, obesity-hypoventilation syndrome and in patients who have been recently extubated and are high risk of morbidity
Has NOT been shown to benefit patients with asthma exacerbations, hypoxemic respiratory failure, or in patients with altered mental status
Contraindicated in altered mental status, increased airway secretions, gastric distention, airway obstruction, recent esophageal surgery, cardiac arrest, inability to protect the airway, facial trauma/surgery
--Invasive Mechanical Ventilation: allows for higher inspiratory pressures and addresses the contraindications for NIV (inability to protect the airway)
Indications: hypoxemic and ventilatory respiratory failure, contraindication to NIV, inability to protect the airway
2. Meningitis workup/empiric therapy
IV vancomycin, Ceftriaxone with addition of ampicillin if >50yo
Dexamethasone if considering s.pneumo
Acyclovir if features of encephalitis are present
Who needs a CT? Immunocompromised, focal neuro deficits, hx of prior stroke or CNS malignancy, new seizure within 1 week, major alteration in consciousness, papilledema on exam
3. What could have caused such a prolonged course?
Chronic meningitis is defined as >4 weeks
Fungal: cryptococcus, coccidio, histo, blasto
Bacterial: lyme, TB
Non-infections: autoimmune, neoplastic processes
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