Severe Neck Pain with Fever: Is it Meningitis?
A 58-year-old man presented to the ED after 2 days of body aches and neck pain. He described the neck pain as 10 on a scale of 10 (with 10 being high) and spasm-like with radiation to his upper arms. The patient also admitted to having a chronic nonproductive cough. On review of systems, the patient was found to have urinary frequency, generalized weakness, and abdominal pain. He had also had a 10-lb weight loss in the previous 2 weeks. The patient denied having fevers, chills, trouble breathing, chest pain, headaches, nausea, vomiting, or diarrhea. The patient had been hospitalized the previous week because of exacerbation of his chronic obstructive pulmonary disease (COPD) and underlying pneumonia.\nThe patient had a medical history pertinent for COPD and had undergone multiple intubations in the past. He was on albuterol and prednisone at home. He denied having any allergies. The patient had undergone 1 hernia surgery in the past. He smoked half a pack of cigarettes per day and used intranasal cocaine and heroin. He denied alcohol use or IV drug use.\nOn presentation to the ED, the patient was awake, alert, and in no acute distress. Vital signs included a temperature of 100.7°F, heart rate of 116 beats/minute, blood pressure of 135/62 mmHg, respiratory rate of 18 breaths/minute, and oxygen saturation of 98% on room air. The head, eye, ear, nose, and throat exam was negative. The patient had cervical spinal tenderness and a positive Kernig’s sign. He also had intermittent wheezes on lung exam. Results of the heart exam were normal. The patient also had right upper quadrant tenderness with a negative Murphy’s sign, no guarding, and no peritoneal signs. The neurologic exam was normal for motor, strength, and cranial nerves.\nLaboratory results included a white blood cell (WBC) count of 20.1 and sodium levels of 134 mEq/L. Lactate levels were normal. Lumbar puncture showed 634 cells/μL WBCs with 93% neutrophils and 83 red blood cells. Cerebrospinal fluid protein levels were elevated at 366 mg/dL, and glucose was 60 mg/dL. Computed tomographic examination of the brain was negative for any acute process.\nBecause of the results of the lumbar puncture, the patient was suspected to have bacterial meningitis. The patient was started on dexamethasone, vancomycin, ampicillin, and rocephin. The infectious disease department was contacted, and the patient was also given cefepime and acyclovir because of his recent hospitalization and drug use.\nOn admission, the patient continued to spike fevers and have pain in his neck. Blood cultures showed gram-positive cocci in clusters. On neurologic exam, the patient was now found to have decreased strength in his hands and decreased motor function in his bilateral distal extremities. Magnetic resonance imaging (MRI) of the spine showed a left paracentral soft-tissue mass thought to be an epidural abscess that was impinging on the spinal cord and was suggestive of anterior cord compression with focal edema.\nThe next day, a neurosurgeon performed a C2 to C3 epidural fluid collection and drainage. The patient was then continued on IV antibiotics for 6 weeks. The patient continued to deny IV drug use.