Anatomy Case Study: The Case of the Contagious Boyfriend

A 16 year-old boy named Mark Rushmore is brought into the emergency clinic by his parents at 9 am. He is suffering from a high fever and severe headache. His parents tell Dr. Kudos that he developed a headache the night before and went to bed early. Mrs. Rushmore tells him Mark had trouble waking Mark and seems delirious and unsure of his surroundings. Dr. Kudos examines Mark and finds that although conscious, he is having trouble remembering details and has trouble focusing on the questions he is being asked. Dr. Kudos asks Mark to lie down on the bed and try to raise his head.

He does so but as he raises his head, he flexes at the hip and the knee. Dr. Kudos suspects meningitis and performs a lumbar puncture between L3 and L4. The results confirm that Mark has a form of bacterial meningitis. He is immediately admitted to the hospital for treatment.

Dr. Kudos finds out from Mark`s parents that he has a girlfriend who he took to the movies two nights ago. Dr. Kudos then contacts Angela`s family and requests that they bring her to the hospital for tests. Thankfully Angela`s tests are negative. With careful supervision, Mark recovers in about two weeks and returns to school.

Considerations

1. Dr. Kudos performed a physical test on Mark called Brudzinski`s test. Mark raised his head off of the bed and involuntarily flexed at the hip and the knee. Why might this be considered a positive test for spinal meningitis? What nerve causes Mark to do this?
2. Dr. Kudos performed a lumbar puncture, or spinal tap, at the L3-L4 level. What is the anatomical significance of this region? What substance would be collected here?
3. Among other treatments, what type of medication would most likely be prescribed for Mark? Why?
4. Why did Dr. Kudos ask if Mark had a girlfriend? Why did he ask Angela to
   come in for tests?
5. Once Mark was diagnosed with bacterial meningitis, doctors, nurses, and the people in close contact with him might be prescribed a round of antibiotics. Why?
6. If Mark had been found to have a form of viral meningitis, what could be done for him? Would his prognosis in that case (viral meningitis) have been worse?

Disclosure of issues

1. Brudzinski’s test may be observed in about 50% of all adults who develop acute pyogenic meningitis.  The patient is made to lie down and the physician places one hand behind the patient’s head and the other hand on the patient’s chest.  Using the hand behind the head, the physician lifts it up thus bending the neck (the other hand prevents the body from rising).  The patient may bend the knees and hips to demonstrate a positive sign for Brudzinski’s test.  This sign apparently develops due to irritation of the nerve bundles arising from the spinal cord (motor nerve roots) while it passes through the infected spinal meninges (membranes that cover the spinal cord).  The spinal meninges because inflamed and swollen in association with the bacterial meningitis.  It compresses the motor nerve roots causing irritation.
2. Lumbar puncture is usually performed in between L3 and L4 region.  This is because the spinal cord ends at the conus medullaris (between L1 and L2).  Beyond the conus medullaris, the spinal cord progresses in the form of a horse-tail-like suspended nerve bundle known as the ‘cauda equina’.  The outer layer (dura) and the middle layer (arachnoid) of the meninges end at S1 in the form of a dura sac.  Around this region lumbar puncture (and also other procedures such as administration of LA and contrast media) can be performed.  The fluid that bathes the brain and the spinal cord, known as ‘cerebro-spinal fluid’ (CSF) can be collected.  The CSF is a watery fluid containing proteins and glucose.  It is present in the space present between the inner layer (pia) and middle layer (arachanoid) of the brain and the spinal cord (subarachnoid space).  It is formed by certain specialized cells present in the choroid plexus of the brain.
3. Antibiotics or ‘antimicrobial agents’ are the most important agent required in the treatment of acute bacterial meningitis.  They should be administered immediately.  Some of the commonly administered antibiotics for this condition include 3rd generations cephalosporins (for H. Influenza Type B infection); Penicillin, Amoxicillin or 3rd generation Cephalosporins (for N. Meningitis infection); Vancomycin and 3rd Generation Cephalosporins (for Streptococcus Pneumoniae infection); and 3rd Generation Cephalosporin (for E. Coli infection).  The antibiotics have to be administered for varying periods ranging from 7 to 15 days, depending on the severity and type of infection.  Besides, antibiotics, general nursing (IV fluids, nutrition and oxygen) and antipyretics (to control the fever and pain) may also be required.  Studies have shown that corticosteroids may produce some benefits in about 50% adults.  They may be administered in some patients having a high-risk of developing certain complications such as altered mental status and raised intracranial pressure.
4. Acute pyogenic meningitis is a highly infectious disorder that tends to spread rapidly through close contacts.  The infection spreads through contact with fluids from the nose and respiratory tract.  It tends to spread through coughing, sneezing, kissing, sharing towels, toothbrushes, utensils or cigars.  The bacteria that cause pyogenic meningitis initially colonize the naso-pharynx and later gain access to the blood to enter the brain and other parts of the central nervous system (CNS).  The patient’s girlfriend had come in close contact with the patient in the last few days and hence was at a high-risk of developing the potentially-fatal infection.  Several tests such as lumbar puncture, blood tests, CT scans of the head, chest X-rays, etc may be required to detect meningitis.
5. The patient’s close contacts including the care-givers were also at risk of developing the infection as they had come in contact with his body fluids.  Hence, they had to be prophylactically administered similar antibiotics (to prevent meningitis).  Nowadays, vaccines are also available commercially to protect against a few types of bacterial meningitis.
6. Viral meningitis is usually a less severe condition than bacterial meningitis, and the outcome (prognosis) is usually better.  Individuals with mild infection develop self-limiting symptoms such as malaise, mild fever, body ache, neck pain and stiffness, etc.  The condition usually gets better by itself without any treatment (within a few days).  The individual should drink a lot of fluids and may have to consume painkillers to reduce pain and fever.  Antibiotics are usually not required because they are not effective against viral infections.  However, secondary infections with bacteria may require a course of antibiotics.  Rarely, viral meningitis may be serious in nature.  Under such circumstances treatment is essential.  Various complications such as seizures and severe inflammation may treated by administering antiepileptic and corticosteroids.  The individual should be isolated for a few days, as he/she may infect others.

References

1. Bhargava, I. (2000). Color Workbook for Neuroanatomy. Chennai: East-west Books.
2. Hankey, G. J., & Wardlaw, J. M. (2002). Clinical Neurology. London: Mansons.
3. Mayo Clinic (2006). Meningitis. Retrieved December 18, 2006, from MFMER Web site: http://www.mayoclinic.com/health/meningitis/DS00118/DSECTION=1
4. Roos, K. L., &  Tyler, K. L. (2004). Bacterial Meningitis and Other Suppurative Infections. In Ed. Braunwald, E., Fauci, A., Kasper, D., Hauser, S., Longo, D., and Jameson, J. (Ed), Harrison’s Principles of Internal Medicine. New York: McGraw-Hill.
5. Saberi, A., and Syed, S. A. (1999). “Meningeal Signs: Kernik’s Sign and Brudzinski’s Sign.” Hospital Physician, 23-24. http://www.turner-white.com/pdf/hp_jul99_signs.pdf
6. Wener, K. (2005). Meningitis. Retrieved December 18, 2006, from Medline Plus Web site: http://www.nlm.nih.gov/medlineplus/ency/article/000680.htm