WBR1095

Author	Chetan Lokhande
Exam Type	USMLE Step 3
Main Category
Sub Category	Head and Neck, Neurology, Infectious Disease
Prompt	An 11-month-old previously healthy African American female from Haiti comes to Emergency room (ER) with generalized tonic clonic seizures with 1-day history of lethargy, fever and altered mental status. Enroute to hospital, emergency medical team intubated her and gave a dose of lorazepam, with no remission. In the ER 1 more dose of lorazepam was given and patient was transferred to ICU for further management, where vitals were within normal limits. Overnight EEG showed a pattern of status epileptics. The patient was medically paralyzed and put on a ventilator. Complete blood count, Chem 10 and CT scan all are within normal limits. She was given a dose of quinine for malaria, but stopped due to negative thick and thin smear. What is the next step in the management of this patient?
Answer A	Start antiepileptic medications.
Answer A Explanation	Incorrect: Antiepileptic medications should not not be started before obtaining a lumbar puncture.
Answer B	Start broad-spectrum antibiotics.
Answer B Explanation	Incorrect: First a lumbar puncture should be performed before starting antibiotics.
Answer C	Start steroids.
Answer C Explanation	Incorrect: Steroids have not been proved to be the effective in meningitis except in Tb meningitis. Also a lumbar puncture is the best initial step in this case to rule out meningitis from encephalitis.
Answer D	Start with antiviral and antimalarial treatment together.
Answer D Explanation	Incorrect: Before starting any antibiotic therapy or empirical treatment lumbar puncture must be performed to rule out meningitis from encephalitis.
Answer E	Order a Lumbar Puncture.
Answer E Explanation	Correct: The best next step in the management of fever and seizures is doing a lumbar puncture to rule out meningitis from encephalitis.
Right Answer	E
Explanation	A history of fever and seizures in a 11 month old child is highly suggestive of an infection . Since the patient is from Haiti where malaria and other parasitic infection are endemic an empirical therapy of anti malarial should be started right away . Since the thick and thin smears are negative malaria is ruled out and other infectons should be thought about. The next step in the management is do a lumbar puncture and rule out other infection like meningitis from encephalitis. Educational objective: Rule out encephalitis and meningitis before starting empirical therapy in a case of unknown sezirues with fever. Lumbar puncture is always the next best step in the management. Educational Objective: References:
Approved	Yes
Keyword	Lumbar puncture, Meningitis, Encephalitis.
Linked Question
Order in Linked Questions