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INTRODUCTION

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The management of infectious diseases requires an understanding of the presenting clinical manifestations and knowledge of microbiology. Many infections present with constellations of focal and systemic signs and symptoms that in typical cases are highly suggestive of the diagnosis, though the disease might be caused by any of several different organisms. Making a clinical diagnosis with subsequent laboratory confirmation is part of the art of medicine. This chapter presents 24 cases and brief discussions of the differential diagnosis and management of those infections.

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The reader is referred to earlier chapters of this book for characterizations of the organisms; to Chapter 47 for information about diagnostic microbiology tests; and to textbooks of medicine and infectious diseases for more complete information about the clinical entities.

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CENTRAL NERVOUS SYSTEM

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CASE 1: MENINGITIS

A 3-year-old girl was brought to the emergency room by her parents because of fever and loss of appetite for the past 24 hours and difficulty in arousing her for the past 2 hours. The developmental history had been normal since birth. She attended a day care center and had a history of several episodes of presumed viral infections similar to those of other children at the center. Her childhood immunizations were current.

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Clinical Features
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Temperature was 39.5°C, pulse 130/min, and respirations 24/min. Blood pressure was 110/60 mm Hg.

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Physical examination showed a well-developed and well-nourished child of normal height and weight who was somnolent. When her neck was passively flexed, her legs also flexed (positive Brudzinski sign, suggesting irritation of the meninges). Ophthalmoscopic examination showed no papilledema, indicating that there had been no long-term increase in intracranial pressure. The remainder of her physical examination was normal.

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Laboratory Findings
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Minutes later, blood was obtained for culture and other laboratory tests, and an intravenous line was placed. Lumbar puncture was performed less than 30 minutes after the patient arrived in the emergency room. The opening pressure was 350 mm of cerebrospinal fluid (CSF) (elevated). The fluid was cloudy. Several tubes of CSF were collected for culture, cell counts, and chemistry tests. One tube was taken immediately to the laboratory for Gram staining. The stain showed many polymorphonuclear (PMN) cells with cell-associated (intracellular) gram-negative diplococci suggestive of Neisseria meningitidis (Chapter 20).

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Blood chemistry tests were normal. The hematocrit was normal. The white blood cell count was 25,000/μL (markedly elevated), with 88% PMN forms and an absolute PMN count of 22,000/μL (markedly elevated), 6% lymphocytes, and 6% monocytes. The CSF had 5000 PMNs/μL (normal, 0–5 lymphocytes/μL). The CSF protein was 100 mg/dL (elevated), and the glucose was 15 mg/dL (low, termed hypoglycorrhachia)—all consistent with bacterial meningitis. Cultures of blood and CSF grew serogroup B N meningitidis.

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Treatment
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Intravenous cefotaxime therapy was started within 35–40 minutes of the ...

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