A 24-year-old man was admitted with a generalized tonic–clonic seizure

A 24-year-old man from Brooklyn, NY, was admitted with a generalized tonic–clonic seizure. The patient was complaining of headache and fever 24 hours before the seizure episode.

On admission, the patient was lethargic but arousable and confused. He had nuchal pain when his neck was flexed. He did not have focal neurologic deficits. No rash was seen.

Cerebrospinal fluid (CSF) showed 1354 white cells/µL with 89% neutrophils and 11% lymphocytes. CSF and serum glucose levels were 28 mg/dL and 80 mg/dL, respectively, and CSF protein was 65 mg/dL. A CSF Gram stain reported Gram-positive diplococci. The patient was started on intravenous vancomycin, ceftriaxone, and dexamethasone. A blood culture obtained 36 hours after admission has returned results of Streptococcus pneumoniae with a penicillin minimum inhibitory concentration (MIC) = 0.06 µg/mL.

What changes will you make to this patient’s therapeutic plan?

• start chloramphenicol and penicillin; discontinue vancomycin, ceftriaxone, and dexamethasone
• start penicillin; continue dexamethasone; discontinue vancomycin and ceftriaxone
• continue ceftriaxone; stop dexamethasone
• continue vancomycin; discontinue ceftriaxone and dexamethasone

This question appears in Med-Challenger Emergency Medicine Review with CME

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