P3C064: Pediatric Meningitis Disguised as Eclampsia

Introduction: Adolescent patients are at risk for pediatric diseases and common adult pathologies. As a result, anchoring based on age or early diagnostic data and over reliance on specific aspects of history can delay accurate diagnosis and appropriate therapy.

Case Description: A 17 year old female with history of recurrent urinary tract infections presented to a pediatric emergency department (ED) with headache, dizziness, chills for 2 days. Based on history, triage obtained a urinalysis(UA) and urine pregnancy test. Initial vital signs showed only tachycardia to 122. Urine pregnancy returned positive and UA had trace protein, 1+ leukesterase, nitrite negative, few bacteria. Given bHCG was send out lab/unable to obtain transvaginal ultrasound (TVUS) was not available, transfer to adult facility with obstetric services was coordinated. However, prior to transfer, patient rapidly decompensated, becoming increasingly tachycardic, febrile and encephalopathic which progressing to seizure. Suspicious for eclampsia or ectopic pregnancy versus septic abortion plans continued for transfer. Further clinical deterioration with second seizure and drop in blood pressure prompted intubation for airway protection, antiepileptic administration, broad spectrum antibiotics and ultimately vasopressor support. Non-contrasted CT scan of the head showed only sinus disease. She transferred emergently to an adult ED with obstetric consultation. Her hypotension and lack of proteinuria excluded eclampsia as seizure etiology. TVUS revealed gestational sac without fetal pole/yolk sac suggesting spontaneous abortion, less likely source of infection, thus alternate infectious etiologies were sought. She was admitted to medical critical care unit sedated, on vasopressor, antibiotic and ventilatory support. Approximately 15 hours after initial presentation, lumbar puncture demonstrated turbid/cloudy fluid and pleocytosis consistent with bacterial meningitis; antimicrobial therapy tailored accordingly. Cerebrospinal fluid (CSF) bacterial and fungal cultures proved unrevealing, as did blood and urine cultures (suspected due to several antimicrobial therapies prior to cultures). With appropriate therapy, the patient was weaned off sedation, vasopressors and mechanical ventilation. MRI in effort to elucidate meningitic source demonstrated ​​diffuse paranasal sinus disease with right mastoid opacification, mild enhancement of perisinus meninges and question of skull base erosion. Further history revealed prior endoscopic sinus procedures. Patient transferred back to the pediatric facility where she underwent ENT washout with focus on skull base and mastoid. She completed a course of antibiotic therapy for meningitis and made a full recovery. Notably, patient had not yet received her teenage meningitis vaccinations which were administered prior to hospital discharge.

Discussion: In pediatric clinical practice, teens seen as “small adults” biases clinicians from common, perhaps more likely diagnoses. In this instance, patient seizures and septic shock were secondary to bacterial meningitis, a much more common pediatric diagnosis relative to eclampsia and septic abortion.

Conclusion: The patient’s positive pregnancy test served as a distractor biasing clinicians leading to multiple hospital transfers, delaying accurate diagnosis and appropriate therapy.