An 11 year old boy with chest pain and fever

A previously well 11 year old boy was transferred to a regional hospital by his local doctor after being given an empirical dose of intramuscular ceftriaxone (25 mg/kg) because of a 24 hour history of fever (40°C), vomiting, headache, neck pain, and rash.

On arrival the patient was alert, afebrile, and seemed to be haemodynamically stable, with a heart rate of 60 beats/min, blood pressure 120/70 mm Hg, respiratory rate 18 breaths/min, and a Glasgow coma score of 14. He had pronounced neck stiffness and a widespread non-blanching petechial rash but no focal neurological signs, and examination of his precordium and lung fields was normal. A blood culture was taken, and he was given a bolus of intravenous normal saline (20 ml/kg) plus cefotaxime (50 mg/kg), dexamethasone (0.15 mg/kg), and ondansetron (0.05 mg/kg).

Initial investigations showed a haemoglobin of 132 g/l (normal range 110-150), platelet count 288×10⁹/l (150-400), and peripheral white blood cell count 34.7×10⁹/l (6.0-17.0) (absolute neutrophil count 24.3×10⁹/l; bands 6.9×10⁹/l). Sodium was 141 mmol/l (135-145) and glucose was 5.3 mmol/l (3.0-5.4). C reactive protein was 143 mg/l (normal <8 mg/l) and international normalised ratio was 2.0 (0.8-1.2).

Within 90 minutes of arrival at the regional hospital, the patint’s clinical condition deteriorated greatly, with a decreasing level of consciousness (Glasgow coma score 10), and he was subsequently intubated and ventilated. Transfer to the intensive care unit was arranged, and intravenous aciclovir (16 mg/kg eight hourly) was added. A computed tomography brain scan and electroencephalogram were normal. A lumbar puncture was deferred because of the abnormal coagulation profile, but dexamethasone (0.15 mg/kg intravenously every six hours) was continued for four days on the presumptive diagnosis of meningitis. Inotrope support was not needed, and he was extubated within 24 hours of arrival.

On …