Endgames Case Report

An agitated man with earache

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3824 (Published 15 September 2010) Cite this as: BMJ 2010;341:c3824
  1. Matthijs C Brouwer, neurologist,
  2. Diederik van de Beek, neurologist
  1. 1Department of Neurology, Centre of Infection and Immunity Amsterdam (CINIMA), Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, Netherlands
  1. Correspondence to: D van de Beek d.vandebeek{at}amc.uva.nl

    A 39 year old man presented to his general practitioner with a one day history of earache and discharge of bloody pus from his right ear. He reported having a cold during the week before the earache started. The doctor diagnosed him with acute otitis and prescribed amoxicillin with clavulanic acid. Overnight the patient developed headache, nausea, and vomiting and was referred to the emergency department of our hospital.

    In the emergency department he was systemically unwell with a blood pressure of 90/55 mm Hg, temperature of 39.5ºC, and pulse rate of 100 beats/min. He had an altered mental status with agitated behaviour and he did not obey commands. He opened his eyes in response to voices, localised painful stimuli, and uttered inappropriate words. Physical examination showed neck stiffness without other neurological deficits.

    Laboratory results on admission showed a white cell count of 20.1×109/l, platelets 194×109/l, C reactive protein 252 mg/l, and serum glucose of 6.9 mmol/l. His arterial blood gas on 5 l of oxygen via a nasal cannula showed pH 7.45, partial pressure of oxygen 8.6, partial pressure of carbon dioxide 4.5, base excess −0.6, and standard bicarbonate 22.8. A chest radiograph was normal. The patient’s medical history was unremarkable.


    • 1 What is the most likely diagnosis?

    • 2 What investigations may aid in diagnosis?

    • 3 What are the common organisms and risk factors associated with this condition?

    • 4 How should it be treated?


    1 What is the most likely diagnosis?

    Short answer

    The most likely diagnosis is bacterial meningitis.

    Long answer

    The classic triad of symptoms and signs of bacterial meningitis are fever, altered mental status, and neck stiffness, which were all present in our patient. This classic triad cannot be used to prove or exclude bacterial meningitis because it is absent in 56% of adults …

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