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Suspected acute bacterial meningitis with a new focal neurological deficit — MRCEM SBA MCQ

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HardInfection and sepsisSuspected acute bacterial meningitis with a new focal neurological deficitMRCEM SBA

A previously well 43-year-old woman presents with fever, severe headache and neck stiffness. She is newly confused (GCS 14) and has a new left arm weakness. Her blood pressure is 128/76 mmHg, and she has no rash or seizure activity. Bacterial meningitis is strongly suspected. She has no antibiotic allergy. Intravenous access is established, but no samples have been taken and treatment has not started. CT head can be arranged, but will not be immediate. Which management sequence is most appropriate?

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Correct answer: E — Take blood samples, give intravenous dexamethasone and ceftriaxone, perform CT head, then defer lumbar puncture until the focal deficit resolves.

Fever, headache, neck stiffness and new confusion strongly suggest bacterial meningitis. The new arm weakness changes the usual investigation sequence: it is a focal neurological feature for which NICE recommends neuroimaging and advises against lumbar puncture until the concerning feature has resolved. Blood samples and treatment come before imaging; waiting for CT must not postpone antibiotics. Intravenous ceftriaxone is appropriate initial treatment when the organism is unknown, and intravenous dexamethasone should be given with or before the first antibiotic dose if possible. She requires admission and urgent specialist assessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/recommendations)) A delays treatment for CT. B correctly starts treatment but treats imaging as sufficient permission to puncture while the focal deficit persists. C punctures before the indicated imaging. D gets the antibiotic–imaging–puncture sequence right but omits indicated dexamethasone. If the focal feature resolves and lumbar puncture is safe, it should be performed as soon as possible, even though antibiotics have already begun. Dexamethasone must not itself delay ceftriaxone. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/recommendations))

Reference: NICE NG240: Investigating suspected bacterial meningitis in hospital (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations NICE NG240: Antibiotics for bacterial meningitis in hospital (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations NICE NG240: Corticosteroids for bacterial meningitis (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations