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

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HardPaediatric emergenciesSuspected bacterial meningitis with a new focal neurological deficitMRCEM SBA

A 6-year-old boy presents with fever, severe headache and neck stiffness. He is confused but obeys commands (GCS 14). Examination reveals new right arm weakness. His pupils are equal and reactive, his blood pressure is normal, and he has no purpuric rash. Intravenous access is established. You strongly suspect bacterial meningitis; senior paediatric assessment and admission are being arranged. What is the most appropriate investigation and treatment sequence?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Take blood cultures, give intravenous ceftriaxone and dexamethasone, obtain cranial imaging, then defer lumbar puncture until the focal signs resolve.

Fever, headache, neck stiffness and confusion make bacterial meningitis strongly suspected. The new arm weakness is a focal neurological feature: despite his relatively preserved GCS and normal pupillary responses, it is a reason to obtain neuroimaging and not to perform lumbar puncture until the feature has resolved. Blood samples should be taken promptly, but imaging must not delay intravenous antibiotics. At age 6 years, strongly suspected bacterial meningitis also warrants intravenous dexamethasone, ideally with or before the first antibiotic dose; ceftriaxone is the recommended initial antibiotic when the organism is unknown. He requires ongoing senior paediatric care, with lumbar puncture reconsidered when safe. A exposes him to lumbar puncture despite a focal deficit. B delays time-critical treatment for imaging and lumbar puncture. C gets the initial treatment sequence right, but a normal scan alone does not remove the clinical contraindication while focal weakness persists. E correctly prioritises antibiotics over imaging and defers lumbar puncture, but omits indicated dexamethasone.

Reference: NICE NG240: Recommendations — neuroimaging and lumbar puncture (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations NICE NG240: Recommendations — antibiotics for bacterial meningitis in hospital (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations NICE NG240: Recommendations — corticosteroids for bacterial meningitis (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations