Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

Acute Bacterial Meningitis Acute Fatty Liver of Pregnancy 21

and cephalosporin-susceptible, narrow to third-generation

cephalosporin

■If dexamethasone used with vancomycin, consider adding rifampin

to increase vancomycin entry into CSF.

follow-up

During Treatment

■Look for contiguous foci (sinusitis, mastoiditis, otitis media) or dis-

tant infection (endocarditis, pneumonia) with S pneumoniae

■Narrow coverage as culture results and susceptibility data allow

■If patient on adjunctive corticosteroids and not improving as

expected, or if pneumococcal isolate, repeat LP 36–48 hours after

starting antibiotics to document CSF sterility

■Treat close contacts of patients with N meningitidis to eradicate

carriage. If not treated with a third-generation cephalosporin, the

patient should receive chemoprophylaxis as well.

complications and prognosis

Complications

■Seizures, coma, sensorineural hearing loss, cranial nerve palsies,

obstructive hydrocephalus, subdural effusions, CSF fistula (espe-

cially likely with recurrent meningitis), syndrome of inappropriate

antidiuretic hormone

■Consider placing ICP monitoring device

■ICP >15–20, elevate head to 30 degrees, hyperventilate adults

Prognosis

■Average case fatality: 5–25%

■N meningitidis: 3–13%

■S pneumoniae: 19–26%

■L monocytogenes: 15–29%

Acute Fatty Liver of Pregnancy...........................

CAROLINE A. RIELY, MD

history & physical

History

■Nausea and vomiting, bleeding from gums or elsewhere, signs and

symptoms of preeclampsia, coma, either hepatic or hypoglycemic

■Third trimester of pregnancy, or post partem. Often primipara.

■Rare