A 40-year-old presents with 24 h of headache, fever, confusion (GCS 13) and a focal seizure. How do you proceed, and what if the LP is delayed?

Question

Accepted Answer

Fever + headache + confusion + focal seizure must be treated as **meningoencephalitis** until proven otherwise.

**ABCDE and seizure control.** Airway, oxygen, IV access; terminate seizure with **IV lorazepam 4 mg**, check capillary glucose. Bloods including FBC, U&E, LFTs, CRP, coagulation, **blood cultures × 2, HIV test, throat swab, meningococcal/pneumococcal PCR**.

**Empirical therapy within ONE hour — do NOT delay for LP or CT.** Per **Joint UK guideline (McGill et al, J Infect 2016)**:
- **IV ceftriaxone 2 g BD**
- **Add IV amoxicillin 2 g 4-hourly** for Listeria cover if **>60, immunocompromised, pregnant, alcohol-misuse**
- **IV aciclovir 10 mg/kg 8-hourly** for HSV encephalitis (focal neurology, confusion = high pre-test probability)
- **IV dexamethasone 10 mg QDS** with the first antibiotic dose if bacterial meningitis suspected (reduces deafness and mortality in pneumococcal disease)

**Imaging.** This patient has GCS 13, confusion and a seizure — meets criteria for **CT head before LP** (also: focal neurology, immunocompromised, papilloedema, age >60). CT excludes a mass lesion / raised ICP that would contraindicate LP.

**LP — as soon as safe.** Send: opening pressure, cell count and differential, protein, glucose with paired serum, Gram stain and culture, **viral PCR panel (HSV, VZV, enterovirus)**, lactate, bacterial PCR (meningococcal, pneumococcal). Save extra tube for autoimmune work if needed. Continue empirical therapy until results back.

**Consider autoimmune encephalitis** if no infective cause: **NMDAR, LGI1, CASPR2, GAD, AMPA, GABA-B antibodies** in paired CSF and serum; **MRI brain** (mesial temporal hyperintensity in HSV or limbic encephalitis); **EEG** (focal slowing, periodic discharges). Discuss with **tertiary neurology / neuro-immunology** for immunotherapy (steroids, IVIG, plasma exchange, rituximab).

**Public health.** Notify **UKHSA** for suspected meningococcal or Hib disease; arrange **chemoprophylaxis (ciprofloxacin)** for close contacts via PHE.

**Escalation.** ITU for GCS <8, refractory seizures, raised ICP. **MDT** — infection, neurology, ITU, microbiology, neuro-immunology.

**Communication.** Honest conversation with family about a serious illness with significant mortality and morbidity. Document, Datix any avoidable antibiotic delay (1-hour standard), and reflect.

Acute encephalitis / meningitis with delayed lumbar puncture

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