A 34-year-old female caterer of Chinese origin presented to her general practitioner (GP) with a fever of 40°C in a drowsy and incoherent state. The GP administered an intramuscular injection of benzylpenicillin, suspecting meningitis. The patient was referred to the medical admissions unit (MAU) where she was seen immediately by the senior house officer. She gave a 3 month history of feeling unwell with intermittent fevers, myalgia, headaches and neck stiffness. Her headaches were occipital in nature and usually worse in the morning. She reported no rash and no photophobia. There was no history of loss of appetite or weight loss.
The patient had undergone a splenectomy 9 years earlier following a prolonged course of steroids for idiopathic thrombocytopenic purpura. She took prophylactic penicillin after her splenectomy but stopped after 3 years following advice from her GP. There was no other significant past medical history. There was no history of recent travel. She was not taking any regular medications and admitted to having a yearly flu injection.
On examination the patient was sweaty with a temperature of 38.5°C, a pulse of 94 beats/min, and blood pressure of 115/60 mm Hg. She described pain on flexing her neck but Kernigs was negative. There was no rash or photophobia. Fundoscopy and full neurological examination were normal. There were no peripheral stigmata of subacute bacterial endocarditis but she was found to have a diastolic murmur. Her chest was clear and abdomen was soft, with the presence of a splenectomy scar. Her urine dip stick was negative for blood and protein.