An Acute Ibuprofen Overdose Masking a Severe Staphylococcus aureus Meningitis: A Case Report

Acute bacterial meningitis has a low incidence (3/100,000 in the United States) and yet high fatality rate (approximately 14–16%) and classically presents as a triad of fever, neck stiffness, and altered mental status. However, less than half of patients with meningitis present with this classic triad. We present the clinical course of a patient who initially presented to the emergency department after overdosing on ibuprofen for what he described as back pain secondary to mechanical injury. However, the patient's condition quickly deteriorated: he developed tachycardia, mental status changes, was intubated due to respiratory distress, and then suffered an 8-minute PEA arrest before return of spontaneous circulation was achieved. After the patient was stabilized, in addition to the nonsteroidal anti-inflammatory drug (NSAID) overdose Staphylococcus aureus meningitis, bacteremia, and pneumonia were diagnosed. We report this case to illustrate that the initial presentation of meningitis may be extremely unusual especially in the setting of NSAID overdose and the acutely decompensating patient. As the risk of adverse clinical outcomes increases with delays in appropriate antibiotic therapy, it is therefore crucial to recognize the many signs and symptoms of meningitis, typical and atypical, and quickly begin appropriate treatment. 1. Introduction This case exemplifies some of the challenges of diagnosing acute bacterial meningitis in the context of acute ibuprofen overdose. A 53-year-old male presented to a community based academic emergency department by means of a personal vehicle. Additional diagnosis are explored and eventual diagnosis of bacterial meningitis is made. Treatment is started and the patient had a poor clinical outcome secondary to failure of prompt diagnosis. The initial workup and stabilization of acute ibuprofen overdoes are discussed as well as current recommendations for the diagnosis and treatment of bacterial meningitis. 2. Case Presentation A 53-year-old male presented to an academic community Emergency department via personal vehicle. The patient states that he had been having increasing low back pain for four days following a twisting injury at work while lifting a heavy object. At time of presentation, the patient was ambulatory with steady gait. The patient states that, while lifting a box of heavy papers from the trunk of his car, he rotated to the right and felt a “pop.” Following this episode he had pain to the point that he states that he found it painful to get out of bed and attempted to relieve his pain with what he