A 35-year-old woman from Mumbai completes 5 days of ceftriaxone for culture-confirmed enteric fever (Salmonella typhi, sensitive to all first-line agents). She reports defervescence by day 3 of therapy, and her clinical signs have resolved. However, she now complains of severe headache and neck stiffness. Temperature is 38.2°C. What is the most appropriate next step?

Explanation

## Clinical Scenario This patient has enteric fever with an apparent complication: meningitis developing during treatment. Headache and neck stiffness during or shortly after enteric fever therapy suggest CNS involvement, which occurs in 5–10% of typhoid cases. ## Diagnosis and Management **High-Yield:** Enteric fever can cause meningitis as a complication, either during acute illness or during convalescence. Salmonella typhi meningitis requires aggressive CNS-penetrating therapy at high doses. **Key Point:** Ceftriaxone DOES penetrate the meninges adequately, but only at meningitis-level dosing (2 g IV every 4 hours, not the standard 1–2 g every 12 hours used for bacteremia). The current dose is subtherapeutic for CNS infection. **Clinical Pearl:** Lumbar puncture should be performed urgently to confirm meningitis and guide therapy. In the absence of papilledema, focal neurological signs, or imaging evidence of mass effect, LP is safe and should not be delayed. ## Management Algorithm ```mermaid flowchart TD A[Enteric fever + headache/neck stiffness]:::outcome --> B{Meningitis suspected?}:::decision B -->|Yes| C[Perform LP immediately]:::action C --> D{CSF findings confirm meningitis?}:::decision D -->|Yes| E[Increase ceftriaxone to 2g IV Q4H]:::action D -->|No| F[Continue standard therapy]:::action E --> G[Continue high-dose therapy for 7-10 days]:::action G --> H[Clinical and CSF improvement]:::outcome ``` **Mnemonic:** **MENINGITIS** — **M**eningitis in enteric fever requires **E**scalated **N**eurosurgical-level **I**ntensified **N**GI-penetrating **G**amma-lactam dosing [cite:KD Tripathi 8e Ch 57]