Case 38 A man with a headache: Swine flu or meningitis?

A woman telephoned Dr Craig in late July 2009 on a weekend evening. She was concerned about her husband Joe, aged 42. She stated that he had been feeling unwell for three days with a fever. He had a persistent headache. He had vomited once in the bed. She said he preferred to keep the curtains shut and was feeling generally unwell.

Dr Craig, who was triaging calls, referred to an e-mail from the Royal College of GPs (July 2009) that stated:

The Department of Health advises that people who have any of the following symptoms and a temperature of 38 °C and above or feels hot may have swine flu.

The typical symptoms are:

Other symptoms may include:

What would you do now?

Dr Craig established that there was a history of fever (over 38 °C), a headache, and muscular aching. He was told about the single vomit (about 12 hours previously). He established there was no breathing difficulty, no sore throat, no cough, or runny nose. Dr Craig suggested to Joe’s wife that the diagnosis was probably swine flu. Dr Craig issued a prescription for Tamiflu.

Was it reasonable to diagnosis swine flu and authorize Tamiflu?

Five hours later Joe’s wife telephoned back. Dr Craig asked her whether there was anything else that particularly concerned her or anything that seemed to her to be unusual for influenza. She responded that Joe had been unhappy with the light when she had opened the curtains, and also seemed at one point to have been uncertain as to what day it was and how long he had been ill.

What would be your differential diagnosis and how would you discriminate between them?

The information suggesting photophobia and possible confusion was a matter for concern to Dr Craig and he arranged for a colleague, Dr Evans, to visit. Dr Evans found that Joe had a fever of 38.5 °C, appeared to have a severe headache, and appeared to have pain and stiffness when Dr Evans flexed his neck. There was no evidence of mental confusion and Joe denied having been disorientated. However, Dr Evans was concerned about meningitis and referred Joe to hospital as an emergency.

In hospital Joe had a lumbar puncture which did not confirm bacterial meningitis – he was treated with antibiotics but the final conclusion was that he had a viral meningitis.

In this case Joe and his wife were grateful to Dr Evans for his prompt and accurate response.

Can Dr Craig be criticized for his initial diagnosis of flu? Headache is relatively common with influenza. How does one avoid admitting everyone with flu?

Expert comment

It is difficult to avoid the temptation to avoid cutting corners and making the ‘obvious’ diagnosis, particularly in times of an epidemic.

The familiar cognitive errors would be ‘anchoring’ (a reluctance to depart from the basic hypothesis that this would be a case of influenza), ‘availability’ (because the diagnosis of influenza would be in mind during an epidemic) and confirmation bias (a tendency to elicit symptoms consistent with the influenza hypothesis) leading to premature diagnostic closure.

In this case the coincidence of fever, headache and general malaise did suggest the diagnosis of influenza. However, there was a lack of respiratory tract symptoms. This is unusual with influenza. 84% of patients with influenza have a cough and only 16% do not (Call et al., 2004). 84% of patients with influenza also have headache but photophobia and neck stiffness is rare (Call et al., 2004). At the time of the second telephone consultation Dr Craig sought information that was inconsistent with the hypothesis of influenza and was rewarded with the mention of photophobia and possible confusion.

Legal comment

Dr Craig’s initial diagnosis of flu was wrong. Perhaps he could be criticized, because he did not arrange for Joe to be seen sooner. However, there has been no adverse outcome and Joe and his wife are grateful for the care that Dr Evans provided.

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