CC:headache HPI:patient came to the ER because of worsening headache, that started 5 days ago, on the left side of the head and now radiating to the right side of the head, scoring 9/10, pressure like, continues ,gradual increasing, tylanol could not relief it.
ROS: GEN: fatigue, subjective weight loss, fever, chills, night sweats. Skin: rash on her forehead, left side. Ears: no hearing loss, no tinnitus. Mouth: no sore throat. Chest: no chest pain, palpitations, no SOB. GI:N/V, constipation. GU: none. Neuro: numbness in the left hand, no seizure, no paralysis, no memory loss.
Head CT scan: No evidence of intracranial hemorrhage, acute infarction, mass or midline shift. the ventricles and basal cisterns are within normal limits. the visualized portions of the Paranasal sinuses and mastoid air cells are clear.
Enteroviruses — Aseptic meningitis the most common cause of viral meningitis .
Cerebrospinal fluid (CSF) findings are typical of other viral meningitides and include a white blood cell (WBC) count that is generally less than 250 cells/microL, a modest elevation in CSF protein concentration (generally less than 150 mg/dL), and a normal glucose concentration.
Herpes simplex meningitis — Primary HSV has been increasingly recognized as a cause of viral meningitis in adults. In contrast to HSV encephalitis, which is almost exclusively due to HSV-1, viral meningitis in immunocompetent adults is generally caused by HSV-2.
genital lesions are present in approximately 85 percent of patients with primary HSV-2 meningitis and generally precede the onset of CNS symptoms by seven days. The CSF profile includes a pleocytosis with a predominance of lymphocytes, and a normal CSF glucose concentration .
HSV meningitis can also occur without evidence of genital lesions, although this is less common.
Suspected viral meningitis — The approach to empiric therapy in the patient with viral meningitis will depend upon the clinical appearance of the patient and underlying host factors. Patients who are elderly, immunocompromised, or have received antibiotics prior to presentation may be considered for empiric therapy for 48 hours, even if viral meningitis is the suspected diagnosis. Otherwise, the clinician can consider observing the patient without antibiotic therapy.
If HIV is a diagnostic consideration, then blood testing for HIV RNA and HIV antibody should be performed. (See "Diagnostic assays for HIV infection" and "Techniques and interpretation of HIV-1 RNA quantitation " .)
If aseptic meningitis due to HSV is suspected (eg, concomitant genital lesions), empiric therapy with acyclovir (10 mg/kg intravenously every eight hours) can be administered. (See "Acyclovir: An overview" .)