Case Presentation On Viral Meningitis

1. Case presentation on viral meningitis
Presented by :
METI.BHARATH KUMAR
16DK1T0014
Pharm-D(Intern)

2. Demographics
• Name :xyz
• Age :24YRS
• Sex:female
• Admission No:944
• Department : general medicine
unit :FM-7
• Date of admission :6/1/22
• Consultant physician:Dr Maheswara Reddy

3. Subjective evidence
• A 24yrs old female patient admitted in female
medical unit with complaints of
-fever since 10days
-altered sensorium
-fever associated with chills and rigors
-headache and body pains associated with
vomitings

4. Objective evidence
• CT and MRI normal study
• CBP : increased WBC count
• CSF analysis : glucose :54mg/dl
proteins:136mg/dl
cells: 130cells (90% lymhocytes)

5. Assesment
• Based on subjective and objective evidences
current condition is diagnosed as viral
meningitis

6. Planning
vitals
• Temp : febrile
• PR: 110bpm
• RR: 18/min
• SPO2 98% at RA
• BP:100/50 mmhg
• RBS: 96mg/dl
• Cvs : s1s2+
• RS : b/l AE +
• CNS:plantar b/l extension
treatment
• Inj taxim 2g iv bd
• Inj artesunate 120mg iv
• Inj clindamycin 300mg od
• Cap doxcycline bd
• Inj acyclovir 500mg iv tid
• Inj mannitol 100li iv tid
• Tab pct 500mg po tid

7. Drug chart
s.n
o
generic bran
d
indication Dose ROA frequ
ency
acyclovir To reduce vral infection 500mg po tid
2 artesunate To reduce malaria 120mg Iv Od
3 cefotaxim taxi
m
To reduce infection 2g Iv Bd
4 clindamycin To reduce fungal infection 300mg iv Od
5 doxycycline To reduce bacterial infection 200mg Po Bd
6 Pantoprazole pant
op
To reduce gi irritatio 40mg Iv Od
7 B complex Vitamin supplement 500mg po Od
Patient is kept on inj acyclovir 500mg iv tid . Pt improved
symptomatically from day 2 , advice to continue for next 14
days

8. discussion
• Meningitis is an inflammation (swelling) of the
protective membranes covering the brain and
spinal cord. A bacterial or viral infection of the
fluid surrounding the brain and spinal cord
usually causes the swelling.
• Pathophysiology. The brain is protected by the
skull and the pia, arachnoid, and dural meninges
as well as the blood–brain barrier. When any of
these defenses are breached by a microbial
pathogen an infl ammatory response within the
CSF occurs

9. • Classification and Risk Factors. Most commonly classified
based on the infecting pathogen and location at the onset
of illness.
• 1. Community-acquired meningitis. Patients have not been
recently hospitalized and/or undergone any recent
procedures (e.g., CSF shunt). Predisposing factors include
preexisting diabetes mellitus, otitis media, sinusitis,
pneumonia, and alcohol abuse. Pathogens can include
bacterial, viral, fungal, or parasitic agents.
• 2. Nosocomial meningitis and ventriculitis. Most commonly
related to infections associated with CSF shunts, CSF drains,
intrathecal drug therapy, deep brain stimulation hardware,
neurosurgery procedures, and head trauma. Also usually
associated with a typical nosocomial bacterial pathogen
(e.g., methicillin-resistant Staphylococcus aureus [MRSA] or
vancomycin-resistant Enterococcus spp)

10. CAUSES OF MENINGITIS
• A. Bacterial.
Predisposing factors depend on age, comorbid status, immune state,
and/or alcoholism.
• 1. Streptococcus pneumoniae. Most common cause of both
community and nosocomial infections despite the patient age or
immune status.
• 2. Haemophilus influenzae type B. Vaccination efforts have declined
rates in children.
• 3. Neisseria meningitidis (serogroups A, B, C, W135, and Y). Most
common pathogen in healthy young adults.Serogroup Y is
predominant in the United States and the second most common in
parts of Europe. Serogroup B is the most common strain across
Europe. Serogroup A has been responsible for large outbreaks in
the meningitis belt of Africa.

11. • 4. Listeria monocytogenes. Most commonly occurs in
infants and patients over the age of 50 years with cell-
mediated immune deficits and/or alcoholism.
• 5. Streptococcus pyogenes (group A beta-hemolytic
streptococci). Usually secondary to otitis media.
• 6. Streptococcus agalactiae (group B beta-hemolytic
streptococci). Most often occurs in poorly controlled
diabetic patients with an associated infection who are
greater than 65 years of age.
• 7. Staphylococcus (S. aureus or coagulase-negative
staphylococcus). Most frequently occur in the setting of
neurosurgical procedures or placement of CSF shunts.

12. • 8. Gram-negative bacilli (Pseudomonas or enteric
pathogens). Have been associated with
nosocomial meningitis in patients over the age of
50.
• 9. Mycobacterium tuberculosis (MTB). Usually
occurs in the setting of extrapulmonary
disseminated disease (see Chapter 14,
Tuberculosis, for more information).
• 10. Spirochetes. Treponema pallidum (secondary
syphilis) and Borrelia burgdorferi (Lyme disease)

13. • B. Viral.
Most commonly affect children but can occur at any age.
• 1. Enteroviruses (e.g., Coxsackie A and B, echovirus, poliovirus, and
enterovirus 71). Account for the majority of viral meningitis cases
with a fecal–oral transmission during late summer and autumn in
temperate climates (occurs year-round in the tropics).
• 2. Herpes simplex virus (HSV-1, HSV-2). HSV-2 accounts for the
majority of cases in association with primary genital herpes. In
immunocompetent patients, pure HSV meningitis is a self-limiting
condition, whereas HSV meningitis in immunocompromised hosts
or HSV encephalitis is a life-threatening medical emergency
requiring treatment.
• 3. Varicella-zoster virus (VZV). Almost always associated with
reactivation (e.g., shingles) rather than primary infection (e.g.,
chickenpox).
• 4. HIV. Most often occurs in the setting of acute infection (e.g.,
acute retroviral syndrome—lymphadenopathy, dermatitis,
pharyngitis, and oral candidiasis).

14. • 5. Measles–mumps–rubella (MMR) viruses. Rates have
declined with vaccination efforts, but the most
common cause in unvaccinated patients would involve
mumps (more common in males with or without
parotid gland swelling).
• 6. Arthropod-borne viruses and West Nile virus. Most
commonly associated with meningoencephalitis (see
Chapter 33, Infectious Encephalitis).
• 7. Lymphocytic choriomeningitis virus and Hantavirus.
These are rare causes associated with contact by
infected rodents.

15. C. Fungal. Pathogens most commonly occur in nosocomial
infections or immunocompromised patients such as
transplantation of stem cells or solid organs and with
HIV/AIDS (i.e., CD4 cell count below 200 cells/mm³).
While Candida and Aspergillus species are common,
other pathogens include:
1. Cryptococcus neoformans
2. Histoplasma capsulatum
3. Coccidioides immitis
D. Parasitic. Rare cause of community-acquired meningitis,
but the freshwater amoeba Naegleria fowleri can cause
primary amebic meningoencephalitis. Amoeba gain
access to the meninges and brain through disruption of
the cribriform plate and olfactory nerve and are nearly
always fatal.

16. CLINICAL PRESENTATION OF
MENINGITIS.
While the clinical presentation of meningitis may vary in children and
older adults, the classic triad is: acute onset fever, neck stiffness,
and altered mental status.
• A. Fever. Present in the majority of patients but may be absent in
older adults or immunocompromised.
• B. Neck Stiffness. Occurs in the majority of patients and most
commonly associated with headache.
• C. Altered Mental Status. Is typically defi ned as a Glasgow coma
score of less than 12 or a change in the patient’s baseline mental
status (e.g., dementia)
• D. Headache. Occurs in response to meningeal infl ammation. E.
Photophobia. Reduced tolerance to bright light presumed to be due
to meningeal infl ammation of the trigeminal nerve (ophthalmic
branch of cranial nerve 5). More commonly occurs with viral
meningitis. F. Nausea and Vomiting

17. CSF analysis
• Normal CSF values are: glucose 45 to 80
mg/dL with a bloodto-CSF glucose ratio
greater than or equal to 0.6; protein 15 to 45
mg/dL; and white blood cell (WBC) count less
than 5/mcL. CSF values should be obtained as
soon as possible following LP, as delays can
alter the cell count and glucose (falsely low
values).

18. Typical CSF Findings for Meningitis
Pathogen WBC Count Differential CSF/Serum
Glucose
Protein
Viral 50–1,000 Lymphocytic
*
≥0.6 Minimally
elevated
Bacterial** 500–5,000 Neutrophilic ≤0.4 Elevated
Tuberculosis 50–300 Monocytic ≤0.3 Elevated
Cryptococcu
s
20–500 Monocytic ≤0.5 Elevated

19. Treatment
As it is diffi cult to differentiate bacterial from viral or fungal meningitis on
clinical grounds alone, patients often are placed on empirical antimicrobial
therapy based on the most likely pathogen that should be initiated as soon as
the diagnosis is considered.

21. Viral Meningitis
1. HSV a. Immunocompetent host. Usually due to
HSV-2 with primary genital herpes. Thus, the
treatment is directed to genital herpes. b.
Immunocompromised host. Usually treatment is
with acyclovir 10 mg/kg IV q8 (adjusted for renal
failure) for 14 to 21 days.
2. 2. VZV. Usual treatment is the same as for
shingles with acyclovir 10 mg/kg IV q8 for 7 to
10 days or valacyclovir 1 g PO q8 for 7 to 10
days.