Case report

1. Noon Conference
MaryGlen Vielleux –MS3
3/13/2019

2. © 2016 Virginia Mason Medical Center 2
Objectives
Aseptic Meningitis
• Discuss clinical presentation
• Discuss etiologies
• Review diagnostic criteria
• Review illness script
• Discuss treatment

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Meningitis vs Encephalitis
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Normal cerebral function Cerebral dysfunction
Nuchal rigidity Altered mental status
Headache Personality changes
Malaise Focal neuro deficits
Photophobia Speech changes
Nausea Movement disorders
Vomiting Paresthesias
Seizures Seizures

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What are the most common causes of viral
meningitis in immunocompetent hosts?
a. HSV > CMV > Enterovirus
b. Enterovirus > HSV > VZV
c. EBV > HSV > VZV
d. VZV > HSV > CMV

5. © 2016 Virginia Mason Medical Center 5
What are the most common causes of viral
meningitis in immunocompetent hosts?
a. HSV > CMV > enterovirus
b. Enterovirus > HSV > VZV
c. EBV > HSV > VZV
d. VZV > HSV > CMV

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Etiologies of Aseptic Meningitis
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Viruses Bacteria/Fungal Drugs Autoimmune
Enterovirus Tuberculosis TMP-SMX Behcet’s
HSV Leptospirosis NSAIDs Sarcoidosis
VZV Lyme disease IVIG SLE
HIV Syphilis Antiepileptics Hashimoto’s
EBV Rickettsia Cetuximab
CMV Cryptococcus Infliximab
West Nile Toxocariasis Azathioprine
Mumps Cysticercosis Pyridium

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Diagnostic criteria
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CSF Analysis
Opening Pressure High
Color Mildly cloudy
Cells 0-1,000 mm3
Differential Mononuclear
Glucose 9 mg/dL
Protein 66 mg/dL
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What is the most likely cause of slowly progressive
fever, headache, and neck stiffness in a patient with
AIDS (CD4: 89)?
a.Cryptococcus
b.Histoplasma
c. Blastomyces
d.Coccidiodes

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CSF Analysis
Opening Pressure High
Color Mildly cloudy
Cells 0-1,000 mm3
Differential Mononuclear
Glucose 9 mg/dL
Protein 66 mg/dL
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What is the most likely cause of slowly progressive
fever, headache, and neck stiffness in a patient with
AIDS (CD4: 89)?
a.Cryptococcus
b.Histoplasma
c. Blastomyces
d.Coccidiodes

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Treatment
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• If viral vs bacterial unclear, dexamethasone + empiric
antibiotics should be initiated.
• For suspected HSV or VZV, initiate IV acyclovir at
10 mg/kg administered every eight hours, then
transitioned to orals for 10-14 days total of treatment.
• Supportive care with fluid management.
• Consider repeat CSF analysis if no improvement in 48 hrs
or if persistent fever for 8 days without another reason.

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Illness Scripts
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Bacterial Meningitis Viral Meningitis
Epidemiology
Strep pneumo, N. meningitidis,
 50 or with immunodeficiency: Listeria
 Hosp acquired: Staph and gram negs
More common overall
Enterovirus, HSV, VZV, HIV, CMV, West Nile,
Mumps
Time course Acute Acute
Clinical
presentation
Fever, nuchal rigidity, lethargy
Purpuric rash
Fever, nuchal rigidity, lethargy
Typically less severe
Diagnostics
Labs: leukocytosis
CSF: High opening pressure, Cells: 1,000-
50,000, Low glucose (<40), High protein (100-
500), PMN predominance
CSF lactate can be elevated
Labs: variable depending on the etiology
CSF: Normal opening pressure, Cells: 50-
1,000, glucose (>45), high protein (45-200),
lymphocyte predominance
Consider CSF PCR studies
Therapeutics
Dexamethasone + ceftriaxone + vancomycin
(add ampicillin in age 50+ and alcoholics)
Largely supportive
Acyclovir 10mg/kg IV q8 for HSV, VZV

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References
Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention. American Family Physician.
2017 Sep 1;96(5):314-322.
Fungal Meningitis. 2016. CDC.gov
Etiologies and Management of Aseptic Meningitis in Patients Admitted to an Internal Medicine
Department . Irène Jarrin, Pierre Sellier, Amanda Lopes, Marjolaine Morgand, Tamara Makovec,
Veronique Delcey, Karine Champion, Guy Simoneau, Andrew Green, Stéphane Mouly, Jean-François
Bergmann, Célia Lloret-Linares. Medicine (Baltimore) 2016 Jan; 95(2): e2372.
Dynamed Plus: Aseptic Meningitis.
Aseptic meningitis in adults. Allan R Tunkel, MD, PhD, MACP. Martin S Hirsch, MD Jennifer Mitty, MD,
MPH. Sept. 2018. Uptodate.com
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