Aseptic MeningitisAseptic MeningitisBy: Seth YandellBy: Seth Yandell

Case PresentationCase Presentation

HPI: 31 y/o WF who 3 days prior to HPI: 31 y/o WF who 3 days prior to presentation had finished a 5 day course presentation had finished a 5 day course of Telithromycin prescribed by her PCP for of Telithromycin prescribed by her PCP for a URI, developed a severe HA approx 24 a URI, developed a severe HA approx 24 hours ago. The onset was sudden, the hours ago. The onset was sudden, the pain was located behind her eyes and in pain was located behind her eyes and in the back of her head, was throbbing in the back of her head, was throbbing in nature, and she rated it a 6/10 . She had nature, and she rated it a 6/10 . She had some associated neck stiffness and lower some associated neck stiffness and lower back pain. The HA was not relieved by back pain. The HA was not relieved by Naprosyn. No fevers or chills.Naprosyn. No fevers or chills.

Case Presentation con’tCase Presentation con’t PMH: Notable for HSV2-her initial outbreak PMH: Notable for HSV2-her initial outbreak

was four years ago with no lesions in the was four years ago with no lesions in the last 9 months. Pt states that about one last 9 months. Pt states that about one week after her initial outbreak she week after her initial outbreak she developed meningitis and she was told it developed meningitis and she was told it was secondary to her herpes outbreak. was secondary to her herpes outbreak. Also has well controlled asthma.Also has well controlled asthma.

Current meds- Advair, Naprosyn, OCPCurrent meds- Advair, Naprosyn, OCP SH-no sick contacts, no recent travel, SH-no sick contacts, no recent travel,

married and her husband was her only married and her husband was her only sexual partner, No IVDUsexual partner, No IVDU

Case Presentation con’tCase Presentation con’t

FH-non contributory, no migraine FH-non contributory, no migraine history, no h/o malignancyhistory, no h/o malignancy

ROS- +mild difficulty concentrating, ROS- +mild difficulty concentrating, +photophobia, otherwise negative+photophobia, otherwise negative

PE- afebrile, VSSPE- afebrile, VSS only positive findings were mild only positive findings were mild

nuchal rigidity, lower back pain on nuchal rigidity, lower back pain on Kernigs manuever, and a positive Jolt Kernigs manuever, and a positive Jolt accentuation signaccentuation sign

General DefinitionGeneral Definition Asepsis-Asepsis- Pronunciation: (a-sep'sis, a-)Pronunciation: (a-sep'sis, a-)

A condition in which living pathogenic organisms are A condition in which living pathogenic organisms are absent; a state of sterility (2). Etymology: G. [a-] priv. + absent; a state of sterility (2). Etymology: G. [a-] priv. + [sepsis,] putrefaction[sepsis,] putrefaction

meningitismeningitis - - Pronunciation: (men-in-ji'tis) Pronunciation: (men-in-ji'tis)Inflammation of the membranes of the brain or spinal cord.Inflammation of the membranes of the brain or spinal cord.

Aseptic meningitisAseptic meningitis – refers to patients who have clinical – refers to patients who have clinical signs and laboratory evidence for meningeal inflammation signs and laboratory evidence for meningeal inflammation with negative routine bacterial cultureswith negative routine bacterial cultures

History of MeningitisHistory of Meningitis

It has been recognized since as early as the 15It has been recognized since as early as the 15thth Century, when Hippocrates taught “If, in a fever, the Century, when Hippocrates taught “If, in a fever, the neck be turned awry on a sudden, so that the sick can neck be turned awry on a sudden, so that the sick can hardly swallow, and yet no tumour appear, it is hardly swallow, and yet no tumour appear, it is

mortal.-Aphorism XXXV.”mortal.-Aphorism XXXV.” It was first described as a specific disease entity by It was first described as a specific disease entity by

British physician Thomas Willis (1621-1675) and British physician Thomas Willis (1621-1675) and Italian anatomist and pathologist Battista Morgagini Italian anatomist and pathologist Battista Morgagini (1682-1771)(1682-1771)

The earliest suspected epidemic in the US occurred in The earliest suspected epidemic in the US occurred in Medfield, MA, in 1806 when on autopsy pus was noted Medfield, MA, in 1806 when on autopsy pus was noted between the patients dura and pia mater (thought to between the patients dura and pia mater (thought to be bacterial meningitis).be bacterial meningitis).

Common SymptomsCommon Symptoms

FeverFever HeadacheHeadache Altered mental statusAltered mental status Stiff neckStiff neck PhotophobiaPhotophobia Nausea/vomitingNausea/vomiting

Physical ExamPhysical Exam

Can vary depending on the etiology Can vary depending on the etiology +/- Fever+/- Fever +/- Lethargy+/- Lethargy +/- Kernig’s sign+/- Kernig’s sign +/- Brudzinski’s signs+/- Brudzinski’s signs +/- Jolt Accentuation of Headache +/- Jolt Accentuation of Headache

signsign

Kernig’s signKernig’s sign Vladimir Kernig was a Russian physician who first described his sign in 1882. This is Kernig's Vladimir Kernig was a Russian physician who first described his sign in 1882. This is Kernig's

original description: original description:

"I have observed for a number of years in cases of Meningitis a symptom which is apparently "I have observed for a number of years in cases of Meningitis a symptom which is apparently rarely recognized although, in my opinion, it is of significant practical value. I am referring to rarely recognized although, in my opinion, it is of significant practical value. I am referring to the occurrence of flexion contracture in the legs or occasionally also in the arms which the occurrence of flexion contracture in the legs or occasionally also in the arms which becomes evident only after the patient sits up....the stiffness of neck and back will ordinarily becomes evident only after the patient sits up....the stiffness of neck and back will ordinarily become much more severe and only now will a flexion contracture occur in the knee and become much more severe and only now will a flexion contracture occur in the knee and occasionally also in the elbow joints. If one attempts to extend the patient’s knees one will occasionally also in the elbow joints. If one attempts to extend the patient’s knees one will succeed only to an angle of approximately 135°. In cases in which the phenomenon is very succeed only to an angle of approximately 135°. In cases in which the phenomenon is very pronounced the angle may even remain 90°."pronounced the angle may even remain 90°."

Kernig’s SignKernig’s Sign

Brudzinski’s signsBrudzinski’s signs Jozef Brudzinski was a Polish physician who described many Jozef Brudzinski was a Polish physician who described many

meningeal signs in children in the early 1900’s. These meningeal signs in children in the early 1900’s. These include :include :

Symphyseal sign- pressure on the symphysis elicits a Symphyseal sign- pressure on the symphysis elicits a reflexive hip and knee flexion and abduction of the leg.reflexive hip and knee flexion and abduction of the leg.

Cheek phenomenon- pressure on the cheek below the Cheek phenomenon- pressure on the cheek below the cheekbone elicits a reflexive rising and a simultaneous cheekbone elicits a reflexive rising and a simultaneous flexion of the lower arm. The phenomenon is somewhat flexion of the lower arm. The phenomenon is somewhat analogous to the symphyseal sign for the lower extremity.analogous to the symphyseal sign for the lower extremity.

Contralateral reflex- With the patient supine, passive flexion Contralateral reflex- With the patient supine, passive flexion of one knee into the abdomen results in flexion of opposite of one knee into the abdomen results in flexion of opposite hip and knee. Reversely, a forced stretching of a previously hip and knee. Reversely, a forced stretching of a previously flexed limb caused the other to stretch out. flexed limb caused the other to stretch out.

Neck sign- With the patient lying on the back: if the neck is Neck sign- With the patient lying on the back: if the neck is forcibly bended forward, there occurs a reflexive flexion of forcibly bended forward, there occurs a reflexive flexion of the knees. (the one we are most familiar with)the knees. (the one we are most familiar with)

Brudzinski’s Neck SignBrudzinski’s Neck Sign

Jolt Accentuation of HA SignJolt Accentuation of HA Sign

Patient rotates head in horizontal Patient rotates head in horizontal plane two to three times per second, plane two to three times per second, and the test is considered positive if and the test is considered positive if this worsens the headache pain.this worsens the headache pain.

Laboratory findingsLaboratory findings +/- Leukocytosis+/- Leukocytosis Variable CSF FindingsVariable CSF Findings

Differential DiagnosisDifferential Diagnosis

Viral MeningitisViral Meningitis EnterovirusesEnteroviruses Herpes Simplex virus (HSV)Herpes Simplex virus (HSV) HIVHIV Lymphocytic Choriomeningitis virus (LCM)Lymphocytic Choriomeningitis virus (LCM) MumpsMumps Other less common causes include West Nile, St Other less common causes include West Nile, St

Louis Encephalitis, and California Encephalitis Louis Encephalitis, and California Encephalitis (although most commonly assoc. with (although most commonly assoc. with encephalitis). May also accompany primary VZV, encephalitis). May also accompany primary VZV, outbreaks of herpes zoster, EBV, CMV, and outbreaks of herpes zoster, EBV, CMV, and adenoviruses.adenoviruses.

Enteroviral MeningitisEnteroviral Meningitis

Enteroviruses are thought to be the most common cause of viral Enteroviruses are thought to be the most common cause of viral meningitismeningitis

Are a diverse group of RNA viruses including Coxsackie A & B, Are a diverse group of RNA viruses including Coxsackie A & B, Echoviruses, and polioviruses.Echoviruses, and polioviruses.

Account for >50% of cases and approximately 90% of cases in which Account for >50% of cases and approximately 90% of cases in which a specific etiologic agent is identified. Majority of cases are in a specific etiologic agent is identified. Majority of cases are in children or adolescents, but patients of any age can be affected.children or adolescents, but patients of any age can be affected.

As many as 75000 cases occur in US yearlyAs many as 75000 cases occur in US yearly Transmitted primarily by fecal-oral route, but can also be spread by Transmitted primarily by fecal-oral route, but can also be spread by

contact with infected respiratory secretions.contact with infected respiratory secretions. The incidence is increased in the summer months, but cases occur The incidence is increased in the summer months, but cases occur

throughout the year. Sporadic outbreaks are generally associated throughout the year. Sporadic outbreaks are generally associated with specific serotypes (eg, ECV-30), typically related to introduction with specific serotypes (eg, ECV-30), typically related to introduction of new virus strain to a region.of new virus strain to a region.

Enteroviral Meningitis Signs and Enteroviral Meningitis Signs and SymptomsSymptoms

Not very distinctive- typically include Not very distinctive- typically include HA, fever, N/V, malaise, photophobia, HA, fever, N/V, malaise, photophobia, and meningismus. Can also include and meningismus. Can also include rash, URI symptoms, abdominal pain, rash, URI symptoms, abdominal pain, and diarrhea.and diarrhea.

Enterovirus Lab FindingsEnterovirus Lab Findings CSF- findings typical of viral meningitis, with CSF- findings typical of viral meningitis, with

lymphocytic pleocytosis of generally <250 lymphocytic pleocytosis of generally <250 cells/mm3, with modest protein elevation cells/mm3, with modest protein elevation generally <150 mg/dl, and normal glucose, viral generally <150 mg/dl, and normal glucose, viral cultures positive in 40-80% of cases but it usually cultures positive in 40-80% of cases but it usually takes 4-12 days to become positive, PCR is the takes 4-12 days to become positive, PCR is the most specific (close to 100%) and sensitive (97-most specific (close to 100%) and sensitive (97-100%) test and is positive in more than 2/3 of 100%) test and is positive in more than 2/3 of culture negative CSF in patients with aseptic culture negative CSF in patients with aseptic meningitismeningitis

Can also culture throat and stool specimens but Can also culture throat and stool specimens but this typically leads to a significant number of this typically leads to a significant number of false positive resultsfalse positive results

Enterovirus Meningitis Enterovirus Meningitis managementmanagement

Vast majority of patients have a self limited course and Vast majority of patients have a self limited course and require nothing more than symptomatic therapyrequire nothing more than symptomatic therapy

In neonates or adult patients with In neonates or adult patients with hypogammaglobulinemia, IV immunoglobulin may be hypogammaglobulinemia, IV immunoglobulin may be indicatedindicated

For severe enteroviral infections a new investigational drug For severe enteroviral infections a new investigational drug named Pleconaril, which works by integrating into the named Pleconaril, which works by integrating into the capsid of picornaviruses, including enteroviruses and capsid of picornaviruses, including enteroviruses and rhinoviruses, preventing the virus from attaching to cellular rhinoviruses, preventing the virus from attaching to cellular receptors and uncoating to release RNA into the cell, has receptors and uncoating to release RNA into the cell, has been shown in limited use to be effective but is not been shown in limited use to be effective but is not currently FDA approved currently FDA approved

Herpes Simplex MeningitisHerpes Simplex Meningitis Generally caused by HSV-2 (as opposed to encephalitis which is caused by Generally caused by HSV-2 (as opposed to encephalitis which is caused by

HSV-1)HSV-1) dsDNA virusdsDNA virus Increasingly recognized as a cause of aseptic meningitis, with improving Increasingly recognized as a cause of aseptic meningitis, with improving

diagnostic techniques and a continued increase in the transmission of diagnostic techniques and a continued increase in the transmission of HSV-2HSV-2

Can be due to primary or recurrent HSV infectionCan be due to primary or recurrent HSV infection Between 13 and 36% of patients presenting with primary genital herpes Between 13 and 36% of patients presenting with primary genital herpes

have clinical findings consistent with meningeal involvement including HA, have clinical findings consistent with meningeal involvement including HA, photophobia, and meningismus. Occasionally patients present with more photophobia, and meningismus. Occasionally patients present with more severe signs including urinary retention, paresthesias, weakness of upper severe signs including urinary retention, paresthesias, weakness of upper or lower extremities, or ascending myelitis. The genital lesions are or lower extremities, or ascending myelitis. The genital lesions are typically present (85% of the time), and usually precede the CNS typically present (85% of the time), and usually precede the CNS symptoms by seven days. symptoms by seven days.

HSV meningitis can be recurrent, these patients may not have clinically HSV meningitis can be recurrent, these patients may not have clinically evident genital lesions. For patients with benign recurrent lymphocytic evident genital lesions. For patients with benign recurrent lymphocytic meningitis, careful analysis has revealed that over 80% are due to HSV meningitis, careful analysis has revealed that over 80% are due to HSV meningitis. It is also likely the cause of a large percentage of patients meningitis. It is also likely the cause of a large percentage of patients with Mollaret’s meningitis, which is a form of recurrent meningitis with Mollaret’s meningitis, which is a form of recurrent meningitis characterized by large monocytic/macrophage lineage cells in the CSF.characterized by large monocytic/macrophage lineage cells in the CSF.

HSV DiagnosisHSV Diagnosis

CSF- typical of a viral meningitis, with CSF- typical of a viral meningitis, with lymphocytic pleocytosis, modest elevation lymphocytic pleocytosis, modest elevation in protein, and normal glucose. Viral in protein, and normal glucose. Viral cultures are + in approx. 80% of patients cultures are + in approx. 80% of patients with primary HSV meningitis, but less with primary HSV meningitis, but less frequently positive in patients with frequently positive in patients with recurrent HSV meningitis. HSV PCR of the recurrent HSV meningitis. HSV PCR of the CSF is the single most useful test for the CSF is the single most useful test for the evaluation of a patient with suspected HSV evaluation of a patient with suspected HSV meningitis.meningitis.

HSV Meningitis treatmentHSV Meningitis treatment Most cases are self limited and will require only Most cases are self limited and will require only

symptomatic treatment.symptomatic treatment. There are no published controlled trials for the There are no published controlled trials for the

use of antiviral agents for HSV meningitis. There use of antiviral agents for HSV meningitis. There have been anecdotal cases that suggest clinical have been anecdotal cases that suggest clinical improvement with acyclovir treatment. Antiviral improvement with acyclovir treatment. Antiviral therapy is recommended in patients with primary therapy is recommended in patients with primary HSV infection or with severe neurological HSV infection or with severe neurological symptoms. (inpatient-IV acyclovir 10mg/kg Q8°, symptoms. (inpatient-IV acyclovir 10mg/kg Q8°, outpatient with high dose oral outpatient with high dose oral acyclovir/valacyclovir/or famciclovir)acyclovir/valacyclovir/or famciclovir)

Patients with frequent recurrences might benefit Patients with frequent recurrences might benefit from acyclovir prophylaxis, although there are no from acyclovir prophylaxis, although there are no studies of patients with recurrent HSV meningitis studies of patients with recurrent HSV meningitis showing benefit from prophylaxis.showing benefit from prophylaxis.

HIV meningitisHIV meningitis

A subset of patients with primary HIV A subset of patients with primary HIV infection will present with meningitis or infection will present with meningitis or meningoencephalitis, manifested by HA, meningoencephalitis, manifested by HA, confusion, seizures or cranial nerve confusion, seizures or cranial nerve abnormalities.abnormalities.

ssRNA retrovirusssRNA retrovirus

HIV Meningitis DiagnosisHIV Meningitis Diagnosis

Serum might reveal a atypical Serum might reveal a atypical lymphocytosis, leukopenia, and elevated lymphocytosis, leukopenia, and elevated serum aminotransferases. Documentation serum aminotransferases. Documentation of seroconversion or detection of HIV of seroconversion or detection of HIV plasma viremia by nucleic acid techniques plasma viremia by nucleic acid techniques can be used for diagnosis.can be used for diagnosis.

CSF- might show a lymphocytic CSF- might show a lymphocytic pleocytosis, elevated protein, and normal pleocytosis, elevated protein, and normal glucose. CSF cultures are often positive, glucose. CSF cultures are often positive, but are not available in most centers. but are not available in most centers.

HIV Meningitis TreatmentHIV Meningitis Treatment

The meningitis associated with The meningitis associated with primary infection resolves in most primary infection resolves in most patients without treatment, and patients without treatment, and patients are typically assumed to patients are typically assumed to have a benign viral meningitis. This have a benign viral meningitis. This occasionally leads to missing the occasionally leads to missing the diagnosis of HIV.diagnosis of HIV.

Lymphocytic Choriomeningitis VirusLymphocytic Choriomeningitis Virus

LCM is thought to be an underdiagnosed cause of viral LCM is thought to be an underdiagnosed cause of viral meningitis, in one review it was noted to be responsible for meningitis, in one review it was noted to be responsible for 10-15% of cases.10-15% of cases.

ssRNA virus of the arenavirus groupssRNA virus of the arenavirus group LCM is excreted in the urine and feces of rodents, including LCM is excreted in the urine and feces of rodents, including

mice, rats, and hamsters (that probably includes Jorge’s mice, rats, and hamsters (that probably includes Jorge’s hamster Houdini). It is transmitted to humans by either direct hamster Houdini). It is transmitted to humans by either direct contact with infected animals or environmental surfaces. contact with infected animals or environmental surfaces. Infection occurs more commonly in the winter months.Infection occurs more commonly in the winter months.

Symptoms generally include a influenza like illness Symptoms generally include a influenza like illness accompanied by HA and meningismus. A minority of patients accompanied by HA and meningismus. A minority of patients develop orchitis, parotitis, myopericarditis, or arthritis.develop orchitis, parotitis, myopericarditis, or arthritis.

LCM DiagnosisLCM Diagnosis

CSF- typical of other viral meningitis CSF- typical of other viral meningitis causes except that 20-30% of the causes except that 20-30% of the time low glucose levels are present, time low glucose levels are present, and cell counts of > 1000/mm3 are and cell counts of > 1000/mm3 are not unusualnot unusual

Diagnosis is made by documentation Diagnosis is made by documentation of seroconversion to the virus in of seroconversion to the virus in paired serum samples.paired serum samples.

LCM TherapyLCM Therapy

Most patients will recover Most patients will recover spontaneouslyspontaneously

There is no specific anti-viral therapy There is no specific anti-viral therapy available presentlyavailable presently

Mumps MeningitisMumps Meningitis

Caused by paramyxovirus which is a ssRNA virusCaused by paramyxovirus which is a ssRNA virus Prior to the creation of the mumps vaccine in 1967, Prior to the creation of the mumps vaccine in 1967,

it accounted for 10-20% of all cases of viral it accounted for 10-20% of all cases of viral meningitis.meningitis.

Even now this virus causes a significant minority of Even now this virus causes a significant minority of cases in unvaccinated adolescents and adults.cases in unvaccinated adolescents and adults.

In patients who do acquire mumps, CNS infection In patients who do acquire mumps, CNS infection occurs rather frequently, with CSF pleocytosis occurs rather frequently, with CSF pleocytosis detected in 40-60% of patients, and 10-30% of detected in 40-60% of patients, and 10-30% of those have clinical signs and symptoms of those have clinical signs and symptoms of meningitis.meningitis.

Mumps DiagnosisMumps Diagnosis

CSF- similar to other viral causes, but like CSF- similar to other viral causes, but like LCM it can induce a lymphocytic LCM it can induce a lymphocytic pleocytosis with cell counts >1000/mm3 pleocytosis with cell counts >1000/mm3 or a decreased glucose <50mg/dl, can or a decreased glucose <50mg/dl, can isolate the virus from the CSFisolate the virus from the CSF

Can document seroconversionCan document seroconversion Clinical correlation is very helpful, ex. If Clinical correlation is very helpful, ex. If

the patient has parotitis or orchitis.the patient has parotitis or orchitis.

Mumps TreatmentMumps Treatment

Most cases resolve without serious Most cases resolve without serious sequelae, and there is no specific sequelae, and there is no specific therapy availabletherapy available

Miscellaneous virusesMiscellaneous viruses

West Nile Virus, St Louis Encephalitis, California West Nile Virus, St Louis Encephalitis, California Encephalitis, primary VZV, outbreaks of herpes Encephalitis, primary VZV, outbreaks of herpes zoster,EBV,CMV, and adenoviruses.zoster,EBV,CMV, and adenoviruses.

Less common causes of meningitis, but they do Less common causes of meningitis, but they do occur. In most cases the course is self-limited, occur. In most cases the course is self-limited, and the treatment is supportive in nature.and the treatment is supportive in nature.

Drug Induced Aseptic Meningitis Drug Induced Aseptic Meningitis (DAIM)(DAIM)

DIAM SymptomsDIAM Symptoms

DIAM CSF FindingsDIAM CSF Findings

DIAM-Who’s at RiskDIAM-Who’s at Risk

The only disease that seems to have The only disease that seems to have a correlation is SLE, in whom DIAM a correlation is SLE, in whom DIAM appears to occur more commonly.appears to occur more commonly.

Recurrent DIAM does occur, although Recurrent DIAM does occur, although other than re-exposure to an other than re-exposure to an offending agent (not necessarily the offending agent (not necessarily the same agent that caused the initial same agent that caused the initial episode) there is no other known risk episode) there is no other known risk factor for these patients.factor for these patients.

DIAM TreatmentDIAM Treatment

Treatment is simply to stop the Treatment is simply to stop the offending agent and await resolution offending agent and await resolution of the symptoms. Unfortunately, of the symptoms. Unfortunately, since this is a diagnosis of exclusion since this is a diagnosis of exclusion because of the seriousness of a because of the seriousness of a missed bacterial meningitis, it is not missed bacterial meningitis, it is not an easy diagnosis to make until a an easy diagnosis to make until a bacterial infection can be ruled out.bacterial infection can be ruled out.

Bacterial Infections that can Bacterial Infections that can present with negative culturespresent with negative cultures

Parameningeal bacterial infections Parameningeal bacterial infections (epidural, subdural abcess)(epidural, subdural abcess)

Partially treated bacterial meningitis or Partially treated bacterial meningitis or patients who develop meningitis while patients who develop meningitis while already on antibioticsalready on antibiotics

Leptospira speciesLeptospira species Lyme disease (Borrelia burgdorferi)Lyme disease (Borrelia burgdorferi) M. Tuberculosis (look for signs of disease M. Tuberculosis (look for signs of disease

elsewhere in the body as a clinical clue)elsewhere in the body as a clinical clue) Bacterial endocarditisBacterial endocarditis

Malignancy as a cause of Malignancy as a cause of meningitismeningitis

It is also important to keep in mind It is also important to keep in mind that lymphoma, leukemia, and that lymphoma, leukemia, and metastatic carcinomas and metastatic carcinomas and adenocarcinomas can occasionally adenocarcinomas can occasionally present with an aseptic meningitis present with an aseptic meningitis syndrome.syndrome.

Back to our caseBack to our case CT Head- no bleed or massCT Head- no bleed or mass WBC-7.07 with normal diff, CBC/Chem 14 WNL, WBC-7.07 with normal diff, CBC/Chem 14 WNL,

HIV/RPR/ANA all neg.HIV/RPR/ANA all neg. CSF- Clear, 45 WBC with 98% lymphocytes, Protein 105, CSF- Clear, 45 WBC with 98% lymphocytes, Protein 105,

Glucose 50, GM Stain shows rare PMN/many Glucose 50, GM Stain shows rare PMN/many lymphocytes/no organismslymphocytes/no organisms

CSF PCR for HSV was positiveCSF PCR for HSV was positive Hospital course- pt was treated symptomatically initially. Hospital course- pt was treated symptomatically initially.

Her neurological symptoms were slowly improving but she Her neurological symptoms were slowly improving but she developed a genital ulcer on hospital day#2 so she was developed a genital ulcer on hospital day#2 so she was started on oral acyclovir and was discharged on the started on oral acyclovir and was discharged on the following day with profound improvement in the HA and following day with profound improvement in the HA and neck stiffness. She was counseled to discuss possible neck stiffness. She was counseled to discuss possible future prophylaxis with her PCP. future prophylaxis with her PCP.

ReferencesReferences 1. Johnson, Paul R., Aseptic Meningitis, 1. Johnson, Paul R., Aseptic Meningitis, www.uptodate.comwww.uptodate.com.. 2. Saberi, Asif et.al., Meningeal Signs: Kernig’s Sign and Brudzinski’s Sign, 2. Saberi, Asif et.al., Meningeal Signs: Kernig’s Sign and Brudzinski’s Sign,

Hospital Physician, 7/04, pgs 23-24.Hospital Physician, 7/04, pgs 23-24. 3. Uchihara T, Tsukagoshi H., Jolt accentuation of headache: the most 3. Uchihara T, Tsukagoshi H., Jolt accentuation of headache: the most

sensitive sign of CSF pleocytosis, Headache. 1991 Mar;31(3):167-71. sensitive sign of CSF pleocytosis, Headache. 1991 Mar;31(3):167-71. 4. Manning, Robert T., Kernig’s sign, 4. Manning, Robert T., Kernig’s sign, www.whonamedit.comwww.whonamedit.com.. 5. Thomas KE, et al. The diagnostic accuracy of Kernig's sign, Brudzinski's 5. Thomas KE, et al. The diagnostic accuracy of Kernig's sign, Brudzinski's

sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis July 1, 2002;35:46-52. July 1, 2002;35:46-52.

6. Attia, John, et al., Does this patient have acute meningitis?, JAMA, Vol 6. Attia, John, et al., Does this patient have acute meningitis?, JAMA, Vol 282, 7/14/1999, pgs 175-181.282, 7/14/1999, pgs 175-181.

7. Rotbart HA; Webster AD, Treatment of potentially life-threatening 7. Rotbart HA; Webster AD, Treatment of potentially life-threatening enterovirus infections with pleconaril, Clin Infect Dis 2001 Jan enterovirus infections with pleconaril, Clin Infect Dis 2001 Jan 15;32(2):228-35.15;32(2):228-35.

8. Moris, German, et al., The Challenge of Drug-Induced Aseptic Meningitis, 8. Moris, German, et al., The Challenge of Drug-Induced Aseptic Meningitis, Archives of Internal Medicine, 1999, June 14, Volume 159(11), pgs. 1185-Archives of Internal Medicine, 1999, June 14, Volume 159(11), pgs. 1185-1194.1194.

9. Johnson, Kimberly, et al., Lumbar puncture: Technique; indications; 9. Johnson, Kimberly, et al., Lumbar puncture: Technique; indications; contraindications; and complications, www. Uptodate.com.contraindications; and complications, www. Uptodate.com.

Discussion/QuestionsDiscussion/Questions