ACUTE VIRAL MENINGITIS Clinical Manifestations fever, headache, and meningeal irritation - headache usually frontal or retroorbital with photophobia and pain on moving the eyes - with malaise, myalgia, anorexia, nausea and vomiting, abdominal pain and / or diarrhea mild degree of lethargy and drowsiness indicates of involvement of brain parenchyma Epidemiology some viruses have seasonal predilections: increased incidence during summer and
ACUTE VIRAL MENINGITIS Clinical Manifestations fever, headache, and meningeal irritation - headache usually frontal or retroorbital with photophobia and pain on moving the eyes - with malaise, myalgia, anorexia, nausea and vomiting, abdominal pain and / or diarrhea mild degree of lethargy and drowsiness indicates of involvement of brain parenchyma Epidemiology some viruses have seasonal predilections: increased incidence during summer and
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ACUTE VIRAL MENINGITIS Clinical Manifestations fever, headache, and meningeal irritation - headache usually frontal or retroorbital with photophobia and pain on moving the eyes - with malaise, myalgia, anorexia, nausea and vomiting, abdominal pain and / or diarrhea mild degree of lethargy and drowsiness indicates of involvement of brain parenchyma Epidemiology some viruses have seasonal predilections: increased incidence during summer and
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Attribution Non-Commercial (BY-NC)
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ACUTE VIRAL MENINGITIS (3) nonviral infections meningitides with culture negative
(fungal, tuberculous, parasitic, syphillis)
Clinical Manifestations (4) neoplastic meningitis - fever, headache, and meningeal irritation (5) meningitis secondary to noninfectious inflammatory - headache usually frontal or retroorbital with photophobia diseases and pain on moving the eyes Specific Viral Etiologies - with malaise, myalgia, anorexia, nausea and vomiting, abdominal pain and/or diarrhea - mild degree of lethargy and drowsiness (1) Enterovirus - most common cause of viral meningitis - seizures or other focal neurologic signs or symptoms - typical case occurs in the summer months, esp. in indicates of involvement of brain parenchyma children < 15 y/o - PE includes exanthemata, hand-foot-mouth disease, Epidemiology herpangina, pleurodynia, myopericarditis, - some viruses have seasonal predilections: increased hemorrhagic conjunctivitis incidence during summer and early fall - diagnosis by PCR amplification of enteroviral RNA from CSF Laboratory Diagnosis (2) Arbovirus - typically occur in the summer (1) CSF examination - WNV suspected when cluster of meningitis cases are - most important lab test preceded by death of birds in a certain geographic - lymphocytic pleocytosis (25-500 cells/μL) region - normal to slightly elevated protein (20-80 mg/dL) - history of tick exposure sought in cases of Colorado - normal glucose (may be decreased in mumps and tick fever or Powassan virus infection LCMV) (3) HSV-2 - normal to mildly elevated opening pressure - probably the second most common viral cause of - organisms are not seen on Gram’s stain or AF stained meningitis smears or India ink preparations - cultures are invariably negative - PMNs may predominated in the first 48 hrs. - diagnosis made by CSF PCR - As a rule, lymphocytic pleocytosis with low glucose - genital lesions may not be present suggest fungal, listerial, or TB meningitis or (4) VZV noninfectious disorders - suspected in the presence of concurrent chicken pox (2) PCR of viral nucleic acid or shingles - procedure of choice for HSV meningitis - 40% occur in the absence of rash - more sensitive than viral cultures - Can also produce cerebellar ataxia - used routinely to diagnose CMV, EBV, VZV - CSF PCR used in the diagnosis (3) CSF culture (5) EBV - 2 mL of CSF, refrigerated and processed ASAP - may occur with or without evidence of infectious - never stored in ~200C, virus unstable at this temp. mononucleosis syndrome - diagnosis suggested by atypical lymphocytes in the - should be in a ~700C freezer if stored for >20 hrs. CSF or in the peripheral blood (4) Other sources of viral isolation - diagnose by SF PCR - throat, stool, blood, urine - patient with CNS lymphoma may be positive in PCR - enterovirus in stool is not diagnostic in the absence of meningoencephalitis (5) Serologic studies (6) HIV - useful for arboviruses - presence of HIV genome by PCR or p24 protein - less useful for HSV, VZV, CMV, EBV establishes the diagnosis - diagnosis of acute viral infection can be made by - cranial nerve palsies common documenting seroconversion between acute-phase (7) Mumps and convalescent sera or by demonstrating the - typically occurs in late winter or early spring, esp. in presence of virus-specific IgM antibodies males - IgM Abs persist for only a few months after acute - orchitis, oophoritis, parotitis, pancreatitis, or infection except WNV IgM elevations in serum lipase and amylase are - useful mainly for retrospective establishment of a suggestive but can be found with other viruses specific diagnosis - infection confers lifelong immunity - the finding of oligoclonal bands in electrophoresis - diagnosis made by isolation from CSF and/or may be suggestive of certain viruses demonstration of seroconversion (6) Other lab studies (8) LCMV - CBC, liver function tests, ESR, BUN, plasma levels of - typically occurs late fall or winter in individuals with electrolytes, glucose, creatinine, creatine kinase, history of exposure to rodents or their excreta aldolase, amylase, and lipase - with rash, pulmonary infiltrates, alopecia, parotitis, orchitis, or myopericarditis Differential Diagnosis - leucopenia, thrombocytopenia, abnormal liver function tests (1) bacterial meningitis (2) parameningeal infections or partially treated bacterial Treatment meningitis - in the usual case, treatment is symptomatic and hospitalization is not required - patient left undisturbed in a quiet, darkened room - analgesics and antipyretics - monitor fluid and electrolyte status because hyponatremia and SIADH may develop - oral or IV acyclovir for HSV, VZV and EBV - highly active retroviral therapy for HIV meningitis - for patient with known deficient humoral immunity, give IM or IV IgG - pleconaril for enteroviral infections - vaccination (Varivax) for VZV, booster may be required to maintain immunity
Prognosis - most of the times, there’s full recovery - outcome in < 1 y/o: intellectual impairment, learning disabilities, hearing loss