Viral meningitis - Acute
Definition
CNS infection characterized by fever, headache, and meningeal symptoms with moderate, predominantly lymphocytic cerebrospinal fluid (CSF) pleocytosis and absence of bacterial or fungal pathogens in CSF
Medical History
* Immunodeficiency disorder
* Infectious disease in mother complicating pregnancy, childbirth AND/OR puerperium
Findings
* Nuchal rigidity
* Altered mental status
* Brudzinski's sign
* Bulging fontanelle
* Kernig's sign
* Asthenia
* Dysphagia
* Fever
* Flaccid paralysis
* Headache
* Increased heart rate
* Irritability
* Light intolerance
* Myalgia
* Nausea, vomiting and diarrhea
* Rash - Acute
* Tachypnea
* Throat symptom
* Vesicular eruption
Tests
Suspected and known bacterial meningitis
* Glucose measurement, CSF: A cerebrospinal fluid (CSF) glucose level under 40 mg/dL, or a ratio of CSF-to-blood glucose that is 0.4 or less, is consistent with but does not diagnose bacterial meningitis .
Suspected bacterial meningitis
* Cerebrospinal fluid culture: Bacterial culture of the cerebrospinal fluid is critical in making the diagnosis of bacterial meningitis, identifying the causative organism, and selecting the appropriate antibiotic treatment regimen .
Suspected bacterial meningitis
* CSF gram stain method: Cerebrospinal fluid Gram stain is a useful method for the preliminary diagnosis of bacterial meningitis; however, a negative Gram stain does not rule out the disease .
Suspected bacterial meningitis
* Cerebrospinal fluid examination: Cerebrospinal fluid findings consistent with bacterial meningitis include decreased glucose level, increased protein level and WBC count, and positive Gram stain and culture .
Suspected viral meningitis
* White blood cell count with differential, Cerebrospinal fluid: In viral meningitis, the cerebrospinal fluid WBC count is usually less than 500 cells/mm3, with mononuclear cells predominating .
Normal cerebrospinal fluid glucose levels are about two thirds of simultaneously drawn serum glucose levels.
* Plasma random glucose measurement
Suspected hyponatremia
* Sodium measurement, serum: Hyponatremia is a sodium serum concentration less than 136 mEq/L and severe hyponatremia is a serum sodium concentration of less than 120 mEq/L .
Suspected meningitis
* Blood culture: Blood cultures should be obtained in all cases of suspected bacterial meningitis, and blood specimens should collected before the start of antibiotic therapy unless it delays treatment.
Suspected or known viral encephalitis
* Sodium measurement, serum: Hyponatremia due to comorbid conditions may be observed in a small number of patients with viral encephalitis .
The WBC count may be low, normal, or moderately increased. Hemolytic anemia may be present with group A coxsackievirus infections. Thrombocytopenia may be associated with mumps virus and group A coxsackievirus infections.
* Complete blood count
Suspected meningitis
* CT of head: A head CT prior to lumbar puncture (LP) is recommended if the clinical presentation suggests a mass lesion or another cause of increased intracranial pressure .
The chest x-ray findings may be abnormal with pulmonary involvement.
* Plain chest X-ray
Differential Diagnosis
* Enterovirus meningitis
* West Nile meningitis
* Mumps meningitis
* Herpes simplex meningitis
* HIV infection with aseptic meningitis
* Lymphocytic choriomeningitis
* Herpes zoster with meningitis
* Bacterial meningitis - Acute
* NONSTEROIDAL ANTIINFLAMMATORY DRUGS
* Bacterial meningitis, partially treated
* Subarachnoid hemorrhage
* Meningitis due to other organisms
* Systemic lupus erythematosus encephalitis
* Meningitis in Lyme disease
* Rocky Mountain spotted fever - Acute
* Viral encephalitis - Acute
* Arbovirus encephalitis
* Abscess of brain - Acute
* Hepatic encephalopathy - Acute
* ANTICHOLINERGIC POISONING
* PHENOTHIAZINES
* SALICYLATES
* Malignant meningitis
* Sarcoid meningitis
Treatment
Drug Therapy
Acute pain
ACETAMINOPHEN
Adults: 650 to 1,000 mg orally every 4 to 6 hours as needed (maximum 4 g/day)
Pediatrics: 10 to 15 mg/kg orally or rectally every 4 to 6 hours as needed (maximum 5 doses or 4 g/day)
Neonates: 10 to 15 mg/kg orally or rectally every 6 to 8 hours as needed
IBUPROFEN
Adults: 200 to 800 mg orally every 6 to 8 hours as needed (maximum 3.2 g/day)
Pediatrics: 5 to 10 mg/kg orally every 6 to 8 hours as needed (maximum, lesser of 40 mg/kg/day or 2.4 g/day)
ACETAMINOPHEN/OXYCODONE HYDROCHLORIDE
Adults: Oxycodone 5 to 20 mg/acetaminophen 325 to 1,000 mg orally every 4 hours as needed (maximum 4 g acetaminophen/day)
Pediatrics: 0.05 to 0.15 mg/kg of the oxycodone ingredient orally every 4 hours as needed
ACETAMINOPHEN/CODEINE PHOSPHATE
Adults: Codeine 15 to 60 mg/acetaminophen 325 to 1,000 mg orally every 4 hours as needed (maximum 360 mg codeine and 4 g acetaminophen/day)
Pediatrics (3-6 years): 5 mL (12 mg codeine/120 mg acetaminophen per 5 mL) orally every 6 to 8 hours as needed
Pediatrics (7-12 years): 10 mL (12 mg codeine/120 mg acetaminophen per 5 mL) orally every 6 to 8 hours as needed
Persistent vomiting
PROCHLORPERAZINE
Adults: 25 mg rectally twice a day OR 5-10 mg IM, may repeat every 3-4 hours (maximum 40 mg/day) OR 2.5-10 mg IV at a rate not to exceed 5 mg/minute (maximum single dose 10 mg; maximum 40 mg/day)
Pediatrics <20 lbs or < 2 years old: not recommended
Pediatrics 20-29 lbs: 2.5 mg rectally once or twice a day (maximum 7.5 mg/day)
Pediatrics 30-39 lbs: 2.5 mg rectally 2 or 3 times a day (maximum 10 mg/day)
Pediatrics 40-49 lbs: 2.5 mg rectally 3 times a day OR 5 mg rectally twice a day (maximum 15 mg/day)
ONDANSETRON
Adults: 4 mg IV every 6 hours
Pediatrics: 0.1 mg/kg IV every 6 hours
Herpes simplex meningitis
ACYCLOVIR
Adults: 10 mg/kg IV every 8 hours for 14-21 days
Pediatrics: 20 mg/kg IV every 8 hours for 14-21 days
Procedural Therapy
Dehydration
* Intravenous fluid replacement: Intravenous fluid replacement is indicated for patients with dehydration when oral replacement cannot be accomplished .
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