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Welcome to August… We’ve Survived July!!! Noon Conf Today: Emergency Radiology Tomorrow @ 12:15

Welcome to August… We’ve Survived July!!! Noon Conf Today: Emergency Radiology Tomorrow @ 12:15 Lunch from Physician’s Resource Group. Viral Meningitis.

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Welcome to August… We’ve Survived July!!! Noon Conf Today: Emergency Radiology Tomorrow @ 12:15

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  1. Welcome to August… We’ve Survived July!!! Noon Conf Today: Emergency Radiology Tomorrow @ 12:15 Lunch from Physician’s Resource Group

  2. Viral Meningitis • Clinical syndrome of meningeal inflammation with negative bacterial cultures in a patient who did not receive antibiotics before lumbar puncture • Viruses (Enterovirus) most common • Terms aseptic and viral meningitis may be used synonymously

  3. Terminology • Meningitis- inflammation of meninges • CSF Pleocytosis • Encephalitis- inflammation of brain parenchyma • Produces neurologic dysfunction • Myelitis- Inflammation of spinal cord • Flaccid paralysis and reduced reflexes

  4. Enteroviruses • Most prevalent in summer months • 90% of cases of viral meningitis • Clinical features: conjunctivitis, pharyngitis, rash, herpangina, hand-foot-mouth • Rarely may cause CN palsies, flaccid paralysis, pulm edema

  5. Herpesviruses • Wide spectrum of illness • Meningitis- • Infants: possibly fever as only symptom • Older children: meningeal findings • Encephalitis with or without multiorgan involvement • Altered MS, focal deficits, seizures • Sacral radiculopathy • Urinary retention, constipation, paresthesia, weakness

  6. Arboviruses • Arthropod or insect vectors (summer months) • St. Louis Encephalitis • “flu-like” sx to fatal encephalitis • La Crosse (California) encephalitis • may mimic HSV encepalitis • West Nile Virus • Maculopapular rash in 50% of pts • Peripheral neuropathy or paralysis (adults) • Western Equine Encephalitis • Neurologic sequelae in infants

  7. Rabies • Prodrome 2-10 days fever, HA, myalgias, cough, N/V • Hallucinations, nightmares, insomnia • Neuro deterioration in 1-2wks • Coma and death by 3rd wk

  8. Need for Hospitalization • Encephalitis or ill-appearance • Need for empericAbx • Need for IVF or aggressive pain control • Immunocompromised host • Age < 1y/o

  9. Is CT needed prior to LP • S/S of increased ICP • Altered mental status • Papilledema • Focal neuro deficits • Other indications • Immune deficiency • CSF shunt or hydrocephalus • CNS trauma • Hx neurosurgery or space-occupying lesion

  10. Provisional Dx of Viral Meningitis • CSF WBC of <500 cells/microL • >50% Mononuclear cells (lymphs + monos) • Normal CSF glucose • CSF protein <100 mg/dL • Negative CSF Gram stain • Enterovirus disease in the community • Improvement following LP

  11. Presumed Bacterial Meningitis • CSF WBC >1000/microL • Neutrophil predominance • CSF glucose <40 • Ill appearance

  12. EmpericAbx • Low threshold to treat while awaiting cultures • Must treat while awaiting cultures: • Age < 3months • Severely ill • Immunocompromised • Ceftriaxone and Vancomycin

  13. EmpericAntivirals • Acyclovir • All pts -CSF pleocytosis with: • Encephalitis, focal findings on exam, imaging, or EEG • Infants <28 days of age • Vesicles, seizures, lethargy, resp distress, thrombocytopenia, hypothermia, hepatitis, sepsis-like illness, elevated transaminases • Immunocompromised

  14. Complications • Neonates • Encephalitis, viremia, myocarditis, pericarditis, hepatic failure, DIC, pneumonitis • SIADH

  15. Persistent Sx or Atypical Course • If symptoms not improving within 1wkconsider: • Partially treated meningitis • Fungal, mycobacterial (TB), lyme, rickettsial, parasitic • Abscess or parameningealinfxn • ADEM • Vasculitis • Malignancy

  16. In viral meningitis, BG normal or slightly reduced, > 40% of serum glucose

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