A pulmonologist presented a medical case:
40 yo man, ex-fire-fighter, spends time in the woods, diagnosed viral meningitis over 4 weeks ago. Still severe headache, nausea, vomiting.
40 yo man, ex-fire-fighter, spends time in the woods, diagnosed viral meningitis over 4 weeks ago. Still severe headache, nausea, vomiting. CSF cultures and CT scans were not diagnostic. Why, and what to do next?
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Patient demographics
Gender
male
Age
40
Ethnicity
Occupation
retired fire fighter
Chief complaint or problem to solve
40 yo man developed severe HA 4 weeks ago. very atypical for him. Finally went to ER and received a CT of his abd/pelvis due to the vomiting (no eval of his HA). HA continued and got worse, went back to ER and got a head CT. It was negative. Given reglan and toradol and sent home. Symptoms continued. Went back to ER got another head CT and finally an LP. He was admitted with meningitis and started on the cocktail of antibiotics while awaiting the cultures.
Case history
40 yo man developed severe HA 4 weeks ago. very atypical for him. Finally went to ER and received a CT of his abd/pelvis due to the vomiting (no eval of his HA). HA continued and got worse, went back to ER and got a head CT. It was negative. Given reglan and toradol and sent home. Symptoms continued. Went back to ER got another head CT and finally an LP. He was admitted with meningitis and started on the cocktail of antibiotics while awaiting the cultures. However, no one was sure if it was viral or bacterial. Obviously, it wasn't viral or he would have been dead at this point. He wasn't septic - just a severe HA with N/V. He was sent home 5 days later with IV antibiotics at home. He was still not much better. Antibiotics finished and continued to have same symptoms. At this point, still basically bed ridden. Finally goes back to ER. Got another LP, which showed the WBC in CSF down from 300 to 82 I believe. Also, the new CSSF was finally sent for Lyme, west nile, etc. Cultures never grew anything (not surprising). He also go another head CT, which was negative x 3. He was made a follow up with an ID physician the following day. ID doc said viral meningitis. Now, he is still in the bed, can't walk more than 20 feet without throwing up. Still with severe HA.

Pt worked as a fire fighter
Spents a good amount of time in the woods
No health problems
No major family history
Takes no meds
Only surgery has been a C-spine surgery for disk. I believe this was check as a source of infection and nothing was found.
Purpose of case discussion
Diagnostic dilemma: "What are the next steps for evaluation?"
Supplemental Materials

Dr. Cynthia Archer
Internal Medicine
9 doctors agree

In brief: More information needed

First, I would ask what viral etiologies have been excluded or verified.
It is possible this may represent Zika virus infection, or possibly some other issue such as HSV (although the presentation is atypical.) PCR? Is there an MRI? Some of these things don't show up on CT. I would want to review the imaging myself with the neuroradiologist, and maybe alter the seting of contrast, brightness etc. to look for clues. Neurology should also be consulted for such cases. Lyme definitely needs to be excluded, as does RMSF, which presents differently most of the time but can present like this. What did the serum studies show? Was his sodium level low with a normal or low lymphocyte count? What does the electrolyte panel look like now? What about the CBC now? If he has been treated with doxycycline in particular that would be helpful to know. What antibiotic cocktail in was used, and what other antiemetics have been tried? How are current exam, vitals, orthostatics, neurological exam? BP high?

In brief: More information needed

First, I would ask what viral etiologies have been excluded or verified.
It is possible this may represent Zika virus infection, or possibly some other issue such as HSV (although the presentation is atypical.) PCR? Is there an MRI? Some of these things don't show up on CT. I would want to review the imaging myself with the neuroradiologist, and maybe alter the seting of contrast, brightness etc. to look for clues. Neurology should also be consulted for such cases. Lyme definitely needs to be excluded, as does RMSF, which presents differently most of the time but can present like this. What did the serum studies show? Was his sodium level low with a normal or low lymphocyte count? What does the electrolyte panel look like now? What about the CBC now? If he has been treated with doxycycline in particular that would be helpful to know. What antibiotic cocktail in was used, and what other antiemetics have been tried? How are current exam, vitals, orthostatics, neurological exam? BP high?
Dr. Cynthia Archer
Dr. Cynthia Archer
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6 comments
Dr. Cynthia Archer
One thing that comes to mind is posterior leukoencephalopathy syndrome, which most often happens in people with elevated BP, but can present in those with normal BP. Treatment with calcium channel blockade and ace inhibitors can be helpful even in those with normal BP. There have been cases of PRES with CSF pleocytosis, mimicking meningitis or infectious encephalitis. I saw/described one such case
Dr. Cynthia Archer
Also, how about an EEG? sometimes seizures are not obvious.
Dr. Scott Shapiro
Anti-Aging Medicine
8 doctors agree

In brief: You're correct about probably too early for Lyme Antibodies

I'd run Western Blot, No ElISA, check CD57, Complement C4 , EBV and early antigen EBV, HHV6.
Highly suspect for Lyme and probably co-infections : Babesia, Bartonella, Rickettsia, Erlichia, Rocky Mountain Spotted Fever. If Lyme, even though no bands show positive yet, a low CD57 along with a re-activated EBV has been a common pattern I've seen of late.

In brief: You're correct about probably too early for Lyme Antibodies

I'd run Western Blot, No ElISA, check CD57, Complement C4 , EBV and early antigen EBV, HHV6.
Highly suspect for Lyme and probably co-infections : Babesia, Bartonella, Rickettsia, Erlichia, Rocky Mountain Spotted Fever. If Lyme, even though no bands show positive yet, a low CD57 along with a re-activated EBV has been a common pattern I've seen of late.
Dr. Scott Shapiro
Dr. Scott Shapiro
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7 doctors agree

In brief: Three fold answer

Persistent post-meningitis headaches are some of the most difficult category of headaches for treatment.
The inflammatory reaction around the meninges ( even after resolution of the infection) is a constant trigger for migraine like headaches. Additionally the patient may have a superimposed post-LP headache that is causing his profound disability with the bedridden state ( ? Postural headache).

In brief: Three fold answer

Persistent post-meningitis headaches are some of the most difficult category of headaches for treatment.
The inflammatory reaction around the meninges ( even after resolution of the infection) is a constant trigger for migraine like headaches. Additionally the patient may have a superimposed post-LP headache that is causing his profound disability with the bedridden state ( ? Postural headache).
Dr. Mahan Chehrenama
Dr. Mahan Chehrenama
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Dr. Jack Morgan
Internal Medicine
6 doctors agree

In brief: Additional questions

What was the Last CSF WBC cell differential as compared to the First CSF sample obtained ? Was a blood patch ever applied during any of the Spinal Tap procedures ? At this time with all the data I have read, it appears the the meninges are still inflamed .
What was the "ESR" and where fungal blood cultures obtained at the same time as well as other blood cultures during the spinal tap procedures ? What was the antibiotic regiment used ? Could an area in the nasal mucosa be causing a sub-clinical infection vector for causing a re-ineffective process to continue , as a chronic condition ? Does the patient have an elevated "CRP" ?

In brief: Additional questions

What was the Last CSF WBC cell differential as compared to the First CSF sample obtained ? Was a blood patch ever applied during any of the Spinal Tap procedures ? At this time with all the data I have read, it appears the the meninges are still inflamed .
What was the "ESR" and where fungal blood cultures obtained at the same time as well as other blood cultures during the spinal tap procedures ? What was the antibiotic regiment used ? Could an area in the nasal mucosa be causing a sub-clinical infection vector for causing a re-ineffective process to continue , as a chronic condition ? Does the patient have an elevated "CRP" ?
Dr. Jack Morgan
Dr. Jack Morgan
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Dr. Clarence Grim
Internal Medicine - Endocrinology
6 doctors agree

In brief: Retest for Lyme now.

I would do more detailed Lyme testing as a start.
Trust BP OK? What do fundi show? Discuss with ID empiric treatment for Lyme as a trial.

In brief: Retest for Lyme now.

I would do more detailed Lyme testing as a start.
Trust BP OK? What do fundi show? Discuss with ID empiric treatment for Lyme as a trial.
Dr. Clarence Grim
Dr. Clarence Grim
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Dr. John Froude
Internal Medicine - Infectious Disease
6 doctors agree

In brief: Viral meningitis..variable course.

The number of viruses that can cause is great and that's just the ones we know.
Is this patient otherwise healthy? Tuberculosis, although extremely rare in such a presentation and in any case the lymphocytic pleocytosis has improved without specific treatment should always be considered even in the most unlikely situations. A quantiferon gold blood test should be done. HIV should be excluded. Lyme should be excluded. Other viruses vary. I am sure you will have excluded HSV 1/2 and other herpesviruses. I have seen severe meningoencephalitis with slow recovery with West Nile. You might send CSF to the state virology lab. In NY they can screen for a large number of viruses. If at the end of this time you still don't have the answer you probably never will. Most of these patients recover completely although it may take a week or three. Sometimes they are left with permanent impairment to greater of lesser degree.

In brief: Viral meningitis..variable course.

The number of viruses that can cause is great and that's just the ones we know.
Is this patient otherwise healthy? Tuberculosis, although extremely rare in such a presentation and in any case the lymphocytic pleocytosis has improved without specific treatment should always be considered even in the most unlikely situations. A quantiferon gold blood test should be done. HIV should be excluded. Lyme should be excluded. Other viruses vary. I am sure you will have excluded HSV 1/2 and other herpesviruses. I have seen severe meningoencephalitis with slow recovery with West Nile. You might send CSF to the state virology lab. In NY they can screen for a large number of viruses. If at the end of this time you still don't have the answer you probably never will. Most of these patients recover completely although it may take a week or three. Sometimes they are left with permanent impairment to greater of lesser degree.
Dr. John Froude
Dr. John Froude
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2 comments
Dr. Cynthia Archer
Agreed. all of these are things that came to mind and should be ruled out, if it will change management.
Dr. Lois Freisleben-Cook
The CDC may be able to offer specific diagnostic testing of CSF.
Dr. Christopher Cirino
Internal Medicine - Infectious Disease
4 doctors agree

In brief: Viral likely

Did the CSF viral HSV, , Enterovirus family PCR show anything, LCM? Was the CSF white count lymphocytic predominant? West nile virus? In any event, it also sounds like he may have had post-LP.
Viral cultures, although specific, are not as sensitive as PCR studies. As far as other causes, Lyme meningitis is not typically as severe, though may be associated with other cranial nerve issues, e.g. Bell's palsy, radiculitis,etc. It can cause lymphocytic pleocytosis, a finding more characteristics of a viral syndrome. In any event, it is important that there is an answer determined. Did the process start as a viral syndrome, e.g. a cold, runny nose, sore throat, muscle aches or pains and then develop into the meningitis? Did he get an MRI as well? In any event, it is important to ask the ID physician these questions for clarification.

In brief: Viral likely

Did the CSF viral HSV, , Enterovirus family PCR show anything, LCM? Was the CSF white count lymphocytic predominant? West nile virus? In any event, it also sounds like he may have had post-LP.
Viral cultures, although specific, are not as sensitive as PCR studies. As far as other causes, Lyme meningitis is not typically as severe, though may be associated with other cranial nerve issues, e.g. Bell's palsy, radiculitis,etc. It can cause lymphocytic pleocytosis, a finding more characteristics of a viral syndrome. In any event, it is important that there is an answer determined. Did the process start as a viral syndrome, e.g. a cold, runny nose, sore throat, muscle aches or pains and then develop into the meningitis? Did he get an MRI as well? In any event, it is important to ask the ID physician these questions for clarification.
Dr. Christopher Cirino
Dr. Christopher Cirino
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2 comments
Dr. James Davie
Agree...we are stabbing in the dark without some lab data. What was the differential count of WBC in the LP? (Lymphocyte vs neutrophil-predominant). Region of the US assuming no travel (to whittle down the differential of arthropod-borne diseases), PCR pertinent negatives, MRI (if any), EEG results (if any), serologies (if any).
Dr. Derrick Lonsdale
As a fireman, he may have been exposed to smoke inhalation that has, over time accumulated mitochondrial dysfunction, thus initiating the headache and vomiting in the first place. If you can't find lab explanation, try a mitochondrial cocktail with intravenous water soluble vitamins. It does stimulate better cellular oxidation, particularly in brain
Dr. Robert Kohn
Psychiatry
2 doctors agree

In brief: Unsure

Post LP spinal headache? blood patch
no MRI w gad or brain or C spine?? would get look for GAD dural enhancement, cord changes?
all viral studies negative?
ENG r/o vestibular neuronitis?
fluids, antiemetics, potent NSAIDS smptomatic treatment.

In brief: Unsure

Post LP spinal headache? blood patch
no MRI w gad or brain or C spine?? would get look for GAD dural enhancement, cord changes?
all viral studies negative?
ENG r/o vestibular neuronitis?
fluids, antiemetics, potent NSAIDS smptomatic treatment.
Dr. Robert Kohn
Dr. Robert Kohn
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1 comment
Dr. Sudeshan Govender
Consider Lyme disease / tick bite fever. May be too early to detect antibodies . Empiric treatment with doxycycline and acyclovir may be of value . May be superimposed post LP Headaches and vertigo. Suggest bed rest and fluids. Could repeat Lyme disease antibodies at later stage for a academic purposes.

In brief: Severe Headaches N/V

40 year old gentleman, firefighter, with one month of severe headaches, nausea, vomiting after spending time in woods.
CSF cultures neg, LP with WBC, no intracranial pressure reading, no vital signs. Several CT scans performed, unknown if contrast enhanced or not, no findings. No neurological exam findings listed. Foot drop? Long tract signs? Photophobia? HSV and STD serology?
CT was likely contrast aided, however, I would suggest MR Angiogram CNS r/o AVM/ aneurysm and cervical spine, cardiac and abdomen to rule out cardiac and mesenteric ischemia, toxicology panel, EKG/Troponin and stress test, definitely Neurology consultation. If increased ICP consider VP shunt, Neurosurgical consultation. Consider Prion diseases if exposed to wildlife, consider DKA. Clusters of West Nile and N. Meningitis in S. Carolina in media. Im just a GP interesting case, hope carbon monoxide poisoning at home not a factor. Good luck to him.

In brief: Severe Headaches N/V

40 year old gentleman, firefighter, with one month of severe headaches, nausea, vomiting after spending time in woods.
CSF cultures neg, LP with WBC, no intracranial pressure reading, no vital signs. Several CT scans performed, unknown if contrast enhanced or not, no findings. No neurological exam findings listed. Foot drop? Long tract signs? Photophobia? HSV and STD serology?
CT was likely contrast aided, however, I would suggest MR Angiogram CNS r/o AVM/ aneurysm and cervical spine, cardiac and abdomen to rule out cardiac and mesenteric ischemia, toxicology panel, EKG/Troponin and stress test, definitely Neurology consultation. If increased ICP consider VP shunt, Neurosurgical consultation. Consider Prion diseases if exposed to wildlife, consider DKA. Clusters of West Nile and N. Meningitis in S. Carolina in media. Im just a GP interesting case, hope carbon monoxide poisoning at home not a factor. Good luck to him.
Dr. Cornelius O'leary jr
Dr. Cornelius O'leary jr
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1 comment
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