ASEPTIC MENINGITIS FOLLOWING ADMINISTRATION OF CONSCIOUS SEDATION FOR ENDOSCOPIC PROCEDURE

Abstract

Case Report: A 40-year old man was scheduled for outpatient ERCP for evaluation and treatment of choledocholithiasis. Past medical history included AIDS, CD4:190, and hepatitis C. He was taking lopinavir/ritonavir, trimethoprim-sulfamethoxazole, zidovudine, and methadone 110mg/day. ERCP was attempted. He received 100 mg of meperidine and 4 mg of midazolam for conscious sedation. A stone was noted in the CBD. The patient became agitated and procedure was aborted. Eight hours after ERCP, he developed severe headache, nausea, vomiting and fever. Symptoms lasted for 24 hours and resolved spontaneously. During his second ERCP he received 125 mg of meperidine and 4 mg of midazolam. He again pulled out the endoscope after CBD cannulation. Few hours after the procedure he was drowsy and complained of headache, vomiting and low-grade fever. Physical exam revealed nuchal rigidity, positive Brudzinski and Kernig signs. CSF showed WBC137, PMN:43%, lymph:7% and eosinophils:2%; glucose:51 mg/dL, TP:159 mg/dL. GS, culture, cryptococcal antigen and AFB were negative. Head CT scan was unremarkable. The patient's symptoms completely resolved within 24 hours. All cultures remained negative; antibiotics were discontinued after 72 hours and he was discharged in stable condition few days later. Discussion: This man presented with headache, fever, meningismus and altered mental status on two separate occasions, both after ERCP was performed using meperidine and midazolam. His clinical presentation could have been explained by infectious meningitis, especially considering his immunosupressed status. However, all cultures were negative. Further, the rapid resolution of the symptoms and signs favors the diagnosis of aseptic meningitis. The CSF of patients with DIAM typically shows pleocytosis of hundreds to thousand cells per cubic millimeter, normal-to-low glucose values, and increased protein values. Our patient had a discrete elevation of WBC in CSF. The level of glucose and protein in this patient were also characteristic of DIAM. Meperidine and midazolam are drugs routinely used for conscious sedation in endoscopic procedures. No case of DIAM has been reported with use of any of them. In conclusion, the possibility of DIAM should be considered in patients with neutrophilic meningitis and negative CSF culture, especially after developing similar neurologic symptoms and signs upon rechallenge of a specific drug. Therefore, midazolam and meperidine should be considered possible etiological agents of DIAM. OUTCOMES RESEARCH