TMP-SMX Induced Aseptic Meningitis

Abstract

Case Report A 24-year-old previously healthy man was admitted after a four-day history of severe headaches, neck stiffness, nausea, vomiting, and low grade fever and chills. He had been taking TMP-SMX for 18 days for a suspected community-acquired methicillin-resistant Staphylococcus aureus (MRSA) abscess of his right groin. In addition, he noticed sudden onset of a diffuse maculo-papular rash on the day of presentation sparing only his face and palms. The patient denied any history of contact with infected individuals, cough, or sinus discharges. His past medical history was negative. He had never taken TMP-SMX. He smoked cigarettes, but did not report any alcohol or illicit drug use. He had no known medication allergy. On presentation, he was awake and oriented. On physical examination, the patient showed a positive Brudzinski sign and the rash as described above, as well as a painful, 2x2 cm, right groin abscess. Vital signs were remarkable for a temperature of 103°F and a heart rate of 103 bpm. A Complete Blood Count (CBC), Comprehensive Metabolic Profile, urinalysis, chest xray, and a brain CT scan were normal. Lumbar puncture was significant for 427 WBCs with 93% segmented neutrophils, protein of 51, normal glucose, and and no organism on gram stain. The following tests were negative: Rickettsia rickettsi serology, human immunodeficiency virus (HIV) antibody, Erlichia chaffensis serology, Lyme disease serology, herpes simplex virus polymerase chain reaction (PCR) on cerebrospinal fluid (CSF), Enterovirus PCR on CSF, Tularemia serology, cryptococcal antigen, Bartonella serology, venereal disease research laboratory (VDRL) test. Bacterial, viral, acid fast, and fungal cultures and stains also were negative. TMP-SMX was stopped on admission and the patient recovered within three days.