Cases Of Aseptic Meningitis Research Articles

Headaches in a pediatric emergency department: etiology, imaging, and treatment.

To assess the spectrum of diagnoses, the use of CT scans of the brain, and pharmacological treatments in patients presenting to a pediatric emergency department with headaches as the chief complaint. A 1-year retrospective chart review of all children who presented to the emergency department with a headache as the chief complaint. One hundred thirty patients (0.7% of all pediatric emergency department visits, mean age = 9.3 years) were included in the study. Primary headaches included 11 migraine (8.5%) and 2 tension headaches (1.5%). Most of the secondary nonneurological headaches were associated with viral and respiratory illnesses (n=37, 28.5%), while the majority of the secondary neurological headaches included 26 posttraumatic (20%), 15 possible ventriculoperitoneal shunt malfunctions (11.5%), and 3 cases of aseptic meningitis (2.3%). The neurological etiology in 9 of these children (6.9%) was found to be serious (subdural hematoma, epidural hematoma, proven ventriculoperitoneal shunt malfunction, brain abscess, pseudotumor cerebri, and aseptic meningitis). Fifteen patients could not be etiologically classified, either because no specific etiology was found or their discharge diagnoses could not clearly explain the headache. Approximately 10% (5/53) of the CT scans of the head that were performed showed new abnormal findings including hydrocephalus secondary to ventriculoperitoneal shunt malfunction (2), subdural hematoma (1), epidural hematoma (1), and skull fracture (1). Forty-two patients (32%) were treated pharmacologically. Thirty-nine of the 42 treated patients (93%) were given over-the-counter analgesics, and 9 (21%) were given prescribed analgesics. The majority of the headaches in the pediatric emergency department were secondary to concurrent illness and minor head trauma, and required no pharmacological treatment or only treatment with minor analgesics. In a small minority of patients, headaches were secondary to serious neurological conditions, which required immediate medical attention. Computed tomography scans showed new abnormalities in a minority of patients and should be reserved for those with neurological diagnoses such as head trauma and ventriculoperitoneal shunt, as well as for those patients with recent onset of headaches with no clear etiological explanation, and for those with high-risk medical conditions, such as hypocoagulabilities. Future prospective studies are needed to assess the efficacy of the various pharmacological treatments in this population.

Diagnosis and surveillance of herpes simplex virus infection of the central nervous system.

Herpes simplex viruses (HSV) are responsible for neurological disorders that require rapid diagnostic methods and specific antiviral therapy. During 1997, 1431 cerebrospinal fluid samples (CSF) collected from 1339 patients with neurological disorder presentations were processed for HSV detection. Eleven patients were positive for HSV, seven presenting with encephalitis (6/7 due to HSV1) and 4 with aseptic meningitis (4/4 due to HSV2). The incidence of HSV encephalitis was 2.33 cases / 10(6) inhabitants/year. Among encephalitis (HSV encephalitis) cases, 1 patient died due to the late implementation of antiviral therapy, and sequelae were observed in 4 cases. No sequelae were observed in aseptic meningitis cases. Four HSV encephalitis cases were monitored by PCR detection in CSF. Despite acyclovir therapy, PCR remained positive in CSF up to 20 days in 2 cases. This result suggest that the antiviral treatment for HSV encephalitis should be monitored by PCR detection of HSV in CSF.

Viral meningitis.

Enteroviruses account for 85 to 95% of all cases of aseptic meningitis, but the arboviruses and herpes simplex virus are also important etiologic agents. Mumps, lymphocytic choriomeningitis virus, herpes zoster, human herpesvirus type 6, and influenza viruses are rare causes of meningitis. The virology, pathogenesis, epidemiology, clinical manifestations, diagnostic studies, and established and potential antiviral therapies for viral meningitis are discussed. A differential diagnosis of the aseptic meningitis syndrome is provided.

Treatment of lumbosacral radiculopathy with epidural steroids.

Treatment of lumbosacral radiculopathy with epidural steroids.

Meningitis (I) – differential diagnosis; aseptic and chronic meningitis

Meningitis is the most common serious manifestation of infection of the central nervous system. Inflammatory involvement of the subarachnoid space with meningeal irritation leads to the classical triad of headache, fever, and meningism, and to a pleocytosis of the cerebrospinal fluid (CSF). Meningitis is clinically categorized into an acute and chronic disease based on the acuity of symptoms. Acute meningitis develops over hours to days, while in chronic meningitis symptoms evolve over days or even weeks. Aseptic meningitis, in which no bacterial pathogen can be isolated by routine cultures, can mimic bacterial meningitis, but the disease has a much more favorable prognosis. Many cases of aseptic meningitis are caused by viruses, primarily enteroviruses, but bacteria and noninfectious etiologies also cause meningitis with negative cultures. Symptoms of meningeal inflammation with CSF pleocytosis that persist for more than 4 weeks define the chronic meningitis syndrome. The diagnosis is based on the patient history, clinical evidence of meningitis, CSF examination, and often imaging studies. The differential diagnosis is broad, and the predominant CSF cell type can provide clues as to the underlying disease. Empiric therapy is primarily based on the age of the patient, with modifications if there are positive findings on CSF gram stain or if the patient presents with special risk factors. In patients with chronic meningitis, a definite diagnosis is often not available or delayed for days, in which case empiric therapy may have to be initiated. It is important to cover the treatable causes of meningitis, for which the outcome is poor if treatment is delayed.

Aseptic meningitis after treatment with amoxicillin

The development of aseptic meningitis has been associated with various drugs—for example, non-steroidal anti-inflammatory drugs, ranitidine, carbamazepine, vaccines against hepatitis B and mumps, immunoglobulins, co-trimoxazole, and penicillin.1–5 We report a...

Rapid diagnosis of cryptococcal meningitis by microscopic examination of centrifuged cerebrospinal fluid sediment.

The classic India ink test is positive in only half of cryptococcal meningitis cases, and reliable, rapid cryptococcal antigen (CRAG) testing requires technical expertise and facilities not always available. We therefore examined cerebrospinal fluid (CSF) sediment using May-Giemsa, periodic acid-Schiff, and Gram stains in 16 patients with cryptococcal meningitis. The India ink test was positive in seven patients (44%), while microscopic examination of sediment revealed cryptococci in 13 (81%); in six of these 13 the India ink test was negative. Both methods failed to detect the pathogen in the remaining three patients. CRAG testing in CSF was negative in two patients (one with acquired immunodeficiency syndrome, one with diabetes mellitus) whose India ink test also was negative while cryptococci were identified in their CSF sediment. No false positives occurred with CSF May-Giemsa staining in 27 cases of aseptic meningitis with negative cultures for Cryptococcus. In all, microscopic examination of centrifuged and stained CSF sediment proved more sensitive for rapid diagnosis of cryptococcal meningitis than the India ink method, and in two of our patients cryptococci were seen in centrifuged CSF sediment despite negative CRAG and India ink tests.

Index of Suspicion

Index of Suspicion

Detection and identification of enteroviruses RNA by using polymerase chain reaction.

For rapid diagnosis of enteroviral infection in clinic practice, we developed a reverse transcription and polymerase chain reaction (RT-PCR) assay. Primers homologous to the conserved 5' non-coding region were designed by analyzing enteroviral genomes, and then they were used to enzymatically amplify RNA from 31 prototype enteroviral strains and enteroviruses (EV) in cerebrospinal fluid (CSF) of 34 cases of aseptic meningitis and 11 cases of aseptic encephalitis. The RT-PCR products generated with these enteroviral primers were analyzed by agar gel electrophoresis and dot blot hybridization analysis. 31 EV strains showed an obvious monoclonal amplification band, and all dot blot hybridization results were positive. Four other viruses and cells cultured were all negative. The study of sensitivity of the RT-PCR showed that amplification production were positive to 10(-2)-10(-3) 50% tissue culture infective doses. With this assay, 21 (61.8%) of 34 aseptic meningitis and 8 (72.7%) of 11 aseptic encephalitis contained EV RNA in CSF samples. Two cases of meningitis and one of encephalitis with EV infection were still positive during convalescence. Our results suggest that this RT-PCR method was a fast, sensitive and specific technique for detection of common EV infection.

Application of PCR for various neurotropic viruses on the diagnosis of viral meningitis.

Epidemiological studies have indicated that the majority of cases of aseptic meningitis result from viral infections. However, specific viral pathogens for aseptic meningitis can be identified in only some cases even if consistent conventional diagnostic methodologies rare used. To clarify the etiological agents of aseptic meningitis by means of polymerase chain reaction (PCR) for various neurotropic viruses. Cerebrospinal fluid (CSF) samples were collected from 73 children suspected of having meningitis from November 1991 to December 1994. The samples were examined for infectious viruses by cell culture and for viral genomes by PCR. Of 45 samples from patients diagnosed with aseptic meningitis, positive PCR results for enterovirus, mumps virus, cytomegalovirus, and varicella-zoster virus were obtained from respectively 25, 14, 1, and 1. Viral pathogens were thus identified in 41 (91.1%) of the 45 CSF samples. By the combination of PCR methods with conventional virological methods, the diagnosis of viral meningitis was established in 97.8% of the 45 cases. Our findings prove that the application of PCR methods is useful for etiological study of aseptic meningitis, and that the vast majority of cases of aseptic meningitis result from viral infection.

In vitro Characteristics of a Glass Ionomer Cement

Glass ionomer cements were first described by Wilson and Kent and have been used in dentistry since 1969. It has been recommended for bridging ossicular chain defects, fixation of ossicular chain prosthesis, anchoring of cochlear implants, mastoid obliteration, and repair of tegmen and posterior canal wall defects. The biocompatability and stability of this material over time is vital to its usefulness in neurotologic surgery. The purpose of this study was to assess the stability of a glass ionomer cement in the presence of bacteria and in different pH environments. We demonstrated that bacteria readily adhere to the surface and their presence is associated with accelerated loss of matrix. We found the cement to be susceptible to low pH and to release a visible cloud of debris upon contact with fluid. Calcium concentration in the solution was elevated at all pH levels. Although we are able to demonstrate these findings in vitro the clinical relevance is unclear. There have been several cases of aseptic meningitis possibly due to intracranial release of components of the cement. Until further studies are done use of the cement in contact with cerebral spinal fluid should be avoided. This cement, or a similar material, would be useful in neurotologic surgery but prior to widespread use further testing should be done to assess safety.

Aseptic meningitis associated with high dose immunoglobulin: case report

Aseptic meningitis is a recognised complication of high dose intravenous immunoglobulin. We report a case of aseptic meningitis diagnosed on the basis of eosinophilia in cerebrospinal fluid. A 21 year...

Trimethoprim-induced aseptic meningitis and uveitis

We wish to report a case of trimethoprim-related uveitis and aseptic meningitis confirmed by rechallenge. An 18-year-old woman presented with a recent history of recurrent urinary tract infections. The first infection, 5 months previously, was treated with a 7-day course of trimethoprim. She made an uneventful recovery. 2 months later a recurrent urinary tract infection was diagnosed and trimethoprim was again prescribed. Within hours of the first dose of trimethoprim, she described the onset of headache, red and sore eyes, and neck ache. She was reviewed in the emergency department and her therapy was changed to co-amoxyclav. She completed a 7-day course. Her eye pain endured for 2 weeks. A subsequent urinary tract infection, 1 month later, was again treated with co-amoxyclav and she made an uncomplicated recovery. 2 months later she presented to the emergency department with headache, fever, painful red eyes, and photophobia. Earlier in the day she had attended her local medical officer, with a recurrence of urinary tract symptoms. A clinical diagnosis of cystitis was made and she was prescribed trimethoprim. She took her first dose about 4 h before her hospital presentation. On examination, she appeared unwell but was orientated and responsive. Her temperature was 37·5oC. Neck stiffness and a positive Kernig’s sign were both elicited and slit-lamp examination of both eyes revealed white cells in the anterior chamber and a proteinaceous “flare”, consistent with a bilateral anterior uveitis. Small non-tender anterior and posterior cervical lymph nodes were palpable. Her large joints were tender on passive movement. Investigations revealed an ESR of 22, a normal full blood count, white cell count, electrolytes, urea, creatinine, and liver function tests. Urine microscopy showed 11 to 100 10 white cells. Urine cultures yielded a mixed growth. A high vaginal swab showed no growth. For Chlamydia trachomatis, direct fluorescence on a cervical swab and C trachomatis urinary PCR were negative. Cerebrospinal fluid (CSF) microscopy showed 1 red cell, 3 polymorphonuclear cells, and 2 monocytes 10/L. The CSF was sterile. The CSF protein was elevated at 0·66 g/L. Blood cultures were negative. Immunological studies showed a negative antinuclear antibody, and a normal rheumatoid factor. There was no history of previously diagnosed sexually transmitted diseases in either the patient or her sexual partner. She denied any recreational illicit drug use and only occasionally drank alcohol. She was a non-smoker. Her only regular medication was the oral contraceptive pill. In the absence of other infectious or autoimmune diagnoses, an adverse drug reaction to trimethoprim is most likely. Trimethoprim-induced aseptic meningitis has been described in previous case reports. The potential to produce this adverse effect has been shown to occur independently of the combination with sulphonamide drugs. Uveitis, by contrast, has been attributed to the systemic use of sulphonamide derivatives. Of interest, most of these cases were reported in people treated with co-trimoxazole, and none was re-challenged with trimethoprim alone to determine if this drug was capable of inducing uveitis. To our knowledge this is the first case report of trimethopriminduced uveitis. It is possible that this diagnosis is missed due to the frequent use of this drug in combination with sulphamethoxazole for which this particular adverse drug reaction has been well described.

Risk of hospitalization because of aseptic meningitis after measles-mumps-rubella vaccination in one- to two-year-old children: an analysis of the Vaccine Safety Datalink (VSD) Project

To assess the level of increased risk, if any, of hospitalizations for aseptic meningitis after Jeryl-Lynn mumps strain measles-mumps-rubella (MMR) vaccine in the Vaccine Safety Datalink population. A possible increased risk of aseptic meningitis 8 to 14 days after receipt of MMR was observed in a preliminary screening analysis of automated data from the Vaccine Safety Datalink (VSD) project Year 2 analysis. To further evaluate this association a retrospective 10-year matched case-control study was undertaken in the four health maintenance organizations (HMOs) in the VSD project. Cases ascertained from a broad scan of the automated data were validated against a standard case definition. Two controls matched on age, sex, HMO and HMO membership were assigned per case. The VSD project involves the cooperative collection of automated vaccination and medical outcome data from four large HMOs that currently have 500,000 children younger than 7 years of age under surveillance. Review of automated screening results from the first 2 years of data revealed a possible increased risk of aseptic meningitis 0 to 14 days after MMR with a relative risk of 3.61 (95% confidence interval, 1.0 to 13.1) although the total number of cases was small. Although the automated data had suggested a possible association of aseptic meningitis with MMR containing the Jeryl-Lynn strain of mumps, review of validated hospitalized cases during the observation period did not reveal evidence of an increased risk of aseptic meningitis after MMR containing the Jeryl-Lynn strain of mumps (odds ratio < 1.0 for all analyses). Although it is recognized that hospitalized cases represent a minority of the total cases of aseptic meningitis, it is reassuring that in this evaluation no increased risk of aseptic meningitis after MMR vaccine was found.

Un cas de méningite aseptique à la bupivacaïne

Summary A case of chemical aseptic meningitis is reported, following a bupivacain spinal anesthesia. The diagnosis was supported by anamnesia, evolution, and normoglycorachia. This diagnosis was reached by excluding other diagnoses since meningitis following spinal and epidural anesthesia are most often bacterial. The most commonly found bacteria are streptococci. Physiopathology may be explained by the inoculation of bacteremic pathogens into the CSF by droplet contamination of the spinal needle from the oropharyngeal flora of the operator. This shows the importance of wearing a face mask during a lumbar puncture.

The use of Vicryl Collagen as a dura substitute: a clinical review of 78 surgical cases.

We performed a retrospective review of 78 consecutive neurosurgical procedures using Vicryl Collagen, a resorbable mesh of polyglactin 910 coated with bovine collagen, for dural substitution. The complications we encountered were infrequent and mostly minor (5 cases of subcutaneous CSF collections, 2 cases of aseptic meningitis, 1 superficial wound infection), and not unusual for the surgical procedures studied. One patient, however, had a major infection, starting in the superficial tissues, and extending toward the brain. In this patient, the resorption of the dural substitute appeared to be the cause for the intracranial extension of the infection. Three patients were reoperated on for recurrent tumour after a longer interval. We found minimal adhesions and good fibrous incorporation of the Vicryl Collagen into the surrounding normal dura. We conclude that Vicryl Collagen is a valuable alternative to the patient's own fibrous tissues when dural substitution is necessary.

Detection of enteroviruses by polymerase chain reaction in urine samples of patients with aseptic meningitis.

Detection of enteroviruses by polymerase chain reaction in urine samples of patients with aseptic meningitis.

Complications associated with epidural steroid injections.

Warnings about the hazards of epidural steroid injections occasionally appear in both medical and lay literature despite a lack of objective data to support such concerns. This literature review was undertaken to survey reports of adverse reactions associated with that procedure. The following types of publications from peer-reviewed medical literature was surveyed: reports on series of epidural and subarachnoid steroid injections for sciatica; reports of adverse effects of epidural and subarachnoid steroid injections for sciatica; review articles on epidural and subarachnoid steroid injections; and studies of the behavioral and histologic effects of epidural steroids and their vehicle in animals. Several cases of aseptic meningitis, arachnoiditis, and bacterial meningitis and one case of conus medullaris syndrome have been reported after subarachnoid steroid injections. Most of these complications occurred after multiple subarachnoid injections. Two cases of epidural abscess, one case of bacterial meningitis, and one case of aseptic meningitis have been reported following epidural steroid injections. Subarachnoid drug placement could not be ruled out in the meningitis cases. There are few published reports of serious complications following epidural steroid injections. There are a few published reports of complications following subarachnoid steroid injections, most of which were associated with multiple injections over a prolonged time period.

Aseptic meningitis following mumps vaccine. A retrospective survey by the French Regional Pharmacovigilance centres and by Pasteur-Mérieux Sérums & Vaccins.

Since 1989 many case series and observational studies of aseptic meningitis (AM) associated with the use of live attenuated mumps vaccines containing the Urabe AM9 strain have been reported worldwide. The aim of this retrospective reported AM in France following mumps vaccination with monovalent or multivalent vaccines containing the Urabe strain. Fifty-four cases of AM were reported to the Regional Pharmacovigilance centres or to the manufacturer from the time each vaccine was launched up until June 1992. Twenty cases were temporally associated with the administration of a monovalent mumps vaccine and 34 with a trivalent measles, mumps and rubella vaccine (MMR). A mumps virus was isolated in four cases in the cerebrospinal fluid and an Urabe-like strain was characterized twice by polymerase chain reaction (PCR). A probable mumps origin was assumed in 17 other cases where the patients presented with other clinical or biological signs of mumps infection. The clinical outcome of AM, known in 87% of the population, was always favourable. The global incidence of mumps vaccine-associated AM was 0.82/100,000 doses, which is significantly lower than the incidence in the unvaccinated population. Even considering that the actual incidence of AM is much higher when assessed by active surveillance studies, the risk/benefit ratio of mumps vaccine remains in favour of vaccination.

Sandfly fever viruses in Italy.

Two serologically distinct agents, the sandfly fever Sicilian and the sandfly fever Naples viruses, were isolated by Sabin from blood samples taken during an Italian epidemic of febrile illness. Since then, several different viruses have been isolated from sandflies and/or humans in both the Old and New World. Toscana virus, a new virus closely antigenically related to sandfly fever Naples virus, was isolated in 1971 from the sandfly Phlebotomus perniciosus in Italy. Extensive studies on the importance of Toscana virus as a human pathogen demonstrated its association with acute neurologic diseases. A serosurvey for the presence of antibodies to sandfly fever Sicilian, sandfly fever Naples and Toscana viruses indicated that, as in other Mediterranean areas, both sandfly fever Sicilian and sandfly fever Naples viral infections decreased or disappeared after the 1940s in countries performing insecticide-spraying malaria eradication campaigns. In contrast, clinical cases of aseptic meningitis or meningoencephalitis caused by Toscana virus are observed annually in Central Italy during the summer. Toscana virus may be present in other Mediterranean countries where sandflies of the genus Phlebotomus are present.