AM report pearls 4/13 #2: aseptic meningitis

  • Kernig’s and Brudzinski’s signs: both low sensitivity but high specificity for meningitis! Jolt: 60% spec, 97% spec
  • Aseptic meningitis = inflammatory CSF but negative bacterial cultures. Differential includes:
    • Viral meningitis most common!
      • 90% are enterovirus
      • HSV 1/2 (see below for more on this!)
      • HIV
    • Other infectious etiologies
      • Fungal (crypto, cocci)
      • Mycobacterial (TB)
      • Spirochetes (lyme, syphilis)
    • Drug-induced
      • NSAIDs are most common culprits! (*esp in the context of an autoimmune diathesis)
      • Bactrim and AEDs can do it too
    • Autoimmune (eg SLE!)
    • Malignancy
  • Quick hit pearls on HSV meningitis from HH!
    • HSV1 – commonly also a/w encephalitis! Always empirically treat with ACV as this is a treatable and reversible cause of encephalitis!
    • HSV2 – break down into primary vs recurrent. Here is a JAMA Neurology article on neurological complications of HSV2!
      • Primary – often associated with mucocutaneous vesicular outbreak, can get radiculitis/radiculopathy in addition to meningitis
      • Recurrent – no correlation with outbreak (sometimes you will hear the term Mollaret’s meningitis if somebody has >3 recurrent episodes of this!). Will improve without ACV!
    • Classically, LP in context of HSV meningitis will have RBCs on CSF analysis. However, 10% of HSV meningitis does not!
    • CSF HSV PCR has high sensitivity and specificity – 98% and 94% respectively! Is positive within first 24h of sx onset and remains positive for about a week
    • Some old pearls on this! SFGH, Moffitt





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