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Med K Patient Presentation December 5, 207. Craig Bayden Jeanne Rittschof. ID: 22 year old AA male with a headache. Past Medical History Significant for Migraines. Headache…. Started 2-3 days ago Increasing in severity- peaked this morning

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med k patient presentation december 5 207

Med K Patient PresentationDecember 5, 207

Craig Bayden

Jeanne Rittschof

headache
Headache…

Started 2-3 days ago

Increasing in severity- peaked this morning

Entire head and neck hurts, especially with neck movement

Mild Photophobia

“I don’t think it’s a migraine”

and jock itch
And “Jock Itch”
  • Started before the headache
  • Red itchy bumps on scrotum and penis
  • Currently almost resolved
additional symptoms
Additional Symptoms
  • Subjective Low Grade Fever
  • Mild Shortness of Breath
  • Generalized fatigue and weakness
  • Nausea and vomiting this morningED
additional history
Additional History
  • No pets
  • No sick contacts
  • Last Sexual Contact: 18 mos ago
  • No oral sex
  • No cold sores
  • No Known Allergies
slide8
Traveled to Korea in February
  • Camping retreat last week with exposure to wooded areas
    • no ticks
    • no mosquito bites
medical and surgical history
Medical and Surgical history
  • Heart murmur
  • Mild intermittent asthma
  • GERD
  • Migraines
social history
Social History
  • College Student
  • Apartment with rooommate
  • City water
  • No Tobacco/No IVDU/No EtOH
family history
Family History
  • Hypertension
  • Coronary Artery Disease
  • Diabetes Mellitus
home medications
Home Medications
  • Albuterol MDI PRN
  • Prilosec OTC
  • No other medicines including OTCs or Herbals
vital signs
Vital Signs
  • BP 136/76
  • HR 94
  • RR 16
  • T: 37.1C
  • 99% RA
general
General
  • Somnolent (ativan for LP)
ocular exam
Ocular Exam
  • Photophobia
  • PERRLA.
  • Extra Ocular Motions Intact
  • Sclera clear
slide18
ENT
  • Mucus Membranes Moist
  • Oropharynx without lesions or exudates
slide19
Neck
  • Limitted range of motion
  • No carotid Bruits
  • No thyromegally
lymph nodes
Lymph Nodes
  • Bilateral Inguinal Adenopathy, tender, mobile
  • All other lymph nodes within normal limits
cardiovascular
Cardiovascular
  • Regular Rate and Rhythm
  • II/VI systolic ejection murmur at LLSB, w/o radiation to carotids
  • Radial, Posterior Tibial, Carotids 2+ Bilaterally
pulmonary
Pulmonary
  • Clear to Auscultation Bilaterally
  • No consolidation on percussion
  • Respirations unlabored
dermatology
Dermatology
  • No rashes
  • No petechiae
  • No bruises
  • See genitourininary
genitourinary
Genitourinary
  • Lesions covering scrotum and penis
  • Faint, small, circular, red papules
  • Non erupting, non crusting, non painful to palpation
  • No lesions around anus
  • Seemed to be resolving
abdomen
Abdomen
  • Non distended
  • Positive bowel sounds
  • No hepatosplenomegally
  • Soft and non tender to palpation
extremities
Extremities
  • No cyanosis
  • No clubbing
  • No edema
musculoskeletal
Musculoskeletal
  • moves all extremities
  • Strength 4/5 (ativan) equal and bilateral
  • Cannot touch chin to chest
neurological
Neurological
  • Oriented x 3
  • CN II-XII Intact
  • P2P, RAM, Rhomberg and Gait WNL
  • All DTRs 2+ bilaterally
slide30
CBC
  • WBC 7.5
  • Hg 15.7/ Hct 47.6
  • Platelets 214
  • Absolute neutrophils 5.6
  • Absolute lymphocyte count 1
bmp unremarkable
Na 138

K 4.5

Cl 103

CO2 27

BUN 10

Creatinine 1.1

Glucose 94

Ca 9.5

Mg 2.1

Ph 3.3

BMP: Unremarkable
lft s
LFT’s
  • Tbili 0.6
  • AST 82
  • ALT 94
  • Alk phos 67
  • GGT 20
slide33
CSF
  • Clear, colorless
  • 231 nucleated cells
  • 84% Lymphocytes
  • Protein 76
  • Glucose 49
  • Atypical Lymphocytes
imaging
Imaging
  • Head CT: No acute intracranial process
  • RUQ US: No abdominal process
  • CXR: no air space disease
initial management
Initial Management
  • Vancomycin 1 gram IV Q12 hours
  • Ceftriaxone 2 grams IV Q12 hours
  • Acyclovir 800mg IV Q8 hours
  • Doxycycline 100mg IV Q12 hours
studies ordered
Studies Ordered
  • Blood cultures
  • Urine Cultures
  • CSF Cultures
  • HIV ELISA and Quantitative RNA
  • Rapid Influenza Assay
  • Serum RPR
additional csf studies
Enterovirus PCR

HSV PCR

Adenovirus PCR

VZV PCR

CMV PCR

EBV PCR

VDRL

Crypto Antigen

Influenza Virus

Additional CSF Studies
aseptic meningitis differential
Aseptic Meningitis Differential
  • Infectious: viruses, mycobacteria, fungi, spirochetes, tick borne
  • Drugs: NSAIDS, ATG, Sulfas, Quinolones and PCN
  • Malignancy
  • Autoimmune: Bechet’s, Mollaret’s
  • Partially Treated Meningitis
viruses
Viruses
  • Enterovirus
  • HSV 2
  • HIV
  • LCMV
  • Mumps
  • CMV
  • EBV
  • VZV
  • Adenovirus
  • Arbovirus
varicella zoster
Varicella Zoster
  • Human Herpes Virus
  • Causes Chicken Pox
  • Latent in cranial nerve and dorsal root ganglia
  • Reactivates causing a variety of manifestations
reactivation manifestations
Reactivation manifestations
  • Shingles
  • Radiculoneuropathy
  • Ganglionitis
  • Post- herpetic neuralgia
  • Myelitis
  • Encephalitis/ Ventriculitis
  • Arteritis
  • Aseptic meningitis
one finnish study 2006
One Finnish Study (2006)
  • 144 immunocompetent participants with aseptic meningitis
  • 66% had identifiable etiologies (PCR) for aseptic meningitis:
    • Enterovirus 26%
    • HSV2 17%
    • VZV 8%
  • 31% of patients with VZV mengingitis had no rash
references
References
  • Kupila, L et al. Etiology of aseptic meningitis and encephalitis in an adult population. Neurology 2006;66:75-80.
  • Gilden, D et al. Neurologic Complications of the Reactivation of Varicella-Zoster Virus. New England Journal of Medicine 2007;342: 635-646.
  • Up-To-Date (no access off campus)
search pubmed
Search PubMed
  • Aseptic Meningitis & Varicella Zoster Virus
    • Case Reports
    • Reviews
    • Drug Therapy