A 38 Year Old Woman Presents With A 2 Day History Of Severe Headache And Neck Stiffness.

A 38 year old woman is seen in the emergency department with the complains of severe headache and neck stiffness for the last 2 days. On examination she had a temperature of 101 F and BP of 120/70 mmHg. There was no rash seen on the skin. On neurological examination there was mild nuchal rigidity.
CSF analysis was done and the report is given below:

• Appearance = clear
• WCC = 20/ cubic mm (60% lymphocytes)
• Protein = 0.48 gm/l
• Glucose = 2.3 mmol/l ( simultaneous blood glucose = 4.5 mmol/l)
• Gram stain = No organism identified. 

A CT scan Of the brain was done and the image is shown below:

Normal CT scan of the brain.

What is the Differential Diagnosis?

• Aspectic Meningitis
• Viral Meningitis
• Partially treated Bacterial Meningitis
• Tuberculous Meningitis.
• Listeria infection
• Lymes Disease
• Herpes Simplex Encephalitis.

The Final Diagnosis was Viral Meningitis. 

Case Discussion:

Viral Meningitis is an inflammation of the leptomeninges caused by a viral infection in the central nervous system.Viral Meningitis is also sometimes referred as aseptic meningitis. Viral meningitis is often less severe than bacterial meningitis and most patients can get well without any complications. 

It is one of the most common type of meningitis and the causative virus is usually from non-polio enterovirus group. 

Clinical Features: Patients usually present with fever, headache, irritability, nausea, neck stiffness and fatigue within the previous 18-36 hours. 

Headache is almost always present in patients with viral meningitis and is reported to be severe. 

Nuchal rigidity and other signs of meningeal irritation may be seen but not in all the patients. 

Diagnosis:

1. The complete blood count is not sensitive and the serum white cell counts may be normal.

2. CSF studies show slightly raised WCC and mostly lymphocytes, the CSF appearance is normal with normal opening pressure. Protein levels are only slightly elevated and glucose levels are usually normal. CSF gram stain will be negative. 

3. CT scan should be done before lumbar puncture to exclude any structural abnormalities and to prevent the risk of herniation. CT scan is usually normal. 

Treatment:

1. treatment for viral meningitis is usually supportive with proper care for hydration.

2. Controlling fever and pain by anti-pyretics and analgesics. 

3. Intravenous antibiotics should only be started if there is high suspicion of bacterial meningitis. Antibiotics have no role for treating viral meningitis. 

4. Patients who have signs and symptoms of meningoencephalitis should be given acyclovir.