DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute meningitis.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic female, visiting here from another city, presented with severe headache,, which started two days prior to admission. The patient reports that she has been having neck pain for the last three weeks. She was seen by her primary care physician, given some muscle relaxant, without significant relief. She did have some scratchy feeling in the throat and was seen by another physician about a week to 10 days ago and was prescribed Z-Pak. The sore throat resolved. The patient continued having neck pain and stiffness, and she came to this city on Wednesday. Thursday night, the patient started having headache, mostly bitemporal area on the back of the head. The patient did take some Tylenol with a little bit of relief.
By Saturday evening, headache was 10/10, throbbing, and the patient presented to the emergency department. In the ED, upon arrival, the patient had a temperature of 98.4, pulse 98, respiratory rate 16, blood pressure 144/94, O2 sat 99% on room air. Labs revealed leukocytosis. The patient also underwent spinal tap, which revealed wbc’s 674 with polys 79%, lymphocytes 12%, rbc’s 224, glucose 56, and total protein 80 consistent with acute meningitis.
Infectious disease consult has been obtained for further evaluation and management of this patient. The patient has been empirically started on IV ceftriaxone and vancomycin. The patient does state that she has been having a history of recurrent labial herpes and has been recently diagnosed with hypothyroidism. The patient did have nausea and vomiting this morning. The patient also reports a few loose bowel movements last Thursday, which has now resolved.
PAST MEDICAL HISTORY: Hypothyroidism and history of viral meningitis approximately seven years ago.
PAST SURGICAL HISTORY: Status post cholecystectomy secondary to gallstones.
ALLERGIES: NKDA.
HOME MEDICATIONS: Synthroid, Tylenol and Motrin p.r.n., birth control pills, and multivitamins.
FAMILY HISTORY: Mother died of abdominal aortic aneurysm. Sister has some stomach motility disorder.
SOCIAL HISTORY: The patient lives with husband and kids. The patient denies smoking, occasional alcohol intake. Denies illicit drug use.
REVIEW OF SYSTEMS: As per history of present illness, positive for neck pain and stiffness for the last three weeks, worsening headache for the last two days associated with nausea, vomiting, and fever. Denies any abdominal pain. Did have diarrhea last Thursday, which has been resolved now. Did have a sore throat a couple of weeks ago, treated with Z-Pak, resolved now. Denies any visual or hearing deficits. Denies any stuffy nose, cough, sputum, shortness of breath, palpitation, dizziness, and denies any rash. Denies any focal weakness. Appetite fair. No significant weight change. Denies any dysuria, frequency of urination. Rest of the review of systems is unremarkable.
PHYSICAL EXAMINATION: Vital Signs: Temperature 99.6, pulse 74, blood pressure 138/72, respiratory rate 18, and O2 sat 97% on room air. The patient is a well-nourished, young Hispanic female lying on bed without any obvious distress, pleasant and cooperative with history and physical examination. Pupils are equal, round, and reactive to light bilaterally. Extraocular movements are intact bilaterally. HEENT: Clear. Neck with mild stiffness. No scalp tenderness noted. No lymph node, JVD or thyroid noted. Lungs are clear to auscultation bilaterally. Heart: S1 and S2 audible. No S3 or murmur noted. Abdomen: Protuberant, soft, nontender. Good bowel sounds, difficult to palpate any visceromegaly. Neurologically, the patient is awake, alert, and oriented x3. No gross motor or sensory deficits noted. Extremities: No clubbing, cyanosis or edema noted.
LABORATORY DATA: WBC count 30.6, hemoglobin 14.2, hematocrit 40.8, and platelet count 264,000. Serum sodium 139, potassium 4.1, chloride 104, bicarb 26, glucose 120. BUN 12, serum creatinine 0.9. Pregnancy test negative. CSF revealed hazy and pink wbc’s in tube one, 675; tube two, 450. RBCs in tube one, 225; tube two, 225. Xanthochromia negative and differentials in CSF revealed polymorphonucleocytes 79%, lymphocytes 12%, monocytes 7%, eosinophils 2%. CSF glucose 56. CSF protein 80, which is elevated. CSF smear revealed 3+ wbc’s, no organisms. Culture revealed no growth to date. Bacterial antigen detection test negative.
CT of brain unremarkable.
PROBLEMS:
1. Acute meningitis, differential diagnosis as discussed above.
2. Low-grade fever, most likely secondary to above.
3. Leukocytosis secondary to above.
4. Headache secondary to above.
5. Hypothyroidism.
ASSESSMENT: This young Hispanic female with past medical history of hypothyroidism and viral meningitis about seven years ago now presented with neck pain for the last three weeks and severe headache for the last two days with fever, chills, found to have neck stiffness and leukocytosis. Cerebrospinal fluid consistent with acute meningitis, most likely aseptic meningitis, viral in etiology considering normal glucose and elevated protein, but possibility of partially treated bacterial meningitis and herpes simplex virus meningitis cannot be excluded as the patient did take Z-Pak about a week ago and does have a history of recurrent orolabial herpes and rbc’s in the cerebrospinal fluid.
RECOMMENDATIONS:
1. We agree with the IV ceftriaxone and vancomycin pending final CSF culture results.
2. Start acyclovir 10 mg/kg IV q. 8 hours. Discussed with the patient in detail a very low likelihood that she will have HSV meningitis, but considering recurrent orolabial herpes and rbc’s in the CSF, it cannot be excluded; so the patient expressed her willingness to be treated with acyclovir and willing to take the risk of side effects with acyclovir, like blood dyscrasias and other side effects discussed with the patient in detail.
3. Add HSV PCR to already drawn labs. If it turns out negative, we will discontinue acyclovir.
4. We will follow the CSF culture results.
5. Pain control.
The plan was discussed with the patient and nursing staff in detail. Further recommendations to follow.
