Aseptic and Fungal Meningitis - Diagnosis and Management
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Aseptic and Fungal Meningitis - Diagnosis and Management

Aseptic Meningitis (meningeal inflammation with negative bacterial cultures):

 • Etiology: 

     - Infectious: partially treated endocarditis (most common cause), enteroviruses, HACEK orgs (NB: usually NOT culture negative!), HSV, VZV, partially tx’d bacterial meningitis (usually days-wks of tx), any stage of syphilis, Lyme, leptospirosis, mumps, nocardia, TB, fungal (Cryptococcus), brain abscess; 

     - Non-infectious: autoimmune (Behcets, Sarcoid, SLE, SJS), neoplastic (leukemia,

lymphoma), drugs (NSAIDs, antimicrobials, IVIG)

 • Clinical Presentation: Similar to bacterial, usually less toxic. LP: lymphocytic pleocytosis

 • Treatment: if concern for encephalitis (HSV, VZV) → acyclovir 10 mg/kg IV q8H; otherwise tx is supportive. If suspect TB, call ID consult for consideration of quadruple therapy with INH, RIF, PZA and 4th agent (FQ or Aminoglycoside)

Fungal Meningitis:

 • Causes: 

     - Primary (immunocompetent pts): Cryptococcus, blastomyces, histoplasma, coccidioides, and other dimorphic fungi;

     - Secondary (immunocompromised pts): Candida, aspergillus, other molds

 • Diagnosis: Submit CSF for acid-fast stain, India ink preparation, and cryptococcal antigen. Attempt to obtain large volumes (up to 40-50 mL) for culture.

 • Cryptococcal Meningitis Treatment: ampho B IV 3-4 mg/kg qd + flucytosine PO 25mg/kg q6h



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