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Hot heads 3 rd April 2014 Acute Medicine Study Day Sarah Glover Consultant in Medical Microbiology and Infectious Diseases Slide 2 Case 1 19F student Admitted with 12 hour history of myalgia headache neck stiffness photophobia 1 hr history of spreading rash O/E T 36. P 120. Neck stiffness. Rash mostly blanching but some non-blanching Slide 3 Impression in A&E: ?meningococcal meningitis BCs sent, cefotaxime given, public health notified, boyfriend given prophylaxis WCC 15 (neuts 14.5) CRP 67 Slide 4 CT head (2 hrs after arrival): NAD CSF (6 hrs post CT): WCC 13 Polymorphs10 Mononuclear 3 RBC 62 No organisms seen Protein 407 mg/l(0-500) Glucose 4.3 mmol/l No paired serum glucose Slide 5 Blood cultures positive Neisseria meningitidis CSF no growth Positive meningococcal PCR on CSF Treated with 7 days of IV cefotaxime / ceftriaxone Uneventful recovery Slide 6 Commonest causes of community acquired bacterial meningitis Adult 50 yearsStreptococcus pneumoniae Listeria monocytogenes Also cover Listeria if pregnant or immunosuppressed Slide 7 Slide 8 Logan S Viral meningitis BMJ 2008; 336:36-40 Slide 9 % Acute bacterial menignitis in adults. A review of 493 episodes. Durand. NEJM 1993;328:21-8 Absence of one or more classic findings is of little value. 13% had CSF WCC2.2 mmol/l Slide 10 696 episodes 12% had none of the characteristic CSF findings (CSF glucose 2.2g, WCC >2000) Well recognised that meningococcal sepsis with early meningitis may have low CSF WCC Slide 11 Diagnosis Meningococcal septicaemia and meningitis Slide 12 Slide 13 Role of PCR in diagnosis of invasive meningococcal disease NICE: all patients < 16 with suspected meningococcal disease get: blood culture PCR on EDTA blood CSF culture with CSF PCR if culture is negative Data from MRU across all ages: 57% were confirmed by PCR only, 22.5% by culture only, 20.4% by both tests Slide 14 Slide 15 Send blood cultures early Send an early EDTA blood for PCR Request PCR on CSF Early samples are more likely to be positive PCR results may still be positive after antibiotic administration Slide 16 Case 2 42F married secondary school teacher Lives with husband and 2 adult children Normally fit and well BIBA to A&E 2-3 day history flu like symptoms Back ache, severe headache, photophobia Mild dysuria Slide 17 O/E: low grade fever, meningitic, in pain, GCS 15, no focal neurology, no rash Bloods: CRP 8, WCC 13.9 (neuts 10) Cefotaxime started in A&E, referred to medics (no blood culture sent) Slide 18 CT brain 2pm NAD CSF 5pm: WBC 570 Polymorphs10% Mononuclear90% RBC 180 No organisms seen Protein 2114 mg/l (0-500) Glucose 2.9 mmol/l No paired serum glucose IV aciclovir added Slide 19 Other history? Slide 20 No recent travel No contacts unwell No known TB contacts, never lived abroad No immunosuppressive Rx No previous episodes of meningitis Thinks had all childhood vaccinations, unsure of details Married for 10 years No new sexual partners No recent antibiotics Denies exposure to rodents or ticks ROS: mild dysuria/perineal discomfort recently, no response to canestan Slide 21 Differential diagnosis? Slide 22 Aseptic meningitis Acute onset meningeal symptoms and fever, with CSF pleocytosis and no growth on routine bacterial culture Slide 23 Kupila L Etiology of aseptic meningitis and encephalitis in an adult population Neurology 2006 66 75-80 Aseptic meningitis Slide 24 Aseptic meningitis Viral, UK Enterovirus HSV VZV HIV seroconversion Mumps EBV CMV (immunocompromised) Slide 25 Aseptic meningitis Bacterial: Partially treated bacterial meningitis (meningo, pneumo) Listeria TB meningitis Spirochetes: syphilis, Lyme, leptospira Mycoplasma, brucella Parameningeal infection (spinal abscess or intracranial abscess) Endocarditis Slide 26 Aseptic meningitis Fungal Cryptococcus Travel West Nile virus Other arboviruses Cerebral malaria Rodents Lymphocytic choriomeningitis (LCMV) Slide 27 Aseptic meningitis Recent vaccination Non-infection: SAH Malignant meningitis Sarcoid SLE Behcets Drug induced (septrin, NSAIDs) Slide 28 Other investigations in this patient? Slide 29 Pregnancy test negative HIV negative PCRs on CSF (result within 24 hours): Enterovirus not detected VZV not detected Meningococcus not detected HSV 2 DNA DETECTED Slide 30 Other history Husband had prev hx of genital herpes no recent acute flares although mild discomfort a month ago Pt herself had no prev hx genital herpes Treated with IV aciclovir then oral valaciclovir and discharged Readmitted 1 week later with recurrent of symptoms + active genital lesions Slide 31 HSV HSV meningitis vs encephalitis HSV encephalitis: life threatening medical emergency reduced GCS, seizures, focal neurology, confusion, disorientation, personality change, speech disturbance prompt antiviral Rx life saving Usually HSV-1 Reactivation from trigeminal ganglia (prev oral mucosal acquisition) Slide 32 HSV meningitis is often a complication of genital herpes especially HSV-2 36% of women and 13% of men with primary genital HSV-2 infection had aseptic meningitis Frequently occurs in absence of genital lesions / history of genital lesions May occur during reactivation Slide 33 May be complicated by radiculitis, myelitis, recurrent meningitis (with or without genital symptoms) Role of antivirals in HSV-2 meningitis: Indicated for primary genital herpes infection Variability in practice for HSV-2 meningitis Prophylaxis: sometimes given. RCT of valaciclovir 500mg bd Asymptomatic intermittent shedding and transmission years into a monogamous relationship Slide 34 Differences in CSF findings between enterovirus and HSV-2 Clues in this case were dysuria high CSF WCC and high protein Enterovirus (n=22) HSV-2 (n=8) CSF WCC (p