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Question Answered step-by-step Please put this information in SBARAn 18-year-old woman presented with a progressively worsening headache, photophobia feverishness and vomiting. Three weeks previously she had returned to the UK from a trip to Peru. At presentation, she had clinical signs of meningism. On admission, blood tests showed a mild lymphopenia, with a normal C reactive protein and white cell count. Chest X-ray and CT of the head were normal. Cerebrospinal fluid (CSF) microscopy was normal. CSF protein and glucose were in the normal range. MRI of the head and cerebral angiography were also normal. Subsequent molecular testing of CSF detected enterovirus RNA by reverse transcriptase PCR. The patient’s clinical syndrome correlated with her virological diagnosis and no other cause of her symptoms was found. Her symptoms were self-limiting and improved with supportive management. This case illustrates an important example of viral central nervous system infection presenting clinically as meningitis but with normal CSF microscopy.Go to:BackgroundWe present the case of an 18-year-old woman with a history of recent tropical travel who presented with characteristic clinical features of meningitis. However, initial cerebrospinal fluid (CSF) findings including opening pressure, microscopy and biochemistry were normal. Subsequent molecular testing of CSF detected enterovirus RNA by reverse transcriptase PCR (RT-PCR). This case is a fascinating example of how modern molecular diagnostics are changing our clinical understanding of viral illnesses. The case also reinforces the fact that febrile patients who have recently travelled to exotic destinations may not have exotic infections.Go to:Case presentationAn 18-year-old student presented to accident and emergency department for the third time in 3 days. She gave a history of gradually increasing frontal headaches that over the past 4 days had become unbearable and associated with fevers and chills. She had vomited once, and had some mild neck pain and photophobia. Three weeks earlier she had returned from Peru, where she had undertaken voluntary work in an orphanage. She had travelled to Lima and a small rural area near Puna. She did not travel to the Amazon. She was up-to-date with pretravel vaccinations including typhoid, hepatitis A and yellow fever and in keeping with current recommendations for her itinerary, she did not take malaria prophylaxis. She was bitten relentlessly by flying insects, but not ticks and had no history of animal bites or freshwater contact. She was not sexually active. She was well while abroad, other than a brief episode of diarrhoea. Her travelling companions and her family were all well.She had no significant medical history, did not take any regular medications and had not taken any new medication recently, and did not smoke or drink. She had not received any antimicrobial therapy prior to her admission.On examination she appeared unwell. Her vital signs showed a temperature of 37.4°C, blood pressure of 105/70 mm Hg, pulse 100 bpm and oxygen saturation of 100% on air. She had marked photophobia and moderate neck stiffness, but Kernig’s sign was negative. She had no rash, and on full examination no other external signs of disease.Although she described ‘feverishness’ before admission, lack of temperature above 38°C likely reflects the fact that this was not documented, but her symptoms were consistent with a febrile illness.Go to:InvestigationsRelevant blood test resultsInitial blood results: haemoglobin 125 g/L, white cell count (WCC) 3.53×109/L (neutrophils 2.40×109/L, lymphocytes 0.86×109/L), platelets 189×109/L, C reactive protein 14Malaria immunochromatographic test negative, no malarial parasites seen on blood filmHIV1 and 2 antibodies negativeCSF resultsCSF appearance clear and colourlessCSF microscopy: WCC 2/mm3, red blood cells 21/mm3, no organisms seenCSF protein 0.24 g/L, CSF glucose 3.2 mmol/LCSF ferritin 6 ng/mL (normal range <16 ng/mL); no CSF pigments detected; no evidence to suggest intracranial haemorrhageCSF culture: no bacterial growthCSF viral PCR: enterovirus RNA detected; herpes simplex virus (HSV) and varicella zoster virus (VZV) DNA not detected. Results consistent with current enterovirus infectionMicrobiology and Virology resultsNasopharyngeal aspirate respiratory virus nucleic acid detection negative for enterovirus and the rest of the viral screen in respiratory PCR panelDengue virus IgM + IgG antibodies negative; dengue virus PCR negativeSt Louis encephalitis virus IgG (IF) negativeYellow fever virus IgG (IF) negativeEastern equine encephalomyelitis virus IgG (IF) negativeWestern equine encephalomyelitis virus IgG (IF) negativeVenezuelan. equine encephalitis virus IgG (IF) negativeWest Nile virus IgM and IgG antibody negativeRadiological investigationsCXR normalCT of the head on day 1 of admission: normalMRI of the head on day 2 of admission: normalCT of the venogram cerebral on day 2 of admission: no evidence of cerebral venous occlusive diseaseGo to:Differential diagnosisThis case represented a diagnostic dilemma because of the discordance between clinical and initial investigation findings. The clinical features were strongly suggestive of meningitis, most likely of viral or bacterial aetiology, but the initial CSF examination was normal. Central venous thrombosis was therefore considered, and CT angiography was performed and was normal. The diagnosis became apparent on the second day of admission, when enterovirus RNA was detected by RT-PCR in the CSF.Go to:TreatmentDespite the clinical diagnosis of meningitis, the patient was not given empirical antimicrobial therapy prior to lumbar puncture because her illness was indolent in onset, she remained generally well and there was minimal delay in undertaking the procedure. The advantage of this strategy is an improved rate of microbiological diagnosis in bacterial meningitis. In view of her normal CSF findings, she was managed supportively with intravenous fluids, analgesia and antiemetics. Management of enterovirus infections, as subsequently confirmed in this case, is also supportive. The patient was nursed in a side-room with standard enteric precautions to prevent transmission.Go to:Outcome and follow-upThe patient remained haemodynamically stable, and symptomatically improved during her 4-day admission. At follow-up in the infectious diseases clinic 1 week after discharge, she was well. Health Science Science Nursing NURSING 216 Share QuestionEmailCopy link Comments (0)