Transcript ID: 22 year old AA male - UNC School of Medicine

Med K Patient Presentation
December 5, 207
Craig Bayden
Jeanne Rittschof
ID: 22 year old AA male
with a headache
Past Medical History Significant for
Migraines
Headache…
Started 2-3 days ago
Increasing in severity- peaked this morning
Entire head and neck hurts, especially with
neck movement
Mild Photophobia
“I don’t think it’s a migraine”
And “Jock Itch”
• Started before the headache
• Red itchy bumps on scrotum and penis
• Currently almost resolved
Additional Symptoms
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Subjective Low Grade Fever
Mild Shortness of Breath
Generalized fatigue and weakness
Nausea and vomiting this morningED
Additional History
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No pets
No sick contacts
Last Sexual Contact: 18 mos ago
No oral sex
No cold sores
No Known Allergies
• Traveled to Korea in February
• Camping retreat last week with exposure
to wooded areas
– no ticks
– no mosquito bites
Medical and Surgical history
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Heart murmur
Mild intermittent asthma
GERD
Migraines
Social History
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College Student
Apartment with rooommate
City water
No Tobacco/No IVDU/No EtOH
Family History
• Hypertension
• Coronary Artery Disease
• Diabetes Mellitus
Home Medications
• Albuterol MDI PRN
• Prilosec OTC
• No other medicines including OTCs or
Herbals
Rest of Review of Systems
Negative
Physical Exam
Vital Signs
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BP 136/76
HR 94
RR 16
T: 37.1C
99% RA
General
• Somnolent (ativan for LP)
Ocular Exam
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Photophobia
PERRLA.
Extra Ocular Motions Intact
Sclera clear
ENT
• Mucus Membranes Moist
• Oropharynx without lesions or exudates
Neck
• Limitted range of motion
• No carotid Bruits
• No thyromegally
Lymph Nodes
• Bilateral Inguinal Adenopathy, tender,
mobile
• All other lymph nodes within normal limits
Cardiovascular
• Regular Rate and Rhythm
• II/VI systolic ejection murmur at LLSB, w/o
radiation to carotids
• Radial, Posterior Tibial, Carotids 2+
Bilaterally
Pulmonary
• Clear to Auscultation Bilaterally
• No consolidation on percussion
• Respirations unlabored
Dermatology
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No rashes
No petechiae
No bruises
See genitourininary
Genitourinary
• Lesions covering scrotum and penis
• Faint, small, circular, red papules
• Non erupting, non crusting, non painful to
palpation
• No lesions around anus
• Seemed to be resolving
Abdomen
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Non distended
Positive bowel sounds
No hepatosplenomegally
Soft and non tender to palpation
Extremities
• No cyanosis
• No clubbing
• No edema
Musculoskeletal
• moves all extremities
• Strength 4/5 (ativan) equal and bilateral
• Cannot touch chin to chest
Neurological
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Oriented x 3
CN II-XII Intact
P2P, RAM, Rhomberg and Gait WNL
All DTRs 2+ bilaterally
Lab Values
CBC
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WBC 7.5
Hg 15.7/ Hct 47.6
Platelets 214
Absolute neutrophils 5.6
Absolute lymphocyte count 1
BMP: Unremarkable
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Na 138
K 4.5
Cl 103
CO2 27
BUN 10
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Creatinine 1.1
Glucose 94
Ca 9.5
Mg 2.1
Ph 3.3
LFT’s
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Tbili 0.6
AST 82
ALT 94
Alk phos 67
GGT 20
CSF
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Clear, colorless
231 nucleated cells
84% Lymphocytes
Protein 76
Glucose 49
Atypical Lymphocytes
Imaging
• Head CT: No acute intracranial process
• RUQ US: No abdominal process
• CXR: no air space disease
Initial Management
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Vancomycin 1 gram IV Q12 hours
Ceftriaxone 2 grams IV Q12 hours
Acyclovir 800mg IV Q8 hours
Doxycycline 100mg IV Q12 hours
Discuss…
Studies Ordered
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Blood cultures
Urine Cultures
CSF Cultures
HIV ELISA and Quantitative RNA
Rapid Influenza Assay
Serum RPR
Additional CSF Studies
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Enterovirus PCR
HSV PCR
Adenovirus PCR
VZV PCR
CMV PCR
EBV PCR
• VDRL
• Crypto Antigen
• Influenza Virus
CSF
Gram Stain: 1+ PMNs, no
organisms
Culture: no growth
Varicella Zoster CSF PCR Positive
Diagnosis: aseptic meningitis with
Varicella Zoster as causative
pathogen.
Aseptic Meningitis Differential
• Infectious: viruses, mycobacteria, fungi,
spirochetes, tick borne
• Drugs: NSAIDS, ATG, Sulfas, Quinolones
and PCN
• Malignancy
• Autoimmune: Bechet’s, Mollaret’s
• Partially Treated Meningitis
Viruses
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Enterovirus
HSV 2
HIV
LCMV
Mumps
CMV
EBV
VZV
Adenovirus
Arbovirus
Varicella Zoster
• Human Herpes Virus
• Causes Chicken Pox
• Latent in cranial nerve and dorsal root
ganglia
• Reactivates causing a variety of
manifestations
Reactivation manifestations
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Shingles
Radiculoneuropathy
Ganglionitis
Post- herpetic neuralgia
Myelitis
Encephalitis/ Ventriculitis
Arteritis
Aseptic meningitis
Advent of PCR has increased
awareness of VZV as a causative
pathogen for viral meningitis.
One Finnish Study (2006)
• 144 immunocompetent participants with
aseptic meningitis
• 66% had identifiable etiologies (PCR) for
aseptic meningitis:
– Enterovirus 26%
– HSV2 17%
– VZV 8%
• 31% of patients with VZV mengingitis had
no rash
References
• Kupila, L et al. Etiology of aseptic
meningitis and encephalitis in an adult
population. Neurology 2006;66:75-80.
• Gilden, D et al. Neurologic Complications
of the Reactivation of Varicella-Zoster
Virus. New England Journal of Medicine
2007;342: 635-646.
• Up-To-Date (no access off campus)
Search PubMed
• Aseptic Meningitis & Varicella Zoster Virus
– Case Reports
– Reviews
– Drug Therapy