Introduction

As the incidence of bacterial meningitis decreases, the proportion of meningitis cases caused by viruses is increasing [1]. The use of molecular diagnostics has also led to increased recognition of neurological viral infections. Patients with suspected viral meningitis are often treated with antibiotics while a diagnosis of bacterial meningitis is excluded [2]. Acyclovir, which has good in vitro activity against my herpesviruses, is effective. Acyclovir has no activity against enteroviruses [1]. Viral meningitis is traditionally considered a benign, self-limiting illness, but several reports suggest that this might not be the case.

Case Presentation

This is a case of a 63 years old male, came in due to four days history of intermittent fever, undocumented associated with minimal coughing episodes and colds. Patient is a diagnosed case of hypertension, which was controlled by maintenance medication. No previous surgery and malignancy. On physical examination, patient was tachycardia with unremarkable Physical examination. Upon admission, patient was managed as a case of systemic viral illness. Laboratory diagnostics were done such as CBCPC, Urinalysis, CXR, Dengue duo and serum electrolytes.

On first hospital day, patient is on Day 5 of illness, Day 0 afebrile, still with febrile episodes, low grade, intermittent, associated with minimal coughing episodes, non-productive with loss of appetite and generalized body weakness. No nausea and vomiting, no headache nor No abdominal pain. On physical examination, vital signs were stable, febrile with unremarkable systemic physical examination. Ascorbic acid 1 tablet once a day and repeat CBCPC on the next day were ordered. CBC revealed normal.

On Second Hospital Day patient is on Day 6 of illness, Day 0 afebrile, still with febrile episodes, low grade, intermittent, associated with minimal coughing episodes, non-productive with loss of appetite and generalized body weakness. No nausea and vomiting. No abdominal pain. On physical examination, vital signs were stable febrile with unremarkable systemic physical examination. Repeat CBCPC, creatinine, Na, K, Calcium on the next day were ordered. CBC, creatinine, Na, K and Calcium revealed normal.

On Third Hospital Day patient is on Day 7 of illness, Day 0 afebrile, with continuous febrile episodes, low grade. Patient complained of abdominal pain, epigastric, non-radiating. No nausea and vomiting nor headache. Vital signs were stable and on physical examination, epigastric tenderness was noted. These findings, lead to consider GI pathology such as acute cholecystitis hence Upper abdominal ultrasound and CBCPC on next blood extraction and Maalox was started. CBC revealed normal.

On Fourth Hospital Day patient is on Day 8 of illness, Day 0 afebrile. Patient suddenly experienced epistaxis, one episode 1-2 ml of bright red blood, and was claimed without manipulation. The rest of the findings were the same. Patient was referred to ENT service and epistaxis was managed by giving Tranexamic acid 500 mg TIV stat dose. Diagnostics were requested such as PT PTT, CBCPC, Creatinine, Na and potassium tomorrow AM. Patient was then scheduled for nasal endoscopy. IDS referral was considered. PT and PTT and electrolytes were all normal. Nasal endoscopy showed chronic rhinosinusitis.

On Fifth Hospital Day patient is on Day 9 of illness, Day 0 afebrile. Patient still with febrile episodes, low grade, intermittent with occurrence of photophobia and increased in somnolence, Loss of appetite, generalized body weakness. On physical examination, vital signs were stable with noted photophobia and meningeal signs. These remarkable findings lead all attendings to consider meningitis. Blood CS, Chest CT scan, plain cranial CT scan and CXR portable were requested. Referral to neurologist was considered. Blood CS, CXR, Plain chest CT scan, Cranial CT scan were all normal. Lumbar tap was also performed. A clear fluid with normal opening pressure has been analyzed. On cytology, noted with lymphocytic predominance with normal glucose level.

On Sixth Hospital Day patient is on Day 10 of illness, Day 0 afebrile. Patient still with febrile episodes, low grade, intermittent. Still with generalized body weakness, photophobia and increase somnolence. Physical examination and Neuro PE were still the same. Patient was then started with Acyclovir 500 mg TIV q8 while waiting for lumbar puncture.

On Seventh Hospital Day patient is on Day 11 of illness, Day 1 afebrile. The rest of the findings were the same. Cryptococcal antigen latex agglutination test, CSF microbiology, Anti nuclear antibody titer and rheumatoid factor were requested and noted with normal result.

On Eight Hospital Day patient is on Day 12 of illness, Day 2 afebrile. The rest of the findings were the same. Patient was monitored with the same management. Acyclovir has been shifted to Valcyclovir. Steroids and mannitol has been started as supportive medications. On his next succeding days in hospital, patient noted with improvement and underwent physical rehabilitation. Patient has been discharged after 18th hospital day.

Discussion

Our patient came in with initial consideration of systemic viral illness, and by investigation on prevalence and incidence, it’s very rare that we consider meningitis. Our patient did not present any signs and symptoms such as headache, photophobia, and neck stiffness from the time of consult. Our diagnostic work up also revealed unremarkable. But what the literature says with regard to this. Based on CDC, viral meningitis is the most common type of meningitis, and the patient will present to you with fever and constitutional signs and symptoms. The usual manifestations of meningitis are fever, signs of meningeal irritation in immunocompetent adult. Headache characterized as frontal or retroorbital photophobia. Nuchal rigidity usually presents as profound alteration in consciousness such as stupor, coma, or marked confusion do not occur in viral meningitis as well as in our patient. Upon presentation, most patients report fever, headache, irritability, nausea and vomiting, stiff neck, rash or fatigue within the previous 18-36 hours. Headache is almost always present in patients with viral meningitis and is often reported as severe [5]. The most important agents are enteroviruses (including echoviruses and coxsackieviruses), Varicella zoster virus (VZV), HSV, (HSV2>HSV1), HIV an arboviruses. CSF cultures are positive in 30-70%. [1] Approximately two thirds of culture negative cases of aseptic meningitis have a specific viral etiology identified by CSF PCR testing. [1] Based on study of Junhong et al, figure 1 showed percentage of viral pathogens in viral meningitis cases with confirmed etiology. Enteroviruses are the most common causative agent of viral meningitis.

Figure 1: Data of HSV1, HSV2, EBV, VZV, CMV, HHV6 meningitis are extremely limited.

Viral mengitis is not a nationally reportable disease, however it has been estimated that the incidence is approximately 60,000 – 75,000 cases per year. [1] CSF examination- the most important laboratory test in diagnosis of viral meningitis. The typical profile is a pleocytosis, a normal or slightly elevated protein concentration (20-80mg/dl), a normal glucose concentration and a normal or mildly elevated opening pressure (100- 350mmH2O). The total CSF cell count in viral meningitis is typically 25-500/ul. Lymphocyte are typically the predominant cell. The presence of CSF PMN pleocytosis in a patient with suspected viral meningitis in whom a specific diagnosis has not been established should prompt consideration of alternative diagnoses including bacterial meningitis or parameningeal infection. As a rule, a lymphocytic pleocytosis with a low glucose concentration should suggest fungal or tuberculous menigitis.Amplification of viral specific DNA or RNA from CSF using PCR amplication has become the single most important method for diagnosis CNS viral infection. CSF PCR has become the diagnostic procedure of choice and is substantially more sensitive than viral cultures. It is also an important diagnostic test in patient with recurrent episode of aseptic mengitis. The sensitivity of viral culture for the diagnosis of viral meningitis and encephalitis in contrast to its utility in bacterial infections is generally poor. All patients with suspected viral meningitis should have a complete blood count with differential, liver and renal function test, ESR and CRP, electrolytes, glucose and creatine kinase, aldolase amylase and lipase. Neuroimaging studies (CT scan and MRI) are not absolutely necessary. Treatment of almost all cases of viral meningitis is primarily symptomatic and includes analgesic, antipyretics and antiemetics. Fluid and electrolyte status should be monitored. Oral or IV acyclovir may be of benefit in patients with meningitis caused by HSV1-HSV2 and in cases of EBV or VZV. Data concerning treatment of HSV, EBV and VZV meningitis are extremely limited. [1]

Conclusion

Viral meningitis is the most common type of meningitis, and patient will present to you with fever and constitutional signs and symptoms. The usual manifestations of meningitis are fever, signs of meningeal irritation in immunocompetent adult. Upon presentation, most patients report fever, headache, irritability, nausea and vomiting, stiff neck, rash or fatigue within the previous 18-36 hours. Headache is almost always present in patients with viral meningitis and is often reported as severe. In our patient, he presented with low grade fever alone, no meningeal nor headache were noted. The appearance of headache, nuchial rigidity and photohobia were noted late which make this case atypical presentation of viral meningitis.

References

1. McGill F, Griffiths MJ, Bonnett LJ, Geretti AM, Michael BD, et al. (2018) Incidence, aetiology and sequalae of viral meningitis in UK adults: A multicenter prospective observational cohort study.The lan infe dise 18: P992-1003.
2. Kadambari S, Okike I, Ribeiro S, Ramsay ME, Heath PT, et al. (2014) Seven-fold increase in viral meningo-encephalitis reports in England and Wales during 2004â??2013. J Infect 69: 326-32
3. Wan C, Singh NN, (2018) Emedicine medscape; Viral meningitis Clinical presentation updates. Med scape.
4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, et al. (2015) Harrison's principles of internal medicine (19th edn.) McGraw Hill Education. Vo11.
5. (2021) Viral Meningitis. Centers for Disease Control and Prevention (CDC).
6. LozanoBecerra JC, Sieber R, Martinetti G, Costa ST, Meylan P, et al. (2013) Infection of the central nervous system caused by Vazricella zoster virus reactivation: A retrospective case series study. Int J Infect Dis 17:529â??34
7. Martin NG, Iro MA, Sadarangani M, Goldacre R, Pollard AJ, et al. (2016) Hospital admissions for viral meningitis in children in England over five decades: a population-based observational study. Lancet Infect Dis 16: 1279-1287
8. Ai J, Xie Z, Liu G, Chen Z, Yang Y, et al. (2017) Etiology and prognosis of acute viral encephalitis and meningitis in Chinese children: A multicentre prospective study. BMC Infect Dis 17:494.