Tuesday, March 10, 2009

Viral meningitis

A 19 year old male came into my office yesterday for follow up for meningitis diagnosed at his college campus. One month prior to our visit he experienced acute onset of fever, chills, sweats, weakness, headache and stiff neck. He was admitted to the local hospital with a presumptive diagnosis of meningitis. A spinal tap was performed and he was give a single dose of Vancomycin. The results of the CSF (spinal fluid) were reported negative and no further antibiotics were given. He was noted to have a low white blood cell count which subsequently improved. He was diagnosed with viral meningitis and sent home on no treatment. A week after his discharge from the hospital he received a call from the hospital. A blood test showed antibodies to Ehrlichia. He was treated with Doxycyline, 100 mg twice daily for 10 days. He complained that symptoms persisted and the Doxy was renewed for an additional 14 days.

When he came to see me he was still not feeling well. He had persistent low grade headaches, severe fatigue and generalized malaise.

Over the last several years I have seen many patients who have been diagnosed with viral meningitis who have in fact suffered with acute Lyme meningitis.

Although Ehrlichia infection can exist without concomitant Lyme I felt that this was unlikely. Ehrlichia meningitis is extremely rare although a few cases have been reported. In this case the positive serology for Ehrlichia tipped my hand that the "viral meningitis" was actually caused by Lyme disease.

Ehrlichia can be difficult to eradicate since it resides in white blood cells.
For this patient I prescribed Doxycyline 400 mg per day and Rifampin 600 mg per day. This is the most effective combination for Ehrlichia and also covers Lyme disease.

Based on the clinical response future treatments may need to focus more on Borrelia.
I await initial lab studies and will see this patient back in one month.


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