Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Diagnosis and Management of Meningitis with a Mixed Clinical Presentation
May, T. DO, Lowe, D. MD
Kent County Hospital, Warwick, RI
Introduction: Meningitis is a significant cause of mortality with approximately 423,000
deaths globally in 2010. In addition, complications among survivors may persist as
neurologic sequelae, such as hearing loss, epilepsy, hemiplegia, and
neuropsychological impairment. As such, the importance of timely diagnosis and
initiation of treatment is paramount. Appropriate antibiotic and/or antiviral coverage must
be largely based upon the history and presenting symptoms. This can be particularly
challenging given the numerous etiological agents that can cause meningitis. This point
is demonstrated in this case, where a patient with multiple risk factors presented with
symptoms of meningitis and atypical laboratory findings.
Case Description: A 48-year-old Caucasian male with a medical history significant for
asthma presented to his primary care physician for congestion, purulent sinus drainage,
and low-grade fevers. He was given a 7 day course of levofloxacin for presumed sinus
infection. After completion of this course of antibiotics he was symptom free for 9 days.
Thereafter, the patient experienced low-grade fevers, photophobia and headache. He
took ibuprofen and acetaminophen with limited relief and presented to the hospital seven
days later for worsening symptoms. At the time of presentation his vital signs were:
blood pressure 152/94, pulse 112, respiratory rate 17, oxygen saturation 98% on room
air. Physical examination was remarkable for horizontal nystagmus, double vision, and
headache in the frontal and parietal regions exacerbated by palpation. Complete blood
count revealed thrombocytopenia with a platelet count of 120. Due to suspicion for
meningitis lumbar puncture was performed and CSF fluid analysis demonstrated WBCs
1440, glucose 41, and protein 220. Initial antibiotic regimen included intravenous
vancomycin, ceftriaxone, and doxycycline to cover for bacterial meningitis, Lyme
disease, and ehrlichiosus respectively. On the day following admission, Lyme antibody
testing was positive, and was confirmed by western blot. Subsequent studies revealed
an elevated Lyme index of 1.5 to confirm CNS Lyme disease. CSF and blood cultures
showed no growth for 5 days and smears for acid-fast bacilli, babesia, ehrlichia, and
fungus would all be negative. The patient was discharged on a 15 day course of
intravenous ceftriaxone for CNS Lyme disease, and an 8 day course of oral doxycycline
for concerns of ehrlichiosus given the patient’s low platelet count. Ultimately, the patient
had resolution of symptoms except for mild left facial weakness, and follow-up laboratory
studies indicated a chronic thrombocytopenia of unclear etiology.
Discussion: This case illustrates a complex meningitis scenario with the possibility of
three or more separate ongoing processes. This includes Lyme meningitis, Ehrlichiosus,
bacterial meningitis, and aseptic meningitis. Tick-borne diseases are extremely prevalent
in the Northeast regions of the U.S., and patients with Lyme disease can and often be
concomitantly infected with Ehrlichia. Ehrlichia is notoriously difficult to identify by blood
smear, particularly early in the disease course, but should always be considered in the
setting of thrombocytopenia. Additionally, CSF findings showed patterns suggestive of
bacterial meningitis, yet all cultures, smears, and serologies for infectious agents other
than Lyme disease were negative. This may be explained by the patient’s use of
levofloxacin for presumed sinus infection, thus raising the possibility of a partially treated
bacterial meningitis at the time of presentation. A drug-induced aseptic meningitis must
also be considered at the time of presentation given the patient’s heavy use of ibuprofen.