If the patient is 1. Not dehydrated
2. Non Toxic (No signs of sepsis)
3. Non focal neurologic exam (i.e. no reason to
suspect intracranial abscess etc) and not
4. Not immunocompromised
5. Normal or slightly elevated protein (i.e. no
reason to suspect TB), Normal glucose and CSF wbc <
500-800 with negative gram stain.
6. No suspicion of RMSF i.e. rash, persistent HA,
h/o tick bite, hyponatremia, normal platelets etc....
AND especially if his HA feels better post tap!!! .....
I would in such a case do two things:
a) DC with close FU after a PPD
b) If the cell count is say higher than I would like it to be, with a
predominant polymorphonuclear response, i usually hold them in the ED for
4-6 hours and retap. If the shift is now towards mononuclears I would feel
comfortable then with option (a).
Basically if truly aseptic/viral meningitis I do not admit them or give
antibiotics. If I have any doubt, ABx and admit. I don't believe there shoud
be a middle ground for this. If one is not sure this is bacterial, the
patient deserves a full court press with all therapeutic modalities you
I would love to find out what your survey reveals.
Jay Pershad, M.D.
"We care for wee folks"
[log in to unmask]
A hypothetical case which should generate some interesting
It's July and you are seeing a 14 year old male with a 48 hour
history of fever, emesis, worsening headache. PE notable for: T = 38.4, P
= 100, RR = 24, BP = 100/70. He is alert, appears tired but non-toxic, and
has photophobia and nuchal rigidity. Remainder of exam including full
neuro assessment, perfusion, etc is entirely wnl.
You suspect meningitis and have a high suspicion that it is of
viral origin. How many would make a clinical diagnosis of viral meningitis
and send him home (or admit if dehydration is a concern) without a lumbar
puncture? If an LP is performed and results are consistent with an aseptic
meningitis, would you send home? Admit and observe without antibiotics?
Admit and begin Ceftriaxone while awaiting culture results? Admit and
begin Ceftriaxone, Vancomycin, and corticosteroids while awaiting culture
Does anyone know of a cost/benefit analysis assessing each of the
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