Now all these drugs

Now all these drugs can apparently produce headache and a bunch of cells in CSF. Never seen one, but the books mention those. Methotrexate of course we know. Apparently this is an immunosuppressant drug. We talked about CSF glucose, we talked about lactate being normal, tumor necrosis factor being low. In bacterial, these two are high.

Low sugar is very important. Keep that in mind. Now TB meningitis, cancer of the meninges and Toxoplasmosis a lot of times produce a lot of protein in the CSF. Like you are looking at 500, 600 mg. TB meningitis is notorious. You get like 1.2 grams of protein. So if you have a very high protein, think those first: TB, cancer and Toxoplasmosis. You can look for fungal antigens, viral antigens, but those things take time so they are not going to help you on the same day. I forgot to mention Lyme’s, polyradiculitis, and meningoencephalitis, look for Lyme antibody. I’m going to talk about HIV at the end of the talk.

Herpes simplex and TB. If you suspect Herpes simplex encephalitis, your differential is viral meningitis, obviously look at EEG. Start them on acyclovir but you can do PCR for herpes virus.

Fungal meningitis. Regional distribution is important. In the Southwest coccidioides is a common cause. If you have patients on hemodialysis, IV drug use, hyperalimentation, go for Candida first. In the Mississippi valley, with an abnormal chest x-ray, obviously go for TB and also go for histo. We have seen histo in our place from time to time. Treatment: amphotericin B. Remember fever, rash, kidney toxicity, anemia, low platelet, low potassium. Flucytosine: bone marrow, GI, confusion, liver, rash, stones. Fluconazole: especially for HIV crypto-maintenance – I’m going to talk about it – this is a new antifungal drug. I can’t tell you anything more about it than how to spell it. Probably when others don’t work. This is a fairly new drug. But still the standard drug is amphotericin B and flucytosine.

In viral encephalitis, patients are more sick, altered mental status, focal findings, abnormal EEG. Herpes simplex of course. Eastern Equine: high morbidity. Western Equine encephalitis is more benign. Low morbidity. Outside the United States, Japanese and Venezuelan encephalitis is pretty common. Now all these are seasonal, mosquito-borne. Uncommon causes of encephalitis: Rocky Mountain Spotted disease, Lyme, Leptospirosis – this is very rare, very high mortality. Two types of ameba. Non-seasonal, endemic, Herpes simplex: If you are immunosuppressed, remember Zoster varicella. Immunosuppressed, Herpes simplex 6: these are not uncommon, toxo immunosuppressed. Work-up, there is nothing magical here. Acyclovir, we know about it. If you have CMV ganciclovir. If you are dealing with Rocky Mounted Spotted Fever go for tetracycline, chloramphenicol group of drugs.

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