Viral meningitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

The differential diagnosis of viral meningitis includes two step approach. First is differentiating viral meningitis from other diseases which have similar clinical presentation as viral meningitis such as encephalitis, brain abscess, subarachnoid hemorrage, and brain tumour. Second step involves CSF examination and differentiating viral meningitis from bacterial, fungal and other causes of meningitis

Differential diagnosis

Differentiating viral meningitis from other diseases

Viral meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate viral meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]

Differentiating viral meningitis from other diseases

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[2][3] + Cancer cells[4] MRI + + + + + + Cachexia, gradual progression of symptoms
Delerium Tremens + Clinical diagnosis + + + + + + Alcohal intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, tachypnea
Subarachnoid hemorrhage[17] + Xanthochromia[5] CT scan without contrast[7][8] + + + + + + + + Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke + Normal CT scan without contrast + + + + + TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[18][19] + Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[20]

+ + + + + + Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis + Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment + + + + + + + Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioral changes
Herpes simplex encephalitis + Clinical assesment + + + + + History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal + + + History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess + leukocytes >100,000/ul, glucose and protien, red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

+ + + + + + + History of drug abuse, endocarditis, immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity + + Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion + + + + + Tremors, blindness, difficulty swallowing
Electrolyte disturbance or Depends on the cause + + Confusion, seizures
Febrile seizures Not performed in first simple febrile seizures Clinical diagnosis and EEG + + + + Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema + Clinical assesment and MRI + + + + + + History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or Serum blood glucose

HbA1c

+ + + History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Differentiating viral meningitis from other causes of meningitis

Bacterial meningitis may be differntiated from other causes of meningitis by cerebrospinal fluid examination:[21][22][23][24][25]

Cerebrospinal fluid level Normal level Bacterial meningitis[24] Viral meningitis[24] Fungal meningitis Tuberculous meningitis[26] Malignant meningitis[21]
Cells/ul < 5 >300 10-1000 10-500 50-500 >4
Cells Lymphos:Monos 7:3 Gran. > Lymph Lymph. > Gran. Lympho.>Gran Lymphocytes Lymphocytes
Total protein (mg/dl) 45-60 Typically 100-500 Normal or slightly high High Typically 100-200 >50
Glucose ratio (CSF/plasma)[22] > 0.5 < 0.3 > 0.6 <0.3 < 0.5 <0.5
Lactate (mmols/l)[23] < 2.1 > 2.1 < 2.1 >3.2 > 2.1 >2.1
Others ICP:6-12 (cm H2O) CSF gram stain, CSF culture, CSF bacterial antigen PCR of HSV-DNA, VZV CSF gram stain, CSF india ink PCR of TBC-DNA CSF tumour markers such as alpha fetoproteins, CEA

References

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