Patient history: A 66-year-old man presents to the emergency department with 2 days of worsening generalized headache associated with chills and a dry cough but no fever, vomiting, eye discomfort, neck stiffness, weakness, or other complaints.
Examination: Vital signs were normal. Physical exam was normal except for an occasional dry-sounding cough. Specifically, there was no photophobia, neck stiffness, abnormalities on pulmonary examination, or focal findings on neurologic exam.
Initial concerns: Meningitis, encephalitis, influenza, URI, pneumonia
Laboratory: normal except for WBC of 17 with no bands. Flu swab negative
Chest x-ray: normal
CT brain (performed because age >65): normal
CSF: WBC, 350 with 90% lymphs; RBC, 1; glucose, 80 mg/dL; protein, 200 mg/dL
ED Course:The patient was given a dose of dexamethasone and ceftriaxone prior to CT & LP. After the LP results came back a dose of IV acyclovir was ordered, and the patient was admitted. On the floor acyclovir was stopped by the admitting team because there was only 1 RBC in the CSF.
1. Was it a good idea to rule out HSV or VZV meningitis based on low RBC count in CSF?
2. Where can I get a quick refresher on this topic?
Please click below for answers and discussion.