Title : Meningi5s secondary to coxsackie A16 virus in a 34-year-old adult male
Abstract:
Hand Foot and Mouth Disease is a common and highly contagious febrile infection mostly secondary to Coxsackievirus A16. The virus can spread to adults and one of the major complications is viral meningitis. This case describes a case of an adult patient who developed viral meningitis due to transmission from his child.
A 34-year-old male with a past medical history of active smoking and non-insulin dependent diabetes mellitus II presented to the emergency room due to convulsive status-epilepticus activity earlier in the day. Shortly after arrival to the emergency department the patient woke up but developed post-ictal agitation towards the medical staff. The patient was given lorazepam, ketamine, Haldol, and Diazepam to no effect. The patient was intubated with propofol and midazolam, and was admitted to the ICU. According to history from the wife, the patient 3 weeks prior to admission developed a mild rash with red macules and vesicles on his palms and soles of his feet that resolved 1 week ago. Initial labs demonstrated hyperglycaemia, leucocytosis, and elevated lactic acid. MRI of the cranium and cervical spine was unremarkable. Blood was collected for bacterial cultures, West Nile Virus, HSV, HIV antigen and antibodies. The patient was started on ceftriaxone and vancomycin due to meeting septic criteria. The patient the next day underwent a lumbar puncture with 3.5 mL of clear and colourless CSF volume removed. CSF analysis revealed elevated white blood cells, protein, lymphocytes, and glucose indicating a likely viral meningitis diagnosis. The CSF sample was also cultured for H Influenzae, E. Coli, L. Monocytogens, N. MeningiOs, Group B Streptococcus, S. Pneumonia, Cytomegalovirus, Enterovirus, HSV I and II, HHV-6, Parechovirus, Varicella, Cryptococcus. Infectious disease was consulted, and antibiotics were switched from ceftriaxone to cefepime and vancomycin for Pseudomonas coverage. The patient was also started on IV acyclovir for viral meningitis coverage. CSF and blood cultures, as well as the HIV antigen and antibody panel were all negative. The patient was started on dexmedetomidine to assist with weaning off the ventilator. The next day the patient was extubated successfully and switched to nasal cannula. The patient was downgraded from the ICU with improved mental status, resolved leucocytosis and discontinuation of ceftriaxone and vancomycin. EEG was repeated and was unremarkable for ongoing seizures. The patient was able to walk with assistance from physical and occupational therapy and was discharged with acyclovir (PO) for four days.
The patient’s symptoms of altered mental status, post-ictal aggression, and unremarkable MRI prompted a lumbar puncture. Lumbar punctures are generally a safe procedure with some potential complications, but the history of a Coxsackie virus rash on the palms and soles in this patient provided by the wife prompted the procedure to assess for potential viral meningitis. While uncommon in immunocompetent patients, viral meningitis should be diagnosed with a lumbar puncture and treated early to avoid serious complications.
