14 years old male, not a known case of any major illness, came to the emergency with complaints of headache since a week, high grade fever with chills and rigors since last 2 days, 1 episode of seizure (simiology GTCS) on the morning of admission, sudden onlset altered sensorium since the seizure episode.
No history of any viral prodrome/ UTI/ diarrhea/ similar episode in the past.
No history of bleeding from anywhere/ rash/ patechiae/ burning micturation/ oliguria.
No history of Koch's/ Koch's contact.
On enquiry, mother gives history of episode of seizure at 3 years of age, stopped medication after consultation.
On CNS examination, pt was drowsy with post-ictal altered state; responding to deep painful stimuli. Deep tendon reflexes 2+. Clonus was present bilaterally in the ankle.
Patients was started on empirical treatment of antibiotics (ceftriaxone, vancomycin), antimalarials (artesunate) (for query cerebral malaria) along with symptomatic treatment; parenterally. He was fed through nasogastric tube. He did not show much improvement, was still drowsy.
On CBC, WBC, Hb and platelets counts were normal; tested negative for malarial parasite. Serum electrolytes were within normal range.
Lumbar puncture was done for CSF analysis- CSF was clear, colorless, odorless, CSF glucose was elevated (104 g/dl), as were CSF proteins (61 g/dl); on microscopy, no organism seen; on smear (gram and ZN stain), no organism seen; total cell count being 5 cells/cmm (mainly lymphocytes). CSF ADA level was within normal range.
CT scan and MRI of brain showed no significant abnormalities.
Ophthalmology reference was done for fundus changes. Findings were normal.
HSV-PCR of CSF was also advised (reports not available).
With CSF findings being inconlusive and no abnormalities on CT and MRI, pt was started on antiviral Acyclovir injection (800 mg 1-1-1). Pt showed significant improvement and regained consciousness and overall condition improved towards normal.
Diagnosis of Viral Meningitis was made.