Clinical Pearls From Case Conference: Focus on CNS Infections

At Case Conference on August 16, Drs. Hankins and McCreery presented excellent cases of viral CNS infections combined with a great review of pertinent literature.  Here are the key clinical pearls from their presentations.

Dr. McCreery on viral and bacterial meningitis:

  1. Empiric dexamethasone appears to be beneficial in S. Pneumoniae and H. Influenza meningitis but should be stopped if found to have viral meningitis or meningitis caused by other bacteria.
  2. The addition of an aminoglycoside in the treatment of Listeria bacteremia and neurolisteriosis was associated with improved mortality in the MONALISA study – France (OR 0.60 (0.38-0.94) p 0.024) n = 679.  When neurolisteriosis was examined (n=-252 cases), some with bacteremia and some without, the addition of an aminoglycoside was not reported to have been associated with improved outcomes.
  3. Mild HSV-2 meningitis likely does not require treatment, however there may be some benefit among immunocompromised patients related to preventing neurologic sequelea.
  4. Suppressive valacyclovir after HSV-2 meningitis was associated with increased recurrence after cessation.
  5. Data is lacking regarding the utility of suppressive valacyclovir therapy in the treatment of non-genital HSV-2 infection during pregnancy

Randy McCreery MD, UNMC 1st Year ID fellow.

Dr. Hankins on Influenza Encephalitis:

  1. Diagnosis of exclusion in patients with altered level of consciousness and a positive influenza antigen or PCR.
  2. Most often occurs in 24-48 hours after febrile incident.
  3. 95% of patients with influenza encephalitis are younger than 21 years old.
  4. Associated with bilateral thalamic necrosis on MRI.
  5. Guidelines suggest that oseltamivir may be beneficial.  Other studies suggest that methylprednisolone pulse therapy may be beneficial.

Richard Hankins, MD
2nd Year ID Fellow










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