Drug-induced meningitis: A review of the literature and comparison with an historical cohort of viral meningitis cases

A Dilemma in the Diagnosis of Group A Streptococcus (GAS) Meningitis Versus Drug-Induced Aseptic Meningitis: A Case Report

Group A Streptococcus (GAS), also called Streptococcus pyogenes, is a rare cause of adult meningitis. In recent years, many outbreaks of invasive S. pyogenes infections in Europe, involving the emm1.0 subtype of the M1UK lineage, have led to a rising prevalence of GAS meningitis. We present a case with a diagnostic dilemma involving a 55-year-old female with otitis media, S. pyogenes bacteremia, and symptoms of meningitis. However, cerebrospinal fluid (CSF) tests were not completely consistent with bacterial meningitis, with normal glucose levels on CSF analysis, no organism seen on gram stain, and no growth on CSF culture. Drug-induced aseptic meningitis (DIAM) was considered, given the patient's use of ibuprofen prior to admission, and thus, non-steroidal anti-inflammatory drugs (NSAIDs) were avoided during her hospitalization. The GAS bacteremia was treated with intravenous ampicillin. She improved a few days later, but we are uncertain whether the antibiotics or the avoidance of NSAIDs resolved her meningitis symptoms. On discharge, ampicillin was switched to intravenous ceftriaxone, 2 g every 12 hours, to treat possible GAS meningitis for a four-week duration.

Elderly Woman With No Autoimmune Disease With Aseptic Meningitis Caused by Celecoxib

Nonsteroidal anti-inflammatory drug (NSAID)-induced aseptic meningitis (NIAM) is frequently reported in patients with autoimmune disease. Ibuprofen-induced NIAM is the most common case report of NIAM. We report a patient without autoimmune disease who developed NIAM following oral celecoxib administration. A literature review and survey of cases registered in the Japanese Adverse Drug Event Report (JADER) database is also provided. A 73-year-old woman with no autoimmune disease developed a headache the day after taking celecoxib, and NIAM was suspected. The headache resolved quickly following celecoxib discontinuation. Although lumbar puncture was not available in this case, bacterial or viral meningitis was negative, and NIAM could not be ruled out. This case involved an older adult patient without an autoimmune disease, with celecoxib as the causative NSAID. A literature review found numerous cases of autoimmune diseases in younger patients. To date, only one case of celecoxib-induced NIAM has been reported. Analysis of NIAM cases in JADER revealed an onset time of approximately three days. JADER analysis indicated that NIAM tended to occur immediately after administration, although the onset with cyclooxygenase-2 selective agents might be slower.

Monkeypox virus-associated meningoencephalitis diagnosed by detection of intrathecal antibody production

BACKGROUND

In the 2022 mpox-outbreak most patients presented with mild symptoms. Central nervous system (CNS) involvement has previously been described as a rare and severe complication of mpox; however, diagnostic findings in cerebrospinal fluid (CSF) analysis and neuroimaging studies have only been reported in one case previously.

CASE PRESENTATION

We report a previously healthy 37-year-old man with mpox complicated by encephalitis. He first presented with painful skin lesions and genital ulcers; polymerase chain reaction (PCR) from the lesions was positive for mpox. Twelve days later he was admitted with fever and confusion. Neuroimaging and CSF analysis indicated encephalitis. The CSF was PCR-negative for monkeypox virus but intrathecal antibody production was detected. He spontaneously improved over a few days course and recovered fully.

CONCLUSIONS

This case of mpox-associated encephalitis shows that CNS involvement in mpox infection may have a relatively mild clinical course, and that detection of intrathecal antibody production can be used to establish the diagnosis if CSF monkeypox virus-PCR is negative.

Amoxicillin-induced aseptic meningitis: clinical features, diagnosis and management

OBJECTIVES

The clinical features of aseptic meningitis associated with amoxicillin are unknown. The main objective of this study was to investigate the clinical characteristics of amoxicillin-induced aseptic meningitis (AIAM) and provide a reference for clinical diagnosis and treatment.

METHODS

AIAM-related studies were collected by searching the relevant databases from inception to October 31, 2022.

RESULTS

AIAM usually occurred 3 h to 7 days after amoxicillin administration in 13 males and 9 females. Twenty-one patients (95.5%) had recurrent AIAM with a total of 62 episodes. Fever (19 cases, 86.4%) and headache (18 cases, 81.8%) were the most common symptoms. Typical cerebrospinal fluid (CSF) findings were leukocytosis (100%) with lymphocytic predominance (14 cases, 63.6%), elevated protein (20 cases, 90.1%), normal glucose (21 cases, 95.5%) and negative culture (21 cases, 100%). Brain magnetic resonance imaging showed mild meningeal enhancement in one patient. The symptoms resolved mainly within 1-4 days after drug discontinuation in all patients.

CONCLUSION

Clinical attention should be given to the adverse effects of AIAM. The medication history of patients with suspected meningitis should be investigated to avoid unnecessary examination and antibiotic treatment.

Aseptic meningitis followed by mononeuritis multiplex in a patient with primary Sjögren's syndrome

A 38-year-old woman was admitted to hospital because of fever and headache. Increased cerebrospinal cell count and protein without evidence of infection led to a diagnosis of aseptic meningitis. Although she improved with acyclovir and glyceol, she experienced left forearm pain and sensory disturbance with drop fingers. Poor derivation of compound muscle action potentials in the left radial nerve was observed, leading to a diagnosis of mononeuritis multiplex with sensorimotor neuropathy. Because the patient had primary Sjögren's syndrome with anti-Ro/SS-A antibody and salivary gland hypofunction, treatment with methylprednisolone, intravenous immunoglobulin, and intravenous cyclophosphamide was followed by oral glucocorticoid therapy. After these intensive therapies, her drop fingers gradually improved, although sensory disturbance remained. In conclusion, we report a case of aseptic meningitis and subsequent mononeuritis multiplex that was successfully treated with intensive immunotherapy in a patient with primary Sjögren's syndrome.

Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis: A New Approach

Inflammation of the meningeal linings of the central nervous system (CNS), also known as meningitis, is one of the serious presentations in the emergency because it carries high morbidity and mortality. The most common cause is pus-producing organisms. However, non-suppurative meningitis, termed aseptic meningitis, is another cause of meningeal inflammation. Many etiologies stand behind aseptic meningitis. Those etiologies include viral and non-viral, drug-induced, malignancy, and systemic inflammation. Drug-induced aseptic meningitis is a rare type of meningitis. Although it is easily treated, it can be a challenging disease if not present in the differential diagnosis. It is commonly associated with nonsteroidal anti-inflammatory drugs (NSAIDs). Nonetheless, other medications have been also reported to cause aseptic meningitis, including antibiotics. Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the most prescribed antibiotics as a prophylactic and therapeutic drug due to its effectiveness and low cost. Although immunocompromised patients are at a higher risk to develop aseptic meningitis, immunocompetent patients are also at risk. Unrelated to the source of the infection, TMP-SMX carries a risk of aseptic meningitis and should be considered as an etiology in patients presenting with meningeal signs and symptoms. Hereby, we report a young immunocompetent patient who developed aseptic meningitis eight days after being prescribed TMP-SMX. Like all drug-induced aseptic meningitis, all his symptoms resolved two days after stopping the medication.