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Japanese encephalitis
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Pneumococcal meningitis
Rocky Mountain spotted fever
Tuberculous meningitis
West Nile virus neuroinvasive disease
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This patient with a history of type 2 diabetes and cardiovascular disease who presents with a fever, rash, confusion, extrapyramidal symptoms, and a lumbar puncture consistent with viral meningitis most likely has West Nile virus neuroinvasive disease. West Nile (WN) virus is a flavivirus that can clinically present with a wide variety of symptoms ranging from asymptomatic infection to severe meningoencephalitis. The typical presentation among symptomatic patients is a self-limited illness with fever, headache, myalgia, anorexia, nausea, diarrhea, and abdominal pain. A maculopapular rash can also appear in about half of patients. WN can also cause neuroinvasive disease characterized by meningitis, encephalitis, flaccid paralysis, and extrapyramidal symptoms. Risk factors for neuroinvasive disease include advanced age, previous malignancy, genetic predisposition, diabetes, hypertension, alcohol use, and male sex. In cases with central nervous system involvement, lumbar puncture usually demonstrates elevated protein, moderate lymphocytic pleocytosis, and normal glucose. Diagnosis can be secured with the WN virus IgM antibody in the serum and/or cerebrospinal fluid (CSF). The treatment for WN virus is supportive care. Hart et al. studied longitudinal outcomes of West Nile virus neuroinvasive disease. The authors found that 36% of patients experienced persistent cognitive deficits, 44% had persistent cranial neuropathies, and 58% had persistent tremors. The authors recommend longitudinal follow-up for patients with WN virus neuroinvasive disease. Incorrect Answers: Answer 1: Japanese encephalitis is caused by a mosquito-borne flavivirus similar to West Nile virus, dengue virus, and yellow fever. It can also cause encephalitis, with symptoms including headache, fever, confusion, and seizures. However, this disease is endemic to East and Southeast Asia, and would not be expected in this patient without recent travel history. Answer 2: Pneumococcal meningitis is acute bacterial meningitis caused by Streptococcus pneumoniae. Although the presentation can overlap with West Nile virus neuroinvasive disease, a lumbar puncture would be expected to reveal an elevated CSF white blood cell count with an elevated neutrophil count and decreased CSF glucose. Answer 4: Rocky Mountain spotted fever (RMSF) is a tick-borne disease caused by Rickettsia rickettsii infection. It can also cause acute onset fever, headache, myalgia, nausea, rash, and encephalitis. However, RMSF is mostly found in the southeastern United States. In addition, a lumbar puncture generally shows elevated protein and polymorphonuclear pleocytosis in the CSF. Answer 4: Tuberculous meningitis is an infection of the brain and meninges with Mycobacterium tuberculosis that presents with fever, headache, signs of meningeal irritation, and confusion. Lumbar puncture will show elevated opening pressure, pearly clumps in the CSF, elevated CSF white blood cell count with lymphocytes and monocytes, and decreased CSF glucose. Bullet Summary: West Nile virus neuroinvasive disease presents with fever, maculopapular rash, encephalitis, extrapyramidal symptoms, and meningeal signs, usually in children or elderly patients.
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