Mary Christine S.

Ilanga Medicine III November 28, 2019

I. General Data
This is a case of patient NG, 18 years old, male, Filipino, and currently residing in Calumpang, Iloilo
City. He was born on November 14, 2001 and was baptized Roman Catholic. This was his first time
admission in this institution on October 19, 2019.

Informant: The informant is the patient himself with 90% reliability.

II. Chief Complaint

Loss of consciousness

III. History of Present Illness

Two days prior to admission, the patient had an undocumented, intermittent fever with complete relief
upon taking Paracetamol 500 mg every 4-6 hours. It was accompanied by headache with a pain scale of 7
out of 10, associated with non-projectile post prandial vomiting with a vomitus approximating to 60-mL.
Patient took two tablets of metoclopramide with an unrecalled dosage which offered temporary relief to the
symptom. Aside from the above-mentioned symptoms, patient also experienced body malaise, loss of
appetite and nausea. No medication was taken for the said symptoms. No other associated signs and
symptoms. No consultation was done.
One day prior to admission, the aforementioned symptoms persisted. Relief of nausea was noted upon
drinking water. He also experienced headache alleviated by sleeping and aggravated upon waking up. No
medications taken or consultations done.
On the day of admission, there was persistence of the above symptoms. Patient woke up from a nap to
urinate but fainted prior to urination, his mother noticed that he was already lethargic. His mother tried to
wake him up by massaging his limbs but still unconscious and disoriented which then prompted his mother
to rush him in this institution. It was reported that on the way to the hospital the patient had vomited
characterized as clear, watery, and non-projectile. Thus, patient was subsequently admitted.

IV. Past Medical History

Contagious diseases: No other diseases recalled.
Other medical illness/hospitalizations: No other previous hospitalizations. Patient contracted chicken pox
when he was 8 years old
Operations: None.
Allergies/asthma/food sensitivities: shrimp
Injuries: none

V. Personal History and Growth and Development

HEADSSS
Diet: The patient eats twice a day and his diet consist mostly of chicken, pork, 2 cups of rice and seldom eat
vegetables. He drinks carbonated drink three times a day, every day. His water intake is about 1 liter per
day or 8- 10 glasses.

Home: He lives with his parents. No known environmental hazard noted.

Education: He is currently a grade 11 student at a public high school, with honors. He is also the student
council president of their school and has no academic-related problems encountered at school but
experiences minimal stress due to piles of work in the council.
 Mary Christine S. Ilanga Medicine III November 28, 2019

Activities: He was not involved in any sports, and usually spends most of the time playing mobile games.

Drugs: No illicit drug abuse. He does not smoke and he occasionally drinks alcohol.

Sexual: He is openly gay and he does not engage in a same-sex relationship. Occasionally he cross-dresses.
He is not sexually active.

Suicidal ideations: He has history of suicidal attempts, tried hanging himself but was caught by the parents.
Reason for committing suicide was not mentioned. “Nag bitay ko galing na dakpan”. As claimed

VI. Immunization History

Vaccine Dose Route of Schedule Remarks

Administration
BCG 0.05 mL Intradermal At birth Presence of BCG scar at the
right deltoid of patient

Monovalent Hepa B-Birth 0.05 mL Intramuscular At birth Given at the health center.
dose
OPV-0 2 drops Oral At birth or as Given at the health center.
early as 15
days
OPV-1,2,3/IPV 2 drops;0.1mL Oral 6 weeks, 10 Given at the health center.
weeks and 4
weeks; 6 week
and 14 weeks-
1 year of age
Pentavalent Vaccine (DTwP- 0.5 mL Intramuscular 4-8 weeks, 10- Unrecalled
Hib-HepaB) 16 weeks, 14
weeks-12
months
RVV 1, 2, 3 5 drops Oral 6 weeks, 10 Unrecalled
weeks and 4
weeks
PCV 1, 2, & Booster 0.5 mL Intramuscular 6 week, 14 Unrecalled
weeks, and 9
months
Influenza 6 months – up; No influenza vaccine
yearly
Measles 1 0.5 mL Subcutaneous 9-12 months Reported that the patient had
only 1 dose of Measles vaccine
(9 months old)

Vitamin A 1 mL Oral 9-12 months Unrecalled

Japanese Encephalitis (1st 0.5 mL Subcutaneous 9-12 months No vaccine received.

 Mary Christine S. Ilanga Medicine III November 28, 2019

dose)
DTap-IPV-HiB 0.5 mL; 1 dose Intramuscular 12-18 months Unrecalled

MMR, Varicella 0.5 mL Subcutaneous 12-15 months Unrecalled

Hepa A Series 0.5 mL(1st Intramuscular 12 months-2 Unrecalled

dose); 1.0 mL years
(2nd dose)
DTaP-IPV 0.5 mL Intramuscular 4-6 years Unrecalled

Td 0.5 mL Intramuscular 15 years Unrecalled

Measles Booster dose Subcutaneous 15 years Informant reported that the

patient had received this vaccine
when he was Grade 7

VII. Family History

Patient’s parents are both alive. His mother, 52 years old, is allergic to shrimps and dust. His father, 53
years old, is generally well. He has a total of 10 siblings. Eight of them are allergic to shrimp and dust. His two
uncles at the paternal side were diagnosed with Parkinson’s disease as claimed. His two uncles were also
positive for DM and HPN. Patient’s relatives at the maternal side are generally well. No other heredo-familial
disease noted in the family.

VIII. Socio-economic and Environmental History

Patient is a grade eleven student. He belongs to an extended type of family. Monthly income of the family
is estimated to be P 25, 000.00 and it came from the accumulated incomes of four working family members.
Patient is an active student participating in lots of school activities. He is currently the Student Council
President of their school.

Patient lives in a congested, urban area. House is a bungalow-type which is made up of mixed materials
with 6 bedrooms and 1 comfort room with a flushed-type toilet. Septic tank is situated beside the house. Patient
lives with his parents, 9 other siblings, an in-law, and a niece/nephew. Mineral water is used for drinking and
for domestic use, water from a treated deep well is utilized. Garbage is collected by the garbage truck daily. The
family has no pets but there are stray cats and dogs seen at the vicinity. There are no environmental hazards
noted. Infectious or contagious diseases rampant in the neighbourhood are sore eyes and cough.

IX. REVIEW OF SYSTEMS

X. YES NO YES NO
GENERAL NOSE AND SINUSES
Weight Loss Sinus Pain
Weight Gain (33kg-37kg) * Nose Bleeds
Weakness Nasal Stuffiness
Loss of Appetite Itching
Fatigue Discharges
Fever Colds
Mary Christine S. Ilanga Medicine III November 28, 2019

Difficulty Sleeping * THROAT

Chills Thrush
SKIN Sore Tongue
Sores Sore Throat
Rashes Non-healing Sores
Lumps Hoarseness
Itching Dry Mouth
Dryness Bleeding Gums
Changes in Skin Color Bleeding Dentures
Changes in Nails NECK
Changes in Hair Swollen Glands
Changes in Moles Stiffness
HEAD Pain
Lightheadedness Lumps
Headache BREASTS
Dizziness Pain
EYES Nipple Discharge
Vision Loss Lumps
Spots Discomfort
Specks RESPIRATORY
Redness Wheezing
Pain Sputum Production
Flashing Lights * Shortness of Breath *
Excessive Tearing Painful Breathing
Double Vision * Hemoptysis
Decreased Visual Acuity Dyspnea
Blurry Vision Cough
EARS CARDIOVASCULAR
Earaches Paroxysmal Nocturnal
Dyspnea
Decreased Hearing Palpitation *
Tinnitus *

YES NO YES NO
Pain Finger/Toe Color Change
during Cold
Orthopnea Claudication
Discomfort MUSCULOSKELETAL/Extremities
GASTROINTESTINAL Weakness
Vomiting Swelling
Trouble Swallowing Stiffness
Painful Defecation Body malaise/weakness *
Mary Christine S. Ilanga Medicine III November 28, 2019

Nausea Joint Pain *

Incontinence Limitation of Activity
Heartburn * PSYCHIATRIC
Early satiety * Tension
Excessive Belching * Mood Changes
Diarrhea Memory Changes
Constipation Nervousness
Changes in Bowel Habit Depression
Changes in Appetite NEUROLOGIC
Abdominal Pain Tremor
URINARY Tingling Sensation
Urgency Paralysis
Polyuria Numbness
Painful Urination Fainting
Nocturia Changes in Speech
Incontinence Changes in Orientation
Hematuria Changes in Mood
Anuria Changes in Memory
GENITAL Blackouts
Testicular Pain HEMATOLOGIC
Scrotal Swelling Transfusion Reactions
Scrotal Pain Easy Bruising
Discharges from Sores Easy Bleeding
Vaginal Discharge ENDOCRINE
Sores Polyuria
Pelvic Pain Heat/ Cold Intolerance
Lumps Excessive Thirst *
Itching Excessive Sweating
Dysmenorrhea Excessive Hunger
PERIPHERAL VASCULAR Change in Hand or Foot
Size
Swelling with
Redness/Tenderness
Swelling of
Calves/Feet/Leg

XI. Physical Examination

General Survey:
Patient was lying supine with two pillows, awake, conscious, ambulatory, and responsive to questions. He
is oriented to time, place and person. He appears thin and weak. He has an IV cannula at right brachiocephalic vein
(D5LR 1L). He is wearing face mask and currently not in cardio-pulmonary distress.
Vital Signs:
Mary Christine S. Ilanga Medicine III November 28, 2019

Patient Result Normal

Temperature 37.8 °C 36.5 to 37.5 °C

Blood pressure 110/70 mmHg 110-135/65-85 mmHg

0xygen Saturation 98% room air 95 to 100%

Pulse rate 114 beats per minute 60 to 100 beats per minute

Respiratory rate 20 counts per minute 12 to 18 breaths per minute

Cardiac rate 117 bpm 60 to 100 beats per minute

Anthropometric Measurements:

Height: 5 feet and 6 inches (167.64 cm)

Weight: 37kg
BMI: 13.1 kg/m2

Interpretation for Anthropometric measurements:

Z-score Normal Interpretation

BMI-for-age (5 to 19 Below -3 Between -2 to -1 (17.5 to Severely wasted

years old) 19.6) (Severely wasted is below
-3; -3:15.8); Patient’s
BMI: 13.1

Height-for-age (5 to 19 Between -1 and -2 Between 2 to -2 (161.9 Normal in height-for-age

years) cm to 191.1 cm) (167.64 cm)
Mary Christine S. Ilanga Medicine III November 28, 2019

Physical Exam:

Skin:

Inspection: Skin is fair in color, without lesions, rashes, sores, itching, cyanosis, or jaundice noted. Short and black
hair. No clubbing noted.

Palpation: Skin is soft to touch with good turgor. Capillary refill time is less than 2 seconds.

Head
Inspection: Hair is short and straight. The head was normocephalic, symmetrical in shape, and is proportionate to
the body size. Face is symmetrical, no deformities and swelling present. No facial involuntary movements, scars, nor
birthmark are seen. No deformities, masses, and lesions in the scalp.

Eyes
Inspection:
Right eye was covered due to blurring of vision and dizziness
Left eye: Bulbar conjunctiva is clear with tiny vessels visible, palpebral conjunctiva is pale with no discharges, and
sclera is anicteric and white. Cornea is transparent, moist, and smooth. No swelling and masses noted on the
lacrimal gland or sac. No abnormal discharges noted. Pupils are equally round and reactive to light and
accommodation.

Ears:

Inspection: Ears are equal in size and similar in appearance with no visible masses, deformities, and lesions noted.
Upper pinna of the ears is aligned with the outer canthus of the eyes.
Mary Christine S. Ilanga Medicine III November 28, 2019

Palpation: Both ears are non-tender, smooth, firm, mobile and had good recoil. No palpable masses and lesions
were noted. Non-palpable pre and post auricular lymph nodes. Mastoid process is non-tender.

Nose:

Inspection: Nose is midline, color is the same with the face .Nares are patent and nasal septum is also midline with
no perforations.
Palpation: Firm, solid placement, no nodules or pain reported. No tenderness noted upon palpation of the sinuses.

Mouth:

Inspection: Lips are dry and pinkish in color, without lesions, swelling, and drooping noted. No swelling and
bleeding noted in the gums and is pink in color. Tongue is midline, pink, smooth, and midline fissures are present.
Uvula is midline and the tonsils are not inflamed.

Neck:

Inspection: Trachea is in the midline. Thyroid rise during swallowing and then fall during resting.
Palpation: Lymph nodes are non-palpable, trachea is palpated midline, and thyroid gland is smooth, firm, and non-
tender.

Respiratory

Inspection: (+) Right anterior chest deformity. No other remarkable findings.

Palpation: Symmetric lung expansion, tactile fremitus, no lumps. Anterior right chest palpated to be depressed.

Percussion: Resonant on all areas.

Auscultation: normal breath sounds, no adventitious sound heard, vesicular breath sounds, no crackles, wheezes, or
ronchi noted.

CARDIAC:
Inspection: Precordium is adynamic. No visible masses noted. No lesions or scars noted.
Palpation: No tendernesss in any area. PMI was palpable on the 5th intercostal space, left midclavicular line. No
palpable heaves and thrills.
Auscultation: S1 and S2 sounds were heard upon auscultation. No irregular cardiac rate, rhythm, or murmur on
auscultatory points.

ABDOMEN
 Inspection: Scaphoid Abdomen. Erythema, dilated veins, rashes, and abdominal pulsations were not noted.
No inflammation and masses were seen.
 Auscultation: Normo-active bowel sounds were heard. No bruit. Bowel clicks=13/min
 Percussion: Tympanitic gastric and splenic area.
 Palpation: no tenderness noted upon palpation. (-) Murphy’s sign.

EXTREMITIES
Mary Christine S. Ilanga Medicine III November 28, 2019

 Inspection: Upper and lower extremities were symmetrical. No varicose veins or nodule noted. No swelling
was seen on both right and left lower extremities.
 Palpation: Dry and warm to touch. No masses were noted. Capillary filling <2 seconds.

Neurologic Function
Mental Status: Patient was alert, relaxed and cooperative. Speech was fluent and words were clear. Thought process
was coherent and insight was good. Recent and remote memories were intact. There was no evidence of disordered
thinking.

Manual Muscle Testing (MMT):

Muscle Group Right Left

Shoulder flexors 5 5

Shoulder extensors 5 5

Shoulder abductors 5 5

Shoulder adductors 5 5

Elbow flexors 5 5

Elbow extensors 5 5

Pronators 5 5

Supinator 5 5

Wrist flexors 5 5

Wrist extensors 5 5

Plantar flexors 5 5

Dorsiflexors 5 5

Sensory Assessment: Patient had 100% intact sensation as to pain, light, touch and deep pressure on all exposed
body surfaces.

Deep Tendon Reflex:

Right Tendon Left

Normoreflexic Biceps brachii Normoreflexic

Normoreflexic Triceps brachii Normoreflexic

Normoreflexic Brachioradialis Normoreflexic

Normoreflexic Patellar Normoreflexic

Normoreflexic Achilles Normoreflexic

Mary Christine S. Ilanga Medicine III November 28, 2019

Superficial Reflex: Patient has (-) Babinski reflex on both feet.

Cranial Nerves:

Cranial Nerves Right Left

I. Olfactory Able to distinguish smell of coffee with Able to distinguish smell of coffee with eyes
eyes closed and left nostril covered closed and right nostril covered

II. Optic Pupils round and reactive to light Pupils round and reactive to light
accommodation with positive direct and accommodation with positive direct and
consensual light reflex consensual light reflex

III. Oculomotor Able to open right eyelid Able to open left eyelid

Able to look up and down, medially, and Able to look up and down, medially, and
upward inward. upward inward.

(+) direct pupillary reflex (+) direct pupillary reflex

(+) consensual light reflex (+) consensual light reflex

IV. Trochlear Able to move eye downward and inward Able to move eye downward and inward

V. Trigeminal Able to sense object on surface of right Able to sense object on surface of left side
side of the face of the face

Able to elevate and depress the jaw with Able to elevate and depress the jaw with no
no deviation or asymmetry deviation or asymmetry

(+) blink corneal reflex (+) blink corneal reflex

(+) jaw jerk (+) jaw jerk

VI. Abducens Able to look outward and laterally Able to look outward and laterally

VII. Facial Able to perform all facial expressions with Able to perform all facial expressions with
no deviation or asymmetry no deviation or asymmetry

(+) Blink Reflex on the right eye (+) Blink Reflex on the left eye

VIII. Vestibulocochlear Can hear 3 out of 3 words on whispered Can hear 3 out of 3 words on whispered
voice test with left ear covered voice test with right ear covered

IX. Glossopharyngeal Able to swallow Able to swallow

X. Vagus (+) Gag reflex (+) Gag reflex

XI. Spinal/Accessory Able to shrug shoulders with or without Able to shrug shoulders with or without
resistance. resistance.

Able to perform right lateral neck flexion Able to perform left lateral neck flexion with
with left rotation against resistance right rotation against resistance
Mary Christine S. Ilanga Medicine III November 28, 2019

XII. Hypoglossal Can perform all tongue movements with Can perform all tongue movements with no
no deviation deviation

Test for Meningitis:

(-) Brudzinski’s sign

(-) Kernig’s sign

SALIENT POINTS

HPI undocumented, intermittent fever,

headache, non-projectile, post-prandial
vomiting, body malaise, loss of appetite
and nausea, weakness, loss of
consciousness

PMH Chicken pox at 8years old, allergies to

shrimp

Family history 8 siblings had allergies to shrimp,

mother is also allergic to shrimp, two
uncles are positive of DM and HPN and
Parkinson’s disease as claimed.

Personal hx Patient only prefers meat, chicken and

pork in his diet. Has history of suicidal
ideation, openly gay. Occasional drinker.

ROS Trouble sleeping, Double vision

Flashing lights, Tinnitus, Neck stiffness,
Shortness of breath , Palpitation,
Heartburn, Excessive belching, Early
satiety, Joint pain, Malaise/Weakness,
Excessive thirst

Socio-Economic and Environmental Lives in a congested, urban area,

History infectious diseases present in the
community include cough and sore
throat.

PE Low grade fever present, tachycardia

present, Right eye was covered due to
blurring of vision and dizziness , anterior
chest was slightly depressed. (+) Right
anterior chest deformity

PRIMARY IMPRESSION: TB Meningitis

Mary Christine S. Ilanga Medicine III November 28, 2019

Rule in: undocumented, intermittent fever, headache, non-projectile, post-prandial vomiting, body malaise, loss of
appetite and nausea, weakness, loss of consciousness

Tuberculous meningitis (TBM) develops in 2 steps. Mycobacterium tuberculosis bacilli enter the host by
droplet inhalation. Localized infection escalates within the lungs, with dissemination to the regional lymph nodes. In
persons who develop TBM, bacilli seed to the meninges or brain parenchyma, resulting in the formation of small
subpial or subependymal foci of metastatic caseous lesions, termed Rich foci.

The second step in the development of TBM is an increase in size of a Rich focus until it ruptures into the
subarachnoid space. The location of the expanding tubercle (ie, Rich focus) determines the type of CNS
involvement. Tubercles rupturing into the subarachnoid space cause meningitis.

In an immunocompetent individual, central nervous system (CNS) TB usually takes the form of meningitis
that causes an acute-to-subacute illness characterized by fever, headache, drowsiness, meningism, and confusion
over a period of approximately 2-3 weeks.

Usually, during the prodromal period, nonspecific symptoms are present, including fatigue, malaise,
myalgia, and fever. In one study, only 2% of patients reported meningitic symptoms. The duration of presenting
symptoms may vary from 1 day to 9 months, although 55% presented with symptoms of less than 2 weeks' duration.

Often, in the first stage of meningitis, patients have infection of the upper respiratory tract, a fact that
should be remembered when the concurrent fever and irritability or lethargy seem out of proportion to the obvious
infection or when general symptoms persist after improvement in the local manifestations. Fever and headache can
be absent in 25% of patients, and malaise can be absent in as many as 60% of patients. Headache and mental status
changes are much more common in elderly persons.

Visual symptoms include visual impairment or blindness and, occasionally, abrupt onset of painful
ophthalmoplegia. Ocular tuberculosis presents a form of granulomatous uveitis. Delayed or wrong diagnosis may be
detrimental to the ocular structures and the health of the individual.

Sudden onset of focal neurologic deficits, including monoplegia, hemiplegia, aphasia, and tetraparesis, has
been reported. Tremor and, less commonly, abnormal movements, including choreoathetosis and hemiballismus,
have been observed, more so in children than in adults.

Work-up:

Computed tomography (CT) scanning and magnetic resonance imaging (MRI) lack specificity but help in
monitoring complications that require neurosurgery.

A complete blood count should be performed, and the erythrocyte sedimentation rate should be determined.

The serum glucose level should be measured; this value is a useful comparison with the glucose level measured in
the cerebrospinal fluid (CSF).

Serologic testing for syphilis should be performed. Complementation testing or its equivalent for fungal infections
should also be performed.

Lumbar Puncture

Use manometrics to check CSF pressure. Typically, the pressure is higher than normal.
Mary Christine S. Ilanga Medicine III November 28, 2019

Inspect the CSF visually and note its gross appearance. It typically is clear or slightly turbid. If the CSF is left to
stand, a fine clot resembling a pellicle or cobweb may form. This faintly visible "spider's web clot" is due to the very
high level of protein in the CSF (ie, 1-8 g/L, or 1000-8000 mg/dL) typical of this condition. Hemorrhagic CSF also
has been recorded in proven cases of TBM; this is attributed to fibrinoid degeneration of vessels resulting in
hemorrhage (Smith, 1947).

CSF analysis

Tests that may be performed on CSF specimens obtained by lumbar puncture include the following:

 Cell counts, differential count, cytology

 Glucose level, with a simultaneous blood glucose level
 Protein level
 Acid-fast stain, Gram stain, appropriate bacteriologic culture and sensitivity, India ink stain
 Cryptococcal antigen and herpes antigen testing
 Culture for Mycobacterium tuberculosis (50-80% of known cases of TBM yield positive results)
 PCR: Results imply that PCR can provide a rapid and reliable diagnosis of TBM, although false-negative
results potentially occur in samples containing very few organisms (< 2 colony-forming units per mL).
 Syphilis serology

Management:

First-line therapy includes isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), streptomycin (SM), and
ethambutol. Second-line therapy includes ethionamide, cycloserine, para-aminosalicylic acid (PAS),
aminoglycosides, capreomycin, and thiacetazone.

Potential new agents include oxazolidinone and isepamicin. Fluoroquinolones useful in the treatment of TBM
include ciprofloxacin, ofloxacin, and levofloxacin. A new rifamycin called rifapentine has been developed.

Rifampicin Streptomycin Ethambutol Pyrazinamide

Isoniazid

10-15 mg/kg PO 10 mg/kg/day PO Daily therapy: 15 Initial TB treatment: Daily therapy

qDay; not to or 10 mg/kg PO mg/kg IM qDay; 15 mg/kg PO qDay
exceed 300 mg/day twice weekly no more than 1 15-30 mg/kg PO
OR (directly observed g/day Prior TB treatment:
qDay; not to
therapy [DOT]); 25 mg/kg PO qDay;
after 60 days, exceed 2 g/day
20-30 mg/kg (up to not to exceed 600 Twice weekly
mg/day decrease to 15 mg/kg
900 mg) 2 therapy: 25-30 PO qDay
times/week mg/kg IM 2
times/week; no
Used in multi-drug more than 1.5
regimen g/day

Aminoglycosides: Amikacin 15 mg/kg/day divided IV/IM q8-12hr

Mary Christine S. Ilanga Medicine III November 28, 2019

Differential Diagnosis:
1. Aseptic/viral meningitis

Aseptic meningitis is an illness characterized by serous inflammation of the linings of the brain (i.e., meninges),
usually with an accompanying mononuclear pleocytosis. Clinical manifestations vary, with headache and fever
predominating. The illness is usually mild and runs its course without treatment; however, some cases can be severe
and life threatening.

Aseptic meningitis syndrome is not caused by pyogenic bacteria, rather by certain viruses such as Enteroviruses.

The time course of acute viral meningitis varies. Onset may occur within a matter of hours after exposure or evolve
more slowly over a few days. Usually, maximum deficit appears within 3-6 days after exposure. Persons infected
with the viruses that commonly cause aseptic meningitis may remain infectious for weeks after contracting the virus.

Characteristic signs of acute viral meningitis include the following:

 Headache
 Fever
 Stiff neck
 Photophobia
 Drowsiness
 Myalgias
 Malaise
 Chills
 Sore throat
 Abdominal pain
 Nausea and vomiting

Focal signs, seizures, and profound lethargy are rarely features of aseptic meningitis. Occasionally, patients may
exhibit altered levels of consciousness, including confusion and visual hallucinations.

Treatment varies with the cause. No specific pharmacologic treatment is available for most cases of viral meningitis;
these patients are managed with supportive therapy, which includes analgesics, antinausea medications, intravenous
fluids, and prevention and treatment of complications.

2. Acute Disseminated Encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated inflammatory demyelinating condition that

predominately affects the white matter of the brain and spinal cord. The disorder manifests as an acute-onset
encephalopathy associated with polyfocal neurologic deficits and is typically self-limiting.

The onset of ADEM usually occurs in the wake of a clearly identifiable febrile prodromal illness or immunization
and in association with prominent constitutional signs and encephalopathy of varied degrees.

There is usually a clearly defined phase of afebrile improvement lasting 2-21 days or more before onset of
neurologic findings.

Generally, patients have shown partial or complete recovery from the prodromal illness at the time of onset of
ADEM.
Mary Christine S. Ilanga Medicine III November 28, 2019

Whether latencies of longer than 21 days implicate a particular febrile illness as the prodrome of ADEM is
unclear.

Association with constitutional symptoms and signs, such as fever

Prominence of cortical signs such as mental status changes and seizures

Acute disseminated encephalomyelitis (ADEM) is often treated with high-dose intravenous corticosteroids, to which
it appears to be responsive. One common protocol is 20-30 mg/kg/d of methylprednisolone (maximum dose of 1
g/d) for 3-5 days. Improvement may be observed within hours but usually requires several days. An oral taper for 4-
6 weeks or some other interval is sometimes appended.

References:

Ramachandran, T. 2017. Tuberculous Meningitis. Retrieved from:

https://emedicine.medscape.com/article/1166190-medication#3/TBMeningitis. November 27, 2019.

Brenton, N. 2018. Acute Disseminated Encephalomyelitis. Retrieved from:

https://emedicine.medscape.com/article/1147044-overview/ADEM. November 27, 2019