Which tests should be performed in the absence of clinical improvement of viral meningitis?

Updated: Jul 17, 2018
  • Author: Cordia Wan, MD; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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If the CSF Gram stain result is negative but moderate-to-severe pleocytosis is noted (WBC >1000 x 109/L), a repeat LP should be considered in 12-18 hours if the patient has not improved clinically. All patients with suspected bacterial meningitis should be treated empirically with appropriate antibiotics.

After the bacterial Gram stain, latex antigen tests, and cultures return negative, antibacterial therapy can be discontinued. If the results of PCR testing of the CSF and the viral culture for herpes simplex are negative, acyclovir can be discontinued; otherwise, a 10-day course is recommended.

If no clinical improvement in the patient is noted and all the common bacterial and viral pathogens have been ruled out, the following tests should be performed and the therapy modified depending on their results:

  • CSF - Venereal Disease Research Laboratories test (VDRL), PCR for CMV, acid-fast stain

  • Skin - Purified protein derivative (PPD) to help exclude tuberculosis

Blood - HIV antibody and PCR, rapid plasma reagent (RPR), Lyme antibody (in areas of endemic disease or if history suggests), toxoplasmosis antibody (especially in infants and newborns)

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