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An atypical case of meningitis

Dr. Christenson presents a case of a middle aged male who presents with fungal meningitis likely related to tooth infection.


Learning points:


1. How do we manage this patient's respiratory failure?

--Noninvasive mechanical ventilation:


  • NIV has been shown to benefit those with COPD exacerbations, cardiogenic pulmonary edema, neuromuscular disease, obesity-hypoventilation syndrome and in patients who have been recently extubated and are high risk of morbidity

  • Has NOT been shown to benefit patients with asthma exacerbations, hypoxemic respiratory failure, or in patients with altered mental status

  • Contraindicated in altered mental status, increased airway secretions, gastric distention, airway obstruction, recent esophageal surgery, cardiac arrest, inability to protect the airway, facial trauma/surgery


--Invasive Mechanical Ventilation: allows for higher inspiratory pressures and addresses the contraindications for NIV (inability to protect the airway)

  • Indications: hypoxemic and ventilatory respiratory failure, contraindication to NIV, inability to protect the airway



2. Meningitis workup/empiric therapy

  • IV vancomycin, Ceftriaxone with addition of ampicillin if >50yo

  • Dexamethasone if considering s.pneumo

  • Acyclovir if features of encephalitis are present

  • Who needs a CT? Immunocompromised, focal neuro deficits, hx of prior stroke or CNS malignancy, new seizure within 1 week, major alteration in consciousness, papilledema on exam




3. What could have caused such a prolonged course?

Chronic meningitis is defined as >4 weeks

  • Fungal: cryptococcus, coccidio, histo, blasto

  • Bacterial: lyme, TB

  • Non-infections: autoimmune, neoplastic processes

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