Aseptic meningitis in a child after systemic treatment with high dose cytarabine

Cytarabine was temporally associated with aseptic meningitis syndrome in an 8-year-old Hispanic girl being treated for acute lymphoblastic leukemia.

Trimethoprim-sulfamethoxazole induced aseptic meningitis in a renal transplant patient

A 45-year-old man underwent renal transplant for end-stage renal disease complicating systemic lupus erythematosis. Within 24 hours of initiating Pneumocystis carinii pneumonia (PCP) prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) he developed fever and confusion. Cerebrospinal fluid examination revealed a pleocytosis but cultures were negative. The patient improved within three days after cessation of the TMP-SMX but symptoms recurred rapidly upon drug rechallenge. Drug-induced aseptic meningitis is an uncommon but well described clinical entity. This is the first case described in a patient following renal transplantation. The literature is reviewed and the clinical features, diagnostic challenges and possible mechanisms of TMP-SMX-induced aseptic meningitis are discussed. This problem may be more common in the transplant population than is recognized given the difficulty of diagnosis combined with the widespread use of TMP-SMX as PCP prophylaxis.

Drug-induced aseptic meningitis: diagnosis and management

Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.

Trimethoprim-sulfamethoxazole-induced aseptic meningitis: case report and literature review

Aseptic meningitis is a rare adverse drug reaction, reported with non-steroidal anti-inflammatory agents (NSAIDs) and with miscellaneous drugs such as trimethoprim-sulfamethoxazole (TMP-SMX). The most common clinical findings reported are fever, headache, stiffness and altered level of consciousness. We report a case of aseptic meningitis related to TMP-SMX ingestion that caused severe derangements of the patient's vital signs, requiring Intensive Care Unit admittance. The prompt diagnosis and discontinuation of the drug resulted in complete recovery. We examine the case according to the literature on this topic. We conclude that, since the signs and symptoms of this unusual drug reaction may mimic those of central nervous system infection, the clinician should consider this etiology when he is faced with a patient with suspected meningoencephalitis, especially if the latter has already been treated at home with unknown drugs. Further studies should investigate the pathogenetic mechanism of TMP-SMX-induced aseptic meningitis.

[A case of famotidine-induced aseptic meningitis]

We reported a 50-year-old woman with a history of mixed connective tissue disease. She had two episodes of meningitis-like symptoms after taking famotidine and tiquizium bromide for treatment of gastric ulcer. From CSF findings (elevated pressure, increase of protein, polymorphonuclear pleocytosis, negative culture) and result of famotidine challenge test, we diagnosed her as a drug induced aseptic meningitis. Because she had taken tiquizium bromide several times previously without any side effects, we concluded that famotidine was a causative drug. She was recovered without sequelae within a few days following cessation of these drugs. This is the first report of H2-blocker induced aseptic meningitis. When we encounter a patient with aseptic meningitis who presents polymorphonuclear pleocytosis in CSF, we should suspect drug induced aseptic meningitis and take a history of drug medication including H2-blocker.

Recurrent aseptic meningitis following non- steroidal anti-inflammatory drugs--a reminder

Non-steroidal anti-inflammatory drugs (NSAIDs) are rarely associated with side-effects affecting the central nervous system. A case of NSAID-induced recurrent aseptic meningitis is presented. Seven episodes of aseptic meningitis were documented in the patient's life-time (up to the age of 30). General practitioners' records available for the latest four episodes showed that a NSAID (naproxen, piroxicam or diclofenac) was prescribed in the month prior to admission on each occasion. The patient was symptom free for a 3-year period during which no NSAID was prescribed. Clinicians should always elicit a careful drug history (including over-the-counter medications) in patients with aseptic meningitis and be aware of this unusual side-effect of NSAIDs.

The challenge of drug-induced aseptic meningitis

Several drugs can induce the development of aseptic meningitis. Drug-induced aseptic meningitis (DIAM) can mimic an infectious process as well as meningitides that are secondary to systemic disorders for which these drugs are used. Thus, DIAM constitutes a diagnostic and patient management challenge. Cases of DIAM were reviewed through a MEDLINE literature search (up to June 1998) to identify possible clinical and laboratory characteristics that would be helpful in distinguishing DIAM from other forms of meningitis or in identifying a specific drug as the culprit of DIAM. Our review showed that nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, intravenous immunoglobulins, and OKT3 antibodies (monoclonal antibodies against the T3 receptor) are the most frequent cause of DIAM. Resolution occurs several days after drug discontinuation and the clinical and cerebrospinal fluid profile (neutrophilic pleocytosis) do not allow DIAM to be distinguished from infectious meningitis. Nor are there any specific characteristics associated with a specific drug. Systemic lupus erythematosus seems to predispose to NSAID-related meningitis. We conclude that a thorough history on prior drug intake must be conducted in every case of meningitis, with special focus on those aforementioned drugs. If there is a suspicion of DIAM, a third-generation cephalosporin seems a reasonable treatment option until cerebrospinal fluid cultures are available.

A rare case of cotrimoxazole-induced eosinophilic aseptic meningitis in an HIV-infected patient

A case of cotrimoxazole-induced meningoencephalitis in an HIV-infected patient without signs of AIDS is reported. The patient developed an apparently generalized seizure, of cotrimoxazole, 1 month after first taking a dose of this drug and a febrile coma after a second dose 3 weeks later. Lumbar puncture revealed eosinophilic aseptic meningitis. The patient quickly recovered without sequelae and was given antiretroviral therapy plus pentamidine aerosolized and pyrimethamine as prophylaxis for opportunistic infections. No other adverse effects were observed. The report describes the diagnosis of this case supported by a commentary, including a literature review.

Recurrence of ibuprofen-induced aseptic meningitis in an otherwise healthy patient

We report the case of a 74-year-old woman who had three episodes of aseptic meningitis in a period of 20 years. These episodes always occurred a few hours after the assumption of a non-steroidal anti-inflammatory drug (NSAID) per os. Nevertheless, the pharmacological anamnesis did not receive proper attention, neither the first nor the second time, and the meningeal syndrome with aseptic liquor was attributed to a viral aggression. However, when the third episode occurred, due to the strict time correlation between the assumption of the drug and the occurrence of symptoms, both the results of the liquoral analysis and the anamnestic records allowed recognition of ibuprofen as the cause of acute meningitis.

Sensorineural hearing loss caused by NSAID-induced aseptic meningitis

Aseptic meningitis is a rare complication of nonsteroidal anti-inflammatory drug (NSAID) use. Otologic symptoms may include sensorineural hearing loss and tinnitus. A 66-year-old woman sought the care of an otologist for sudden bilateral sensorineural hearing loss and a substantial increase in baseline tinnitus. The patient had previously undergone a left tympanoplasty secondary to cholesteatoma and had been treated for atypical face pain with ibuprofen taken every six hours for three months. Magnetic resonance imaging (MRI) with gadolinium demonstrated abnormal enhancement of the dura mater and the surrounding basal cisterns, with extension of enhancing dura mater into the internal auditory canals. Cerebrospinal fluid examination revealed evidence of aseptic meningitis. An audiogram confirmed new bilateral sensorineural hearing loss. Hearing loss and tinnitus resolved and no abnormalities were observed with MRI when nonsteroidal anti-inflammatory medication was discontinued. Otolaryngologists are well aware of the otologic sequelae in patients with meningitis. However, NSAIDs need to be considered as possible causal agents in the evaluation of meningitis with otologic symptoms.