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Headache & Chills


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History: A 66-year-old male presents with 2 days of constant generalized headache associated with chills but no fever vomiting photophobia, eye discomfort, neck stiffness, focal weakness or elevated temperature. He’s also had 6 days of productive cough without blood

Exam: Vital signs were normal except for.  Physical exam was normal except for

Initial Concern(s): Dangerous stuff


  • Blood: normal except for glucose of 180 and WBC of 17 with no bands
  • CT brain: done due to age >65 and was normal
  • CSF: samples due to progressive HA with no other explanation: WBC: 350 with 90% lymphs, RBC: 1, glucose: 80, protein: 200

Course: Patient was given a dose of decadron  and ceftriaxone prior to CT & LP.  After results came back a dose of Acyclovir was ordered.  On the floor steroids and acyclovir were stopped and the patient was treated with ceftriaxone and vancomycin awaiting CSF culture results and antibody screen.


  1. What should you do next?  
  2. Where can I get a quick refresher on this topic?  

Scroll to bottom for case answer and E-meducation 

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  1. What should you do next?  Try to identify the causative organism.  See conclusion for answer.
  2. Where can I get a quick refresher on this topic?  See highlighter area below


E-meducation for ZOSTER MENINGITIS.  Read the yellow highlighted area of the page-shot below from our #1 title.  The Emergency Medicine 1-Minute Consult Pocketbook


CASE CONCLUSION: VZV was positive in the CSF.  Decadron and Acyclovir IV were started and antibiotics were stopped.  The patient’s symptoms improved rapidly after that.

LESSON: Meningitis that seems to be viral is not always benign until you prove it is a non-polio enterovirus.  Viral meningitis can be due to HSV or VZV and other treatable forms of meningitis can mimic a viral cause.  TB and early or partially treated bacterial are just two examples.  Always at least consider Acyclovir and admission in any patient diagnosed with “viral” meningitis in the ED.