A number of viruses can cause aseptic meningitis, including nonpolio enteroviruses, mumps, cytomegalovirus, herpes simplex virus, lymphocytic choriomeningitis, adenovirus, and HIV. Specific diagnosis depends on isolation of the virus or positive results on immunoassay of the CSF. Nonpolio enteroviruses (echovirus, coxsackievirus, and enterovirus) account for about 85 percent of all cases of viral meningitis in the United States.
While the diagnosis of viral meningitis is often straightforward ( Table.22.7-2), there can be overlap of CSF findings with early bacterial meningitis and partially treated bacterial meningitis, making specific diagnosis for some cases difficult in the emergency department. Neutrophils may predominate in the CSF for the first 24 h in viral meningitis. Standard references report up to a 10 percent incidence of lymphocytic predominance in CSF with bacterial meningitis, more common with L. monocytogenes and in neonatal meningitis. Depending on clinical diagnostic certainty, a range of approaches can be employed in the management of presumed viral meningitis, from admission with empiric antibiotic therapy until culture results return, to discharge from the emergency department with follow-up in 24 h.
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