What are the recommendations for managing aseptic meningitis potentially caused by Terzapeptide?

Management of Terzapeptide-Induced Aseptic Meningitis

For suspected Terzapeptide-induced aseptic meningitis, immediately discontinue the medication and provide supportive care while ruling out infectious causes, as drug-induced aseptic meningitis typically resolves with drug discontinuation.

Initial Assessment and Management

• Immediately discontinue Terzapeptide if aseptic meningitis is suspected 1
• Obtain blood cultures before initiating empiric antimicrobial therapy to rule out bacterial meningitis 2
• Start empiric antibiotics immediately if bacterial meningitis cannot be ruled out, as delayed initiation worsens mortality 3
• Perform respiratory isolation until meningococcal meningitis is excluded or patient has received 24 hours of Ceftriaxone 3

Diagnostic Approach

• Perform lumbar puncture (LP) unless contraindicated by:
  • Signs of brain shift (altered consciousness, focal neurological signs, papilledema) 3
  • Respiratory or cardiac compromise 3
  • Rapidly evolving rash 3
  • Infection at LP site 3
  • Coagulopathy 3
• CSF analysis in drug-induced aseptic meningitis typically shows:
  • Lymphocytic pleocytosis 4
  • Normal glucose levels 4
  • Mildly elevated protein 4
  • Negative bacterial and fungal cultures 4

Contraindications to Immediate LP

• Perform neuroimaging before LP if any of these are present:
  • GCS <12 or rapidly deteriorating 3
  • Focal neurological signs 3
  • Papilledema 3
  • Recent seizures 3
  • Immunocompromised state 3

Treatment Recommendations

• Provide supportive care for drug-induced aseptic meningitis 5:
  • Maintain euvolemia to support normal hemodynamic parameters 3
  • Avoid fluid restriction (does not help reduce cerebral edema) 3
  • Use crystalloids as initial fluid of choice 3
  • Consider albumin for persistent hypotensive shock 3
• Manage symptoms:
  • Administer analgesics for headache (avoid NSAIDs as they can also cause aseptic meningitis) 1, 6
  • Provide antiemetics for nausea and vomiting 5
  • Treat seizures promptly if they occur 3

Monitoring and Follow-up

• Monitor neurological status closely, including pupillary responses, level of consciousness, and motor function 2
• Assess for potential long-term sequelae before discharge 3:
  • Cognitive deficits 3
  • Hearing impairment 3
  • Psychological impacts 3
• Perform hearing test if clinician or patient suspects hearing may be affected 3

Important Considerations

• Drug-induced aseptic meningitis is a diagnosis of exclusion - infectious causes must be ruled out first 7
• Chronological criteria supporting drug-induced aseptic meningitis include:
  • Rapid onset after drug initiation 7
  • Rapid improvement after drug discontinuation 7
  • Recurrence with rechallenge 7
• Document the reaction as a drug allergy to prevent future re-exposure 4
• Notify public health authorities of all meningitis cases regardless of etiology 3

Common Pitfalls to Avoid

• Do not delay antibiotics if bacterial meningitis cannot be ruled out immediately 3
• Do not rely solely on clinical examination maneuvers (Kernig sign, Brudzinski sign) to differentiate bacterial from aseptic meningitis due to variable sensitivity and specificity 8
• Avoid NSAIDs for symptom management as they are common causes of drug-induced aseptic meningitis 1, 6
• Do not rechallenge with Terzapeptide unless under medical supervision with informed consent 5
• Remember that drug-induced aseptic meningitis can occur even with medications previously tolerated by the patient 4