How to manage hyperacusis in a patient with aseptic meningitis?

Management of Hyperacusis in Aseptic Meningitis

For patients with hyperacusis in aseptic meningitis, the primary management approach should focus on treating the underlying meningitis while providing supportive care for the auditory symptoms, as there are no specific guidelines addressing hyperacusis management in this context. 1

Initial Assessment and Stabilization

• Immediate stabilization of airway, breathing, and circulation should be the first priority in any patient with suspected meningitis 2, 1
• Document Glasgow Coma Scale (GCS) score to assess severity and monitor changes in neurological status 2
• Obtain blood cultures within the first hour of hospital arrival, before antibiotic administration 2, 1
• Assess for signs of shock, sepsis, or rapidly evolving rash which would alter the management approach 2, 1

Diagnostic Approach

• Perform lumbar puncture (LP) within 1 hour of hospital arrival if no contraindications exist 2, 1
• Check for LP contraindications including focal neurological signs, papilledema, continuous or uncontrolled seizures, GCS ≤ 12 2, 1
• CSF analysis should include cell count and differential, glucose, protein levels, and Gram stain 1
• In aseptic meningitis, CSF typically shows lymphomonocytic pleocytosis (<500 cells/μL), mildly elevated protein, and normal glucose and lactate levels 3, 4

Management of Underlying Aseptic Meningitis

• If bacterial meningitis cannot be ruled out initially, start empiric antibiotics immediately after LP (or after blood cultures if LP is delayed) 2, 1
• For confirmed viral aseptic meningitis, treatment is primarily supportive care 3, 4
• Consider antiviral therapy (acyclovir) if herpes virus etiology is suspected until serological diagnosis is available 4
• Maintain euvolemia to preserve normal hemodynamic parameters 2
• Avoid fluid restriction as it does not help reduce cerebral edema 2

Management of Hyperacusis

• Hyperacusis in aseptic meningitis may be part of the neurological manifestations or potentially related to medication side effects 5, 6
• Create a quiet environment with minimal auditory stimulation to reduce discomfort 5
• Consider discontinuation of any medications that might be contributing to the aseptic meningitis or hyperacusis, particularly NSAIDs, antibiotics, or intravenous immunoglobulins 6, 7
• Monitor for improvement of hyperacusis as the underlying meningitis resolves 5

Special Considerations

• Be alert for drug-induced aseptic meningitis (DIAM) as a potential cause, especially in patients taking NSAIDs, antibiotics, or intravenous immunoglobulins 6, 7
• DIAM typically presents with early onset (within a week of starting medication) and resolves after discontinuation of the offending drug 6
• Patients with systemic lupus erythematosus appear to be more susceptible to NSAID-induced aseptic meningitis 6, 7
• Sensorineural hearing loss and tinnitus may accompany hyperacusis in some cases of aseptic meningitis 5

Monitoring and Follow-up

• Monitor neurological status regularly using GCS 2
• Assess improvement of hyperacusis as the meningitis resolves 5
• Consider audiological evaluation if hyperacusis persists after resolution of meningitis 5
• Most patients with viral aseptic meningitis have good outcomes with supportive care 4

Common Pitfalls to Avoid

• Delaying antibiotics while waiting for LP or neuroimaging in cases where bacterial meningitis cannot be ruled out 1
• Failing to recognize signs of increased intracranial pressure that contraindicate immediate LP 2, 1
• Overlooking medication-induced aseptic meningitis as a potential cause 6, 7
• Continuing medications that may be contributing to the aseptic meningitis or hyperacusis 5, 6