What is the diagnostic workup and treatment for a patient suspected of having COVID-19 (Coronavirus Disease 2019) meningitis?

Diagnostic Workup and Treatment for COVID-19 Meningitis

The diagnostic workup for COVID-19 meningitis should include cerebrospinal fluid (CSF) analysis with SARS-CoV-2 RT-PCR testing, as this is the definitive method to confirm the diagnosis, even when respiratory specimens are negative.

Clinical Presentation

COVID-19 meningitis may present with:

• Fever, headache, and altered mental status as the predominant symptoms 1, 2
• Meningeal irritation signs (neck stiffness, photophobia) 3
• Seizures or epileptic attacks in some cases 4, 3
• Consciousness disturbance, delirium, or psychotic syndrome 4
• Possible absence of respiratory symptoms (COVID-19 meningitis can occur without pulmonary involvement) 2, 5

Diagnostic Workup

Initial Assessment

• Obtain detailed neurological examination focusing on meningeal signs and mental status 1
• Check for fever and other systemic symptoms 2, 5

Laboratory Testing

• Standard NAAT (RT-PCR) testing from nasopharyngeal/oropharyngeal specimens 1
  • Note that respiratory specimens may be negative in isolated COVID-19 meningitis 2
• Complete blood count and inflammatory markers (C-reactive protein, procalcitonin) 1
  • Procalcitonin can help differentiate bacterial from viral causes 1

Cerebrospinal Fluid Analysis

• Perform lumbar puncture to obtain CSF 1, 2
• CSF testing should include:
  • Cell count and differential (typically shows lymphocytic pleocytosis in viral meningitis) 2, 3
  • Protein and glucose levels (viral pattern typically shows elevated protein) 2, 3
  • SARS-CoV-2 RT-PCR testing of CSF (critical for diagnosis) 1, 2, 4
  • Standard bacterial culture and Gram stain 1
  • PCR for other common viral causes (HSV, VZV, enterovirus) 2
  • Consider testing for SARS-CoV-2 antibodies in CSF if PCR is negative 4

Neuroimaging

• Brain MRI is preferred over CT due to superior resolution 1
  • Common findings include:
    • Hyperintense signal changes in white matter 3
    • Enhancement of meninges 3
    • Possible involvement of temporal lobe, frontal lobe, corpus callosum 4
• Consider CT if MRI is unavailable or in emergency situations 1

Additional Testing

• Electroencephalogram (EEG) if seizures or altered mental status are present
  • Typically shows diffuse slow waves in COVID-19 meningitis 4

Treatment Approach

Antiviral Therapy

• Consider antiviral treatment with protease inhibitors such as lopinavir/ritonavir (Kaletra) 2
• Treatment decisions should be based on the most recent clinical evidence and severity of illness 2, 3

Supportive Care

• Manage seizures with appropriate antiepileptic medications if present 4
• Provide adequate hydration and electrolyte management 3
• Monitor for neurological deterioration 1

Anti-inflammatory Treatment

• Consider corticosteroids in cases with significant inflammation
  • Some patients with COVID-19 meningitis have shown good response to corticosteroid therapy 3

Monitoring and Follow-up

• Close neurological monitoring during hospitalization 1
• Consider repeat CSF analysis to confirm improvement 2

Special Considerations

Infection Control

• Implement appropriate isolation precautions during procedures like lumbar puncture 1
• Use personal protective equipment (PPE) during neurological procedures 1

Pediatric Cases

• COVID-19 meningitis has been reported in children as well as adults 6
• The diagnostic approach remains similar, with appropriate age-based considerations 6

Pitfalls and Caveats

• Negative respiratory RT-PCR does not rule out COVID-19 meningitis; CSF testing is essential 2
• COVID-19 meningitis can be the sole presentation without respiratory symptoms 2, 5
• Consider other viral and bacterial causes of meningitis in the differential diagnosis 1, 2
• Avoid lumbar puncture if there are signs of increased intracranial pressure or risk of herniation until imaging is performed 1