Fungal meningitis differential diagnosis: Difference between revisions

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Revision as of 13:05, 4 April 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby; Prince Tano Djan, BSc, MBChB [2]

Overview

The differential diagnosis of fungal meningitis includes a range of medical conditions that can be broadly classified into infectious and non infectious. The cerebrospinal fluid analysis and radiological findings help distinguishing fungal meningitis from other causes of meningitis example bacterial meningitis, protozoal meningeal infection, viral meningeal infection, and non-infectious causes.

Differential Diagnosis

Fungal meningitis must be differentiated from other causes of meningeal irritation as shown below:

Meningeal infection
- Bacterial meningitis
- Protozoal meningeal infection
- Helminthic meningeal infection
- Viral meningeal infection
Non infectious causes
- Behçet's syndrome
- Chronic benign lymphocytic meningitis
- Chemical meningitis
- Drug hypersensitivity
- Isolated granulomatous angiitis of the nervous system
- Granulomatosis with polyangiitis (Wegener's)
- Malignancy
- Mollaret's meningitis
- Sarcoidosis
- Systemic lupus erythematosus
- Vogt-Koyanagi-Harada syndrome^[1]

Differentiating fungal meningitis from other diseases

Diseases	Diagnostic tests				Physical Examination					Symptoms			Past medical history	Other Findings
Diseases	Na+, K+, Ca2+	CT /MRI	CSF Findings	Gold standard test	Neck stiffness	Motor or Sensory deficit	Papilledema	Bulging fontanelle	Cranial nerves	Headache	Fever	Altered mental status	Past medical history	Other Findings
Brain tumour^[2]^[3]		+	Cancer cells^[4]	MRI		+	+	+	+	+		+		Cachexia, gradual progression of symptoms
Delirium tremens		+		Clinical diagnosis		+	+		+	+	+	+	Alcohol intake, sudden witdrawl or reduction in consumption	Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage^[5]		+	Xanthochromia^[6]	CT scan without contrast^[7]^[8]	+	+	+	+	+	+	+	+	Trauma/fall	Confusion, dizziness, nausea, vomiting
Stroke		+	Normal	CT scan without contrast		+	+		+	+		+	TIAs, hypertension, diabetes mellitus	Speech difficulty, gait abnormality
Neurosyphilis^[9]^[10]		+	↑ Leukocytes and protein	CSF VDRL-specific CSF FTA-AbS -sensitive^[11]	+	+	+	+		+		+	Unprotected sexual intercourse, STIs	Blindness, confusion, depression, Abnormal gait
Viral encephalitis		+	Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose	Clinical assesment	+	+	+		+	+	+	+	Tick bite/mosquito bite/ viral prodome for several days	Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis		+		Clinical assesment			+	+	+	+	+		History of hypertension	Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy			Normal				+	+			+		History of alcohol abuse	Ophthalmoplegia, confusion
CNS abscess		+	↑ leukocytes >100,000/ul, ↓ glucose and ↑ protein, ↑ red blood cells, lactic acid >500mg	Contrast enhanced MRI is more sensitive and specific, Histopathological examination of brain tissue	+	+	+		+	+	+	+	History of drug abuse, endocarditis, ↓ immune status	High grade fever, fatigue,nausea, vomiting
Drug toxicity											+	+		Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder				Diagnosis of exclusion		+		+		+	+	+		Tremors, blindness, difficulty swallowing
Electrolyte disturbance	↓ or ↑			Depends on the cause						+		+		Confusion, seizures
Febrile convulsion			Not performed in first simple febrile seizures	Clinical diagnosis and EEG					+	+	+	+	Family history of febrile seizures, viral illness or gastroenteritis	Age > 1 month,
Subdural empyema		+		Clinical assesment and MRI	+	+	+	+	+			+	History of relapses and remissions	Blurry vision, urinary incontinence, fatigue
Hypoglycemia	↓ or ↑			Serum blood glucose HbA1c		+				+		+	History of diabetes	Palpitations, sweating, dizziness, low serum glucose

Differentiating fungal meningitis from other causes of meningitis

Fungal meningitis may be differentiated from other causes of meningitis by cerebrospinal fluid examination as shown below:^[12]^[13]^[14]^[15]^[16]


Cerebrospinal fluid level	Normal level	Bacterial meningitis^[15]	Viral meningitis^[15]	Fungal meningitis	Tuberculous meningitis^[17]	Malignant meningitis^[12]
Cells/ul	< 5	>300	10-1000	10-500	50-500	>4
Cells	Lymphocyte:Monocyte 7:3	Granulocyte > Lymphocyte	Lymphocyte > Granulocyte	Lympho.>Granulocyte	Lymphocytes	Lymphocytes
Total protein (mg/dl)	45-60	Typically 100-500	Normal or slightly high	High	Typically 100-200	>50
Glucose ratio (CSF/plasma)^[13]	> 0.5	< 0.3	> 0.6	<0.3	< 0.5	<0.5
Lactate (mmols/l)^[14]	< 2.1	> 2.1	< 2.1	>3.2	> 2.1	>2.1
Others	ICP:6-12 (cm H2O)	CSF gram stain, CSF culture, CSF bacterial antigen	PCR of HSV-DNA, VZV	CSF gram stain, CSF india ink	PCR of TBC-DNA	CSF tumour markers such as alpha fetoproteins, CEA

References

↑ Koroshetz WJ. Chapter 382. Chronic and Recurrent Meningitis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
↑
↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
↑ ^12.0 ^12.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
↑ ^13.0 ^13.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
↑ ^14.0 ^14.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
↑ ^15.0 ^15.1 ^15.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
↑ Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.
↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.

Template:WH Template:WS

[1] Koroshetz WJ. Chapter 382. Chronic and Recurrent Meningitis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.

[pmid1278192-2] Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192

[pmid3883130-3] ↑

[pmid21371327-4] Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.

[pmid14585453-5] Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453

[pmid1198628-6] Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.

[pmid21694755-7] Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.

[pmid21807345-8] DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.

[pmid22482824-9] Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.

[pmid24365430-10] Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.

[pmid22421697-11] Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.

[pmid23717798-12] 12.0 ^12.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.

[pmid24326618-13] 13.0 ^13.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.

[pmid22880096-14] 14.0 ^14.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.

[pmid10654948-15] 15.0 ^15.1 ^15.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.

[pmid20610819-16] Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.

[pmid20146981-17] Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.

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@@ Line 101: / Line 101: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center"| +
 |style="background: #F5F5F5; padding: 5px; text-align:center"| Normal
-|style="background: #F5F5F5; padding: 5px; text-align:center"| CT scan  without contrast
+|style="background: #F5F5F5; padding: 5px; text-align:center"| [[CT]] scan  without contrast
 |style="background: #F5F5F5; padding: 5px; text-align:center"|
 |style="background: #F5F5F5; padding: 5px; text-align:center"| +
@@ Line 110: / Line 110: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center"|
 |style="background: #F5F5F5; padding: 5px; text-align:center"| +
-|style="background: #F5F5F5; padding: 5px; text-align:center"|TIAs, [[hypertension]], [[diabetes mellitus]]
+|style="background: #F5F5F5; padding: 5px; text-align:center"|[[TIA|TIAs]], [[hypertension]], [[diabetes mellitus]]
-|style="background: #F5F5F5; padding: 5px; text-align:center"|Speech difficulty, gait abnormality
+|style="background: #F5F5F5; padding: 5px; text-align:center"|[[Speech difficulties|Speech difficulty]], [[gait abnormality]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824  }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
@@ Line 117: / Line 117: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]]
-|style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc
+|style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-[[Specificity (tests)|specific]]
-CSF FTA-Ab -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697  }}</ref>
+CSF [[FTA-ABS|FTA-AbS]] -[[Sensitivity (tests)|sensitive]]<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697  }}</ref>
 |style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px; text-align:center" | +
@@ Line 127: / Line 127: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px;" |Unprotected sexual intercourse, [[STI]]<nowiki/>s
+|style="background: #F5F5F5; padding: 5px;" |Unprotected [[Sexual activity|sexual intercourse]], [[STI|STI<nowiki/>s]]
 |style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]],
-Abnormal [[gait]]
+[[Gait abnormality|Abnormal gait]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Viral encephalitis]]
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or xanthochromia, [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]]
+|style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or [[Xanthochromic|xanthochromia]], [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]]
 |style="background: #F5F5F5; padding: 5px;" |Clinical assesment
 |style="background: #F5F5F5; padding: 5px;" | +
@@ Line 145: / Line 145: @@
 |style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" | +
-| style="background: #F5F5F5; padding: 5px;" |Tick bite/mosquito bite/ viral prodome for several days
+| style="background: #F5F5F5; padding: 5px;" |[[Tick bite|Tick bite/]][[Mosquito|mosquito bite]]/ viral prodome for several days
-| style="background: #F5F5F5; padding: 5px;" |Extreme lethargy, rash [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes
+| style="background: #F5F5F5; padding: 5px;" |[[Lethargy|Extreme lethargy]], [[rash]] [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Herpes simplex encephalitis]]
@@ Line 162: / Line 162: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of [[hypertension]]
-|style="background: #F5F5F5; padding: 5px;" |[[Delirium]], cortical [[blindness]], [[cerebral edema]], [[seizure]]
+|style="background: #F5F5F5; padding: 5px;" |[[Delirium]], [[Blindness|cortical blindness]], [[cerebral edema]], [[seizure]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |Wernicke’s encephalopathy
@@ Line 177: / Line 177: @@
 |style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse
+|style="background: #F5F5F5; padding: 5px;" |History of [[alcohol abuse]]
 |style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]]
 |-
@@ Line 183: / Line 183: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |'''↑''' [[leukocytes]] >100,000/ul, '''↓''' [[glucose]] and '''↑''' protien, '''↑''' red blood cells, [[lactic acid]] >500mg
+|style="background: #F5F5F5; padding: 5px;" |'''↑''' [[leukocytes]] >100,000/ul, '''↓''' [[glucose]] and '''↑''' [[protein]], '''↑''' [[red blood cells]], [[lactic acid]] >500mg
-|style="background: #F5F5F5; padding: 5px;" |Contrast enhanced MRI is more sensitive and specific,
+|style="background: #F5F5F5; padding: 5px;" |[[MRI|Contrast enhanced MRI]] is more [[Sensitivity (tests)|sensitive]] and [[Specificity (tests)|specific]],
 [[Histopathological]] examination of brain tissue
 |style="background: #F5F5F5; padding: 5px;" | +
@@ Line 194: / Line 194: @@
 |style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |History of [[drug abuse]], [[endocarditis]], '''↓''' [[immune]] status
+|style="background: #F5F5F5; padding: 5px;" |History of [[drug abuse]], [[endocarditis]], '''↓''' [[Immunity (medical)|immune status]]
-|style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]]
+|style="background: #F5F5F5; padding: 5px;" |[[fever|High grade fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]]
@@ Line 211: / Line 211: @@
 |style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |[[Lithium]], Sedatives, [[phenytoin]], [[carbamazepine]]
+|style="background: #F5F5F5; padding: 5px;" |[[Lithium]], [[Sedatives]], [[phenytoin]], [[carbamazepine]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]]
@@ Line 227: / Line 227: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]]
+|style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], [[Swallowing difficulties|difficulty swallowing]]
 |-
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]]
@@ Line 249: / Line 249: @@
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px; text-align:center" |Not performed in first simple febrile [[seizures]]
-| style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis and EEG
+| style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis and [[EEG]]
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
@@ Line 274: / Line 274: @@
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px;" |History of relapses and remissions
+| style="background: #F5F5F5; padding: 5px;" |History of [[Relapse|relapses]] and [[Remission (medicine)|remissions]]
-| style="background: #F5F5F5; padding: 5px;" |Blurry vision, [[urinary incontinence]], [[fatigue]]
+| style="background: #F5F5F5; padding: 5px;" |[[Blurred vision|Blurry vision]], [[urinary incontinence]], [[fatigue]]
 |-
 | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypoglycemia]]
@@ Line 292: / Line 292: @@
 | style="background: #F5F5F5; padding: 5px;" | +
 | style="background: #F5F5F5; padding: 5px;" |History of [[Diabetes mellitus|diabetes]]
-| style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], [[sweating]], [[dizziness]], low serum, [[glucose]]
+| style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], [[sweating]], [[dizziness]], [[Low blood sugar|low serum glucose]]
 |}