Fungal meningitis differential diagnosis: Difference between revisions

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Revision as of 04:28, 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-specifc CSF FTA-Ab -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 alcohal abuse	Ophthalmoplegia, confusion
CNS abscess		+	↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ 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 50: / Line 50: @@
 |style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumour]]<ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref><ref name="pmid3883130" />
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-|style="background: #F5F5F5; padding: 5px text-align:center" |Cancer cells<ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327  }}</ref>
+|style="background: #F5F5F5; padding: 5px text-align:center" |[[Cancer cells]]<ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327  }}</ref>
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 |style="background: #F5F5F5; padding: 5px;" |[[Alcohol]] intake, sudden witdrawl or reduction in consumption
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-|style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628  }}</ref>
+|style="background: #F5F5F5; padding: 5px;" |[[Xanthochromic|Xanthochromia]]<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628  }}</ref>
-|style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
+|style="background: #F5F5F5; padding: 5px;" |[[CT]] scan  without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
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+|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"|
-|style="background: #F5F5F5; padding: 5px; text-align:center"|✔
+|style="background: #F5F5F5; padding: 5px; text-align:center"| +
-|style="background: #F5F5F5; padding: 5px; text-align:center"|✔
+|style="background: #F5F5F5; padding: 5px; text-align:center"| +
 |style="background: #F5F5F5; padding: 5px; text-align:center"|
-|style="background: #F5F5F5; padding: 5px; text-align:center"|✔
+|style="background: #F5F5F5; padding: 5px; text-align:center"| +
-|style="background: #F5F5F5; padding: 5px; text-align:center"|✔
+|style="background: #F5F5F5; padding: 5px; text-align:center"| +
 |style="background: #F5F5F5; padding: 5px; text-align:center"|
-|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"|Speech difficulty, gait abnormality
@@ Line 115: / Line 115: @@
 |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>
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]]
 |style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc
 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>
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px;text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px;text-align:center" | +
-|style="background: #F5F5F5; padding: 5px;text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px;text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |Unprotected sexual intercourse, [[STI]]<nowiki/>s
 |style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]],
@@ Line 134: / Line 134: @@
 |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;" | +
 |style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or xanthochromia, [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]]
 |style="background: #F5F5F5; padding: 5px;" |Clinical assesment
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px;text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |    ✔
+| style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|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;" |Extreme lethargy, rash [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes
@@ Line 150: / Line 150: @@
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Herpes simplex encephalitis]]
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |Clinical assesment
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of [[hypertension]]
@@ Line 171: / Line 171: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse
@@ Line 182: / Line 182: @@
 |style="background: #DCDCDC; padding: 5px; text-align: center;" |[[CNS abscess]]
 |style="background: #F5F5F5; padding: 5px;" |
-|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;" |Contrast enhanced MRI is more sensitive and specific,
 [[Histopathological]] examination of brain tissue
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|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;" |High grade [[fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]]
@@ Line 208: / Line 208: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |[[Lithium]], Sedatives, [[phenytoin]], [[carbamazepine]]
@@ Line 219: / Line 219: @@
 |style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion
 | style="background: #F5F5F5; padding: 5px; text-align:center" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
 | style="background: #F5F5F5; padding: 5px;text-align:center" |
-|style="background: #F5F5F5; padding: 5px;text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px;text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+|style="background: #F5F5F5; padding: 5px; text-align:center" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]]
@@ Line 239: / Line 239: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |✔
+|style="background: #F5F5F5; padding: 5px;" | +
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[Seizure|seizures]]
@@ Line 254: / Line 254: @@
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |   ✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px;" |✔
+| style="background: #F5F5F5; padding: 5px;" | +
-| style="background: #F5F5F5; padding: 5px;" |✔
+| style="background: #F5F5F5; padding: 5px;" | +
 | style="background: #F5F5F5; padding: 5px;" |Family history of [[febrile]] [[seizures]], [[viral]] illness or [[gastroenteritis]]
 | style="background: #F5F5F5; padding: 5px;" |Age > 1 month,
@@ Line 263: / Line 263: @@
 | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Subdural empyema]]
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
 | style="background: #F5F5F5; padding: 5px; text-align:center" |
 | style="background: #F5F5F5; padding: 5px;" |Clinical assesment and [[MRI]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px;" |✔
+| style="background: #F5F5F5; padding: 5px;" | +
-| style="background: #F5F5F5; padding: 5px;" |✔
+| style="background: #F5F5F5; padding: 5px;" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
 | style="background: #F5F5F5; padding: 5px;" |History of relapses and remissions
 | style="background: #F5F5F5; padding: 5px;" |Blurry vision, [[urinary incontinence]], [[fatigue]]
@@ Line 284: / Line 284: @@
 [[HbA1c]]
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px;" |✔
+| style="background: #F5F5F5; padding: 5px;" | +
 | style="background: #F5F5F5; padding: 5px;text-align:center" |
 | style="background: #F5F5F5; padding: 5px;text-align:center" |
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  ✔
+| style="background: #F5F5F5; padding: 5px; text-align:center" | +
 | style="background: #F5F5F5; padding: 5px; text-align:center" |
-| style="background: #F5F5F5; padding: 5px;" |✔
+| 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]]