Recurrent meningitis in a 38-year-old man with cirrhosis

A Sy he had a nonfocal neurologic examination. At that time, computed tomographic (CT) scan of the head was unremarkable. Table 1 presents lumbar puncture (LP) results on admission (LP 1). Ceftriaxone was administered intravenously, and the patient’s symptoms resolved after the first hospital day. He received antibiotics for 4 days. Blood and cerebrospinal fluid (CSF) cultures remained negative, and the patient was discharged with the diagnosis of aseptic meningitis, presumed to be of viral etiology He remained well until a few days prior to the second admission when his symptoms recurred. The patient had a history of heavy alcohol use, hepatitis C infection, and liver cirrhosis and had undergone portocaval shunt placement 2 years prior to the first admission for aseptic meningitis. He was a former injection drug user. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) had been negative 4 months prior to admission. A tuberculin skin test (PPD) had been positive 12 years earlier, at which time he received prophylactic therapy. He had been born in New York City and had traveled to Puerto Rico three times, the last time being several years earlier. On physical examination at the second admission his temperature was 103”F, his neck was supple, and there was no indication of adenopathy, papilledema, or sinus tenderness. The patient was alert and oriented, according to a nonfocal neurologic examination. The white blood cell count was 5100/mm3 with a normal differential, the hematocrit was 33%, and the platelet count was 123,000/mm3. The serum total protein and albumin were 6.5 and 2.5 mg/dL, respectively. Other routine laboratory values were within normal range, including serum