Encephalitis: The Daily PANCE Blueprint
A 35-year-old man presents to the emergency department with altered mental status, fever, and a recent history of seizures. He has no signs of meningeal irritation, such as photophobia or nuchal rigidity. Neuroimaging reveals temporal lobe involvement. A cerebrospinal fluid (CSF) examination is pending. What is the most appropriate next step in the management of this patient?
A. Start empiric treatment with ceftriaxone and vancomycin
B. Start empiric treatment with acyclovir
C. Wait for CSF polymerase chain reaction (PCR) results before initiating treatment
D. Start empiric treatment with doxycycline
E. Administer intravenous fluids and antipyretics only
Answer and topic summary
The answer is B. Start empiric treatment with acyclovir
Given the patient’s altered mental status, seizures, and temporal lobe involvement on neuroimaging, herpes simplex virus (HSV) encephalitis is a strong possibility. Immediate initiation of empiric acyclovir is crucial, as there is a high mortality associated with HSV encephalitis when treatment is delayed.
- A. Start empiric treatment with ceftriaxone and vancomycin: This regimen is more appropriate for bacterial meningitis, which is less likely given the absence of meningeal signs and the specific neuroimaging findings.
- C. Wait for CSF polymerase chain reaction (PCR) results before initiating treatment: Waiting for confirmatory tests in a case with high suspicion for HSV encephalitis could be fatal.
- D. Start empiric treatment with doxycycline: This would be more appropriate for tick-borne illnesses, but given the neuroimaging findings and clinical presentation, HSV is more likely.
- E. Administer intravenous fluids and antipyretics only: This would not address the underlying cause and could lead to worsening of the patient’s condition.
View blueprint lesson
Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Neurology ⇒ ⇒
Also covered as part of the Emergency Medicine EOR and Internal Medicine EOR topic lists
