P3.N267: Pain Relief or Painful Twist? NSAID-Induced Aseptic Meningitis in an Adolescent Patient

Introduction: Meningitis, characterized by inflammation of the meninges, is commonly due to microbial infections. However, in some cases, cerebrospinal fluid (CSF) studies may not align with bacterial etiologies. Aseptic meningitis, defined by meningeal inflammation without bacterial origin, often presents with a CSF white cell count of >5 cells/mm3 and negative CSF gram stain/culture. Subtypes of aseptic meningitis include viral, drug-induced, systemic diseases, and neoplastic meningitis. While viruses are the predominant cause, a significant portion of cases remain idiopathic. Drug-induced aseptic meningitis (DIAM) , first recognized in the 1980s, is a diagnosis of exclusion, necessitating vigilance in clinical settings [1-3]. We present a case of an adolescent who developed drug-induced aseptic meningitis associated with non-steroidal anti-inflammatory drug (NSAID) use.

Case Description: A 13-year-old male with no significant medical history presented with progressively worsening headaches following a karate class incident. Initially, he experienced head and neck pain which improved with analgesia but then symptoms started recurring, with the addition of nausea, vomiting, chills, dizziness, and gait changes. He was evaluated by his PCP and seen twice in the emergency room with a negative cervical Xray and normal CT head and was given instructions for supportive care including analgesia with Tylenol and Ibuprofen. He re-presented with persistent worsening symptoms and new encephalopathy. Initial laboratory findings showed leukocytosis, elevated inflammatory markers, and abnormal CSF analysis suggestive of meningitis. Extensive infectious workup yielded negative results. Imaging studies were unremarkable. Empirical meningitis treatment was initiated but discontinued following negative PCR and culture. Upon further history, it was noted that patient was taking ibuprofen consistently for two weeks around-the-clock. All NSAIDs were discontinued and the patient's symptoms rapidly resolved, corroborating the suspicion for drug-induced aseptic meningitis secondary to NSAID use [4-7].

Discussion: Differential diagnoses included viral, drug-induced, and autoimmune/inflammatory etiologies. Additionally, complex migraines and demyelinating processes were also considered, but deemed less consistent with the patient’s overall presentation. Notably, the patient's clinical improvement upon NSAID cessation supported the diagnosis of drug-induced aseptic meningitis. Mechanisms underlying DIAM are hypothesized to involve hypersensitivity reactions or inflammatory processes. Symptoms typically manifest within 24-48 hours post-drug ingestion and may include meningeal signs and mental status changes. Early recognition and withdrawal of the offending agent are crucial for management, with favorable prognosis in most cases [5-7].

Conclusion: Prompt recognition and appropriate diagnostic evaluation are vital in suspected meningitis cases. Drug-induced aseptic meningitis warrants consideration, particularly with NSAID use. Rapid symptom improvement post-drug cessation can aid diagnosis. NSAIDs, notably ibuprofen, are commonly implicated. Our patient saw three prior providers who recommended continuation of NSAIDs for symptom control. Awareness of this condition facilitates timely intervention, ensuring optimal patient outcomes.