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exposure to contaminated blood should always raise the possibility of HIV infection As with Lyme and HSV, HIV meningitis may be additionally associated with a cauda equina neuritis, as discussed in Chap 46 In the case of HSV, there is often a preceding genital infection with the virus Aside from viral isolation and serologic tests and, more recently, detection by polymerase chain reaction (see further on), few laboratory examinations are helpful The peripheral white cell count is usually normal but may sometimes be slightly elevated or depressed, with a mild lymphocytosis Eosinophilia should suggest a parasitic infection Most cases of infectious mononucleosis can be identi ed by the blood smear and speci c serologic tests (heterophil or others) LCM should be suspected if there is an intense pleocytosis Counts above 1000 mononuclear cells per cubic millimeter in the spinal uid are most often due to LCM but may occur occasionally with mumps or echovirus 9; in the latter, neutrophils may predominate in the CSF for a week or longer Slightly depressed glucose in the spinal uid is consistent with mumps meningitis and with the viruses mentioned earlier, but it always is a worrisome sign of bacterial or fungal infection Liver function tests are abnormal in many patients with EBV infection, leptospiral infections, and anicteric hepatitis In the majority of patients with M pneumoniae infections, cold agglutinins appear in the serum toward the end of the rst week of the illness Panels of serologic tests for the main viruses that cause aseptic meningitis are available; most use complement xation or enzymelinked immunosorbent assay (ELISA) techniques; an infection is demonstrated by a fourfold increase in titer from acute to convalescent serum drawn at least 10 days apart, but these, of course, do no more than con rm the diagnosis after the illness has mostly passed Serologic reactions of CSF for syphilis should be interpreted with caution, because in ammation of many types, including infectious mononucleosis, can produce a false-positive reaction In the last few years, the polymerase chain reaction (PCR) has been applied to the diagnosis of viral infections of the nervous system, among them CMV and HSV The test detects portions of viral DNA in the spinal uid and is most sensitive during the active stage of viral replication, in contrast to serologic tests, which are more accurate later in the course of the infection There are numerous false-negative and fewer false-positive PCR tests for CMV, but they are nonetheless useful in some circumstances, such as the early diagnosis of fulminant infection in AIDS patients (see later in this chapter).

Several other categories of disease may cause an apparently sterile, predominantly lymphocytic or mononuclear reaction in the leptomeninges, and these should be considered in cases that do not conform to the usual pattern: (1) foci of bacterial infection lying adjacent to the meninges; (2) partially treated bacterial meningitis; (3) speci c meningeal infections in which the organism is dif cult or impossible to isolate fungal and tuberculous meningitis are at times in this category, and the group also includes parasitic infections; (4) neoplastic invasion of the leptomeninges (lymphomatous and carcinomatous meningitis); (5) granulomatous, vasculitic, or other in ammatory diseases such as sarcoidosis, Behcet disease, and granulomatous angiitis; and (6) acute or chronic recurrent in ammatory meningitides of unusual or obscure origin The last of these constitutes a vexing group in which no cause can initially be

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