A 55-year-old male presented to the emergency department with a history of 6 days of fever, chills, and headache. The headache was pressure-like, global, and progressive. There was associated phono-phobia but no photophobia, nausea, or other constitutional symptoms. Two days before the onset of symptoms, the patient had a titanium screw placed in an upper incisor at the dentist' s office, without complications. The patient began postprocedure amoxicillin treatment that same night, using 1 oral dose of 500 mg. He awoke the next morning with the complaints that prompted hospital admittance. On examination, the patient had an oral temperature of 38.3° C, with mild tachycardia (heart rate, 105 beats per min). Neurological examination revealed normal findings, including a normal mental status, supple neck, and absent Kernig' s and Brudzinski' s signs. Results of cardiac; respiratory; head, eyes, ears, nose, and throat; and skin examinations were normal. The patient's serum WBC count was 12,470 cells/µ L (normal range, 3600– 11,200 cells/µ L), with a differential of 80.3% neutrophils (normal range, 44%– 88% neutrophils) and 11.2% lymphocytes (normal range, 12%– 43% lymphocytes). Results of urinalysis were within normal limits. Lumbar puncture revealed a WBC levell of 70 cells/µ L, all of which were lymphocytes. The patient's total protein level was 61.2 mg/dL (normal range, 15– 45 mg/dL), with a glucose level of 51 mg/dL (serum glucose level, 108 mg/dL). Results of CSF bacterial and viral culture were negative, as were those for serum antinuclear antibodies, erythrocyte sedimentation rate, Lyme titers, and HIV status. The patient improved within a few days of discontinuation of amoxicillin therapy and administration of symptomatic pain treatment and intravenous fluids.
The patient had a similar syndrome after a dental procedure a year before this incident. He had received a 1-week course of postprocedure amoxicillin (dosage unknown) and had similar headache, fever, and chills during the entire course of treatment. The symptoms resolved 3 days after completion of amoxicillin therapy, although a mild headache continued for ∼ 1 month. At that time, he refused lumbar puncture after tests for endocarditis were negative. Between the 2 episodes, the patient had no symptoms. We believe that, because these episodes of aseptic meningitis were associated with an offending agent, involved negative culture results, and resolved with cessation of amoxicillin therapy, amoxicillin was the etiology of the 2 episodes of aseptic meningitis in this patient.