Throat and stool cultures are helpful in diagnosing enterovirus CMI as in our series (>90% positivity in the PCR-confirmed enteroviral etiologies). Unfortunately, these peripheral cultures are limited by their late time to completion (more than a week) and are not useful in the initial management of a patient.13 AC220 Neuroimaging is useful in the diagnosis of encephalitides and focal lesions (brain abscess,
neurocysticercosis), particularly when assessing the differential diagnosis. In this case, MRI is the procedure of choice.22 Finally, our study showed that travel-related CMI have a significant morbidity and mortality as almost one third of our patients were admitted to intensive care. The mean duration of hospital stay was greater than in the travel-related pneumonia series23 but similar to the available data on severe imported malaria.24 The management of a traveler presenting with a history of fever and/or neurological and/or psychiatric features (Figure 1) is difficult and therefore should be based on taking a thorough past medical and travel history
as well as a careful examination. As in non-travelers CMI practice guidelines, any danger sign (purpura, altered consciousness, seizures, dyspnea, hypotension, or shock) requires emergency measures and prompt admission to an intensive care unit. In case of return from malaria endemic areas, thin and thick blood smears should Niclosamide be prepared and examined immediately to rule out malaria. If these latter tests are negative and there is no strong suspicion for malaria, a lumbar puncture should be carried out rapidly (provided the buy PTC124 absence of immunosuppression and classic contraindications that involve previous neuroimaging studies) and the fluid caught in five 2 mL tubes (cytology, biochemistry, bacteriology, virology, and serology). While awaiting for blood cultures as well
as CSF PCR, culture, and latex agglutination results (and also if a lumbar puncture is delayed in order to obtain neuroimaging studies), a presumptive and intravenous antimicrobial/antiviral therapy (against bacterial meningitis and HSV-1 encephalitis) is crucial and should be initiated based on the CSF initial patterns (Figure 1). As recommended in the practice guidelines of non-travelers CMI, the empirical intravenous treatment consists of the association of acyclovir, a third generation cephalosporin (cefotaxime or ceftriaxone) and amoxicillin. If tuberculosis is suspected, a quadritherapy should be added. On the other hand, if the clinical presentation is suggestive of a rickettsiosis, doxycycline should be combined. When CSF is normal or non-contributive, serological studies could be helpful to diagnose arboviruses and other common viruses. Finally, in all unexplained situations, it is recommended to conserve two additional CSF and blood tubes for future tests.