Age: 71.0
Sex: F
Vaccine: COVID19-2, FLUA4, VARZOS
Symptoms: Blood thyroid stimulating hormone normal, Borrelia test, CSF glucose normal, CSF lymphocyte count increased, CSF monocyte count decreased
Clinical narrative: PER ID MD NOTE IMPRESSION & PLAN 1.  Recent left facial palsy. Secondary to #2? 2.  Recent L auricular rash, possible shingles, concern for Ramsay Hunt syndrome.  Was on prednisone and Valtrex before admission. 3.  Meningitis with CSF lymphocytic pleocytosis 4.  Intractable nausea and vomiting. 5.  Recent COVID-19 (Pfizer) and shingles/Zostavax vaccine 10/30/2023 and Seqirus QV Flu caccine 10/26/23.  Patient is a 71 y.o. female admitted to the hospital 11/20/2023 by MD  . ID service consult for evaluation of CSF pleocytosis, and suspicion for possible meningitis. The patient was admitted to the hospital on November 20, yesterday, presenting with left facial weakness, headache, dizziness nausea photophobia.  Was evaluated by neurology, was found to have Bell's palsy and left facial weakness.  Had an MRI of the brain that shows enhancement of the left facial nerve and the temporal bone.  It would be consistent with a possible inflammatory or infectious related abnormality of the left facial nerve. At the time of admission the patient had no fever but had a mild leukocytosis of 14,000.  She had blood cultures collected on admission which are in progress.  There was a concern for possible associated meningitis, so she had an LP this morning that shows 43 white cells with 96% lymphocytes and 4% monocytes, the protein is 64 mildly elevated glucose is normal at 65.  She has also 8 RBCs.  The Gram stain and in the ankle and the CSF is negative, and therefore meningitis panel is negative for all the pathogens as well.  She was a started empirically on treatment for possible viral or bacterial meningitis with acyclovir ceftriaxone, vancomycin. She has some associated headache, and some concern for possible Rines and Hunt syndrome. I was asked regarding input for possible CNS infection. At this point her main complaint is intractable nausea, with occasional vomiting and headache.  She also has some photophobia. She does not have eye pain.  The possible Ramsay-Hunt syndrome lesions on the ear are at this point dried out.  There is no vesicles. Other pertinent labs include a negative syphilis EIA, normal renal function, normal TSH, negative ENA panel.  Mild leukocytosis of 11,000, normal hemoglobin and platelets.  ESR is normal with a value of 1.   Review of the chart shows that the patient does not take any immunosuppressive therapy at home other than prednisone 20 mg daily.  This was prescribed November 15 by PA.  I reviewed the outpatient ENT note, they apparently suspected Ramsay Hunt of radicular syndrome.  Review of other additional records shows that she was prescribed Valtrex on November 10 for 7 days by her PCP for treatment of shingles involving the left ear. The notes from ENT indicates she had a left facial palsy and also some lesions in the left ear that were sparing the ear canal. She denies history of previous episodes of meningitis. She has a healthy dog, no exotic animals.  No travel to tropical regions.  No other unusual exposures.