52
Treatment
Table 7. Nervous System Toxicities
7.5 Aseptic Meningitis
Workup/Evaluation:
• MRI brain w/wo contrast with pituitary/sellar cuts protocol.
• AM cortisol, ACTH to rule out adrenal insufficiency.
• Strongly consider lumbar puncture with CSF analysis for opening pressure, cell count
and differential, cytolog y for malignant cells that could indicate leptomeningeal
metastases, protein, glucose, gram stain, viral/bacterial cultures, polymerase chain
reaction (PCR) for herpes simplex virus (HSV) and other viral PCRs depending on
suspicion.
• May see elevated WBC in CSF with normal glucose, normal culture and gram stain.
May see reactive lymphocytes, neutrophils or histiocytes on cytolog y.
Grading Management
G1: Mild: no interference with
function and symptoms not
concerning to patient.
Note: any cranial nerve problem
should be managed as moderate.
• Hold ICPi and discuss resumption with patient
only after taking into account the risks and
benefits.
• Consider neurolog y consult
• Consider empiric antiviral (IV acyclovir) and
antibacterial therapy until CSF results.
• Once bacterial and viral infection negative,
may closely monitor off corticosteroids or
consider oral prednisone 0.5–1 mg/kg/day or IV
methylprednisolone 1 mg/kg/day if moderate/
severe symptoms.
• Steroids can be tapered after 2–4 weeks,
monitoring for symptom recurrence.
• Consider hospitalization for G3–4.
G2: Moderate: some interference
with ADLs, symptoms
concerning to patient (i.e.,
pain but no weakness or gait
limitation).
G3–4: Severe: limiting self-care
and aids warranted
(cont'd)
