Labs:
- CBC
- CMP
- Vitamin B2 (Riboflavin) and Vitamin D25OH
- TSH, Free T4
- ESR, CRP
- Lyme titer with reflexive western blot
- EBV antibodies (looking for cause of new-onset headache only, would not treat)
- PPD if risk factors for tuberculosis
- Consider ANA if arthritis, fatigue, rash
- Consider celiac panel IgA (add IgG only if IgA deficient), esp if GI symptoms
- Consider AM cortisol and ACTH, if > 30 beat pulse change on orthostatic vital signs or persistent tachycardia
Consider LP:
- Head imaging precedes this if focal exam, concern for increased ICP
- Measure opening pressure in lateral recumbent position
- Cell count (1st, 4th tubes), glucose, protein, gram stain, culture, save specimen
- If abnormal consider ID consult and consider sending: Lyme, HSV, Enterovirus, Parechovirus, and LCMV PCRs from CSF, and Ehrlichia panel, Babesia IgG, and Malaria Smear from blood. If lymphocytic pleocytosis give IV Acyclovir until HSV PCR is negative
- If OP > 20, drain CSF until closing pressure is 10-20 and evaluate if symptoms improve (HA, pulsatile tinnitus, visual)
- If patient's symptoms improve or if OP > 28 consider treating for pseudotumor
- Positional post-LP headache does not exclude the diagnosis of pseudotumor
Considerations for Performing an LP
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